				Using the search form

If you prefer to view this article in PDF form, click here.

PAs at the crossroads: Where will the profession go next?

Stephen C. Crane, PhD, MPH

Stephen C. Crane, PhD, MPH, was Executive Vice President/CEO of the AAPA through August 31, 2007. He is now Executive Director of the American Thoracic Society.

The PA profession has experienced unparalleled success over its roughly 40 years of existence, as measured by growth in PA numbers, expansion in PA utilization, and acceptance of PAs by physicians and patients alike. Some of this success stems from the brilliance of the idea for the profession in the first place. Clearly, though, most of the success is the direct result of the profession’s unwavering focus on and commitment to the team practice of medicine for the benefit of patients.

Will this success continue in the future? Some people may be surprised to hear me say this, but I don’t think continued success is guaranteed by any means.

On the one hand, the profession is well-positioned to address critical issues of the accessibility, affordability, quality, and safety of health care. The only question is whether enough PAs will be produced over the coming decade to have a substantial impact on these problems. The production of PAs will be a direct function of increasing the supply of PA faculty and expanding the number of clinical training sites for PA programs. These issues should be at the top of the agenda for PA organizations. My fear is that they are not.

On the other hand, the PA profession could lose its “magic place” and could gravitate to the periphery of health care delivery no matter how many PAs are produced. Here’s why.

First, absent a miraculous advancement in the ability of medical science to prevent and treat illness far beyond what genomics and molecular biology can offer us today, the demand for medical services over the next 10 to 20 years will be overwhelming. The demand, however, will be not just for high tech care at the edges of medical science but also for high touch care at the level of basic patient support. Physicians have delegated more and more functions to PAs, expanding PA scope of practice. Just as PAs have benefited from this expansion, other professions will similarly benefit. Medical advances make this possible by moving physicians into new areas of practice, leaving behind more functions for others to perform safely and effectively. Delegation has been the hallmark of the evolution of the PA profession, and it will be the hallmark of the development and expansion of other health professional groups as well. These groups will compete with PAs both below and at the level of PA function and salary as delivery organizations and policy makers struggle to meet the substantial need for care.

Second, the trend toward specialization in the PA profession, and PAs’ understandable desire that their knowledge and skills in areas of specialized practice be recognized, perversely may result in balkanization—the carving up of the profession into increasingly narrower silos that become disconnected from the larger PA profession as a whole. This is the same process that has occurred among physicians. The well-intended efforts of PA organizations to meet the perceived needs of different groups of PAs also unwittingly may contribute to the speed of this balkanization. Inevitably, professional mobility will be limited, and this ultimately will decrease professional satisfaction for many PAs, as it has for many physicians. If the flexible use of PAs and their ability to adapt rapidly to changing practice circumstances are limited or reduced, the door will be opened considerably wider for other health professions to establish practice and to innovate where PAs otherwise would be the innovators.

Third, as the value of PAs to the health care system increases, the salaries of PAs also will rise. Increased specialization could raise PA salary levels further. In the face of increasing demand for care, either other professions will offer their services at a lower price to gain entry into the system or physicians and delivery organizations will look to delegate more functions to lower-cost personnel. In either case, the demand for PA services could be dampened—and with it the growth potential for the profession.

By no means is the future of the profession bleak. To the contrary, prospects are bright—but only if the adaptability, flexibility, mobility, and capability of PAs to be innovators can be maintained. The model of continuous, lifelong learning, expansion of scope of practice, increasing delegation of functions, and a team approach to patient care is the model best suited to meeting future health service delivery needs. Similarly, the profession must always return to and strengthen its base of knowledge in primary care. More and more PAs must be encouraged to practice in primary care if the health service needs of the nation are to be met effectively.

Finally, rather than advocate for its own special interests, the profession generally and PAs individually must become more involved in efforts to advocate at all levels of government and the private sector for access to affordable, highquality health care and for the prevention of illness and disability. The reputation of the PA profession and its professional organizations should be based on contributions made to the public good, not on accomplishments achieved for the private benefit of PAs, individually or as a group. Such advocacy for the public good, and increasing the number of PAs, will assure more and better care for patients—which is, after all, the goal.