The shortage of physicians in the 1960’s led to Duke University’s first physician assistant (PA) program graduates in October of 1967. With federal backing, the concept of a physician’s assistant spurred the creation of the American Association of Physician Assistants (AAPA) accreditation standards, licensing processes, and continuing education requirements that have stood the test of time. There are over 125,000 physician’s assistants in the U.S. and with an expected growth of 31 percent, the role of this medical assistant will evolve to become more crucial to the healthcare industry.
What a physician assistant does
To better understand what a physician assistant does, it’s important to distinguish it from another prominent profession.
Difference between a physician assistant and a nurse practitioner
Nurse practitioners are primarily registered nurses (RN) who have advanced clinical training, giving them the ability to assess patients, perform physical evaluations and diagnostic tests, and treat illnesses. PAs are licensed medical professionals who work with a lead physician or independently. The difference between these involve:
- Professional focus: While they both have a desire to help people, nurse practitioners take a more long-term approach to patient care, making them more patient-oriented, deciding to focus more on educating and counseling patients to manage their health. They tend to specialize, so they care for certain slices of the population. Physician assistants are more about working with the patient to treat disease and improve their health, making their care more disease-oriented, just like the physician.
- Certification: Both are required to pursue higher and continuing education credits throughout their careers, but the certification processes are different. To be either a nurse practitioner or a PA, candidates need an advanced degree. In fact, physician assistants need to attend a master’s level PA program after their bachelor’s that has a curriculum similar to the one in medical school. Their focus is on medical science. By contrast, nurse practitioners must complete a master’s degree program that’s more focused on humanistic and behavioral science.
PAs need to take the Physician Assistant National Certification Exam (PANCE) to become licensed. To renew their license every decade, they have to achieve 100 continuing medical education credits. NPs need to pass and maintain their RN license and have certifications based on their specialty. They need to recertify every five years, but their continuing education requirement varies by date.
- Differences in clinical experience and preparation: Nurse practitioners need about 500 to 700 hours of learning about diagnostic techniques and case management. They devote much of their clinical learning time to their specialization. A PA student is expected to complete about 2,000 hours along with clinical rotation through multiple specialties. Physician assistants get to choose their medical practice once they graduate.
Responsibilities of a physician assistant
PAs perform the same tasks as a doctor. They do rounds and examine patients. Once they’ve diagnosed any illnesses, they develop appropriate treatment plans, including writing prescriptions and advising patients on preventative care. PA can even assist with surgery. Physician assistants work with a supervising physician but not under the direct supervision of a physician, making that doctor more like a consulting to collaborating partner. This means that they can be relatively autonomous, but each state has its rules on just how independent physician assistants can be, especially when prescribing meds.
Close to 40 percent of PAs work in a hospital, and over 75 percent of those physician assistants work in either an academic medical center or community hospitals. Where doctors have to choose and stick with a specialty, PAs can work in a variety of departments and have multiple specialties. Over 20 percent of them work in emergency departments and over a quarter of them work in non-critical in-patient care units. They can also work in operating rooms. While they can’t perform surgery, surgical PAs can assist in several capacities. Under the direction of a licensed anesthesiologist, for example, they can plan and implement anesthesia protocols, like a certified registered nurse anesthetist (CRNA).
Relationship between a physician and a physician assistant and where they work
As healthcare professionals, physician assistants have close relationships with attending physicians. They are part of the care team and continually collaborate with their supervising physician to come up with the best primary care treatments for patients. In a hospital setting, it’s normal for PAs to collaborate with physicians more than three-quarters of the time, which is not surprising considering that PAs on average see between 50 and 75 patients weekly. There is a growing trend for PAs to work along with nurse practitioners and advanced practicing nurses (APN) to provide primary and preventative care to patients, leaving physicians to act more like managers.
Because more doctors are choosing to specialize, the physician assistant profession seems to be following that trend. A little over 19 percent of PAs worked in family medicine/general practice while approximately 5 percent worked in internal medicine general practice. About 18 percent specialized in surgical, while just 3 percent chose general surgery. About 13 percent chose emergency medicine and critical care. In those arenas, PAs may have the most autonomy, because the attending physician may not always be present. Four percent of PAs chose dermatology, probably because the PA’s role is critical, especially during preoperative and postoperative protocols.
Educational requirements for physician assistants
To be a physician assistant, you’ll need a bachelor’s degree that’s geared towards health science, healthcare, or some related field. There are some pre-PA courses available for those who know what they want to do. If students aren’t coming from a health-related bachelor’s, they’ll need to take prerequisite courses in chemistry, physiology, anatomy, microbiology, and biology, but there may be other courses required depending on the program chosen.
Once they’ve completed their undergraduate degree, a PA student can get the necessary healthcare experience through work or volunteering. On average, students need about three years of hands-on experience along with their bachelor’s to be considered viable candidates for the next level. They can get this experience through a variety of sources, including being an EMT, ER Tech, or a registered nurse.
Being a physician assistant requires a two- to three-year master’s degree from a program accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA), which is recognized by the Council for Higher Education Accreditation (CHEA). There are close to over 250 recognized ARC-PA programs in the U.S. In total, physician assistant programs take between seven and nine years to complete.
The medical-model program
Both medical doctors and physician assistants are trained in the medical model, which is all about providing disease-focused care. This meant treating the patient for symptoms presented. However, psychiatrist and internist, Dr. George Engel critiqued this model. He initiated a discussion about how the medical community interpreted and defined illness and disease, because it was possible for someone to act sick without presenting any symptoms of a verifiable disease. This led to the model expanding and evolving, making room for psychosocial factors that gave physicians insight into how illness and disease were related. This is why the physician assistant profession is able to incorporate health education, counseling, and preventative information.
Cost to become a physician’s assistant
When assessing the cost of attending an accredited PA program, you have to look at a few things. Firstly, private universities are far more expensive than public schools. For a 27-month program at a private institution, the average cost is a little over $91,000. At Duke University, where the PA profession originated, the cost is about $93,000. Students aren’t able to transfer credits or earn credits through their experience, so they’ll have to take the full 58 credits during their first year.
For public schools, the cost depends on whether students are classified as in-state or out-of-state. In-state tuition costs about $50,000, while non-residents have to pay close to $90,000, which is about what private school costs. For Indiana State University, resident tuition is about $40,000 while non-resident tuition is double that cost. Of course, there are fees associated with the programs. Some students need to lease a laptop from the school, and there are potential living and transportation expenses.
When applying to this graduate program, it’s important to consider the financial burden you may already have from your undergraduate degree. While you may not have the same six-figure tuition as a medical student, you’re still going to need to find a way to cover your expenses for that three-year period. Apart from financial need loan programs, such as Perkins and Stafford, there are scholarships, grants, and traineeships that will help you to bankroll your education, including:
- Lesbian, Bisexual, and Gay Physician Assistant Caucus which offers a $1,000 grants for members of the AAPA
- The Physician Assistant Foundation has scholarships for a minimum of $1,000 for a variety of PA specializations and attributes.
- The Indian Health Service (IHS) offers a traineeship that assists American Indian and Alaskan Native students. They have a loan repayment program for up to $20,000 for students who sign up for two years of full-time practice at an Indian health site.
There is a healthy list of financial aid opportunities available to subsidize any student’s physician assistant education goals.
Why choose the physician assistant program over med school
With all that it takes to be a PA, some may wonder, “why not just go for med school?” There are quite a few practical reasons for not becoming an MD/DO.
- Flexibility: A radiologist who finds that they would rather be in anesthesiology would have to go back to school for years to make that switch. Doctors are locked into their professions, whereas physician assistants can transition from one specialty to another with ease. As a PA, you have the flexibility to learn more about obstetrics, dermatology, or even surgery with just one license.
- Less classroom time: Doctors have to invest about 10 to 11 years of their life to get their license. That’s a lot of time. Being a PA requires far less, a three-year master’s level course and about one to two years for clinical rotation and two-month stretches. Within those rotations, they get to understand which specializations they like and excel in, and pursue jobs in those fields.
- Better hours: Doctors work extremely long hours, and if they are off-duty, they are on-call. PAs who don’t work in emergency or urgent care, usually work 40 to 50 hours a week. They have time to pursue other goals and have lives without their profession spilling over.
- Just not for them: Being a medical doctor is an arduous slog, because they have to become subject matter experts in a specialty, and this takes years. On top of that, they have to wade through the bureaucracy and budgetary constraints, which is extra responsibility that pulls them further away from their primary focus, taking care of patients. The physician assistant profession is geared more towards being with patients and handling their care, which makes it just as rewarding and being a doctor is supposed to be.
Licensing necessary to become a physician assistant
After graduation from physician assistant school comes licensing. As mentioned they need to pass the national licensing exam, PANCE, which is composed of two 90-question exams taken in a couple of hours. The application fee for the PANCE depends on the state but can run anywhere from $100 to about $300. Then there’s the license fee, which can be between $200 and $400. States may also have other registration fees.
In addition to that, you need $731 to pay the U.S. Drug Enforcement Administration (DEA). They require all medical entities, such as institutions, practitioners, and researchers to obtain a DEA registration number. This is used to track prescriptions of controlled substances, and with it, medical professionals will be allowed to dispense Schedule II through IV drugs, which include fentanyl and diazepam.
Altogether, you’re looking at anywhere between $1,000 and $1,500 to become a licensed physician’s assistant, but at the end of it, you can attach the “PA-C” designation to your name.
During the last two years of their certification, PAs need to take the Physician Assistant National Recertifying Examination (PANRE). It’s a four-hour 240-question exam that tests medical and surgical knowledge and costs $350.
Core and in-demand certifications for a PA
Along with the PA-C, there are a few other core and in-demand certifications PAs can pursue. Some of these do not require much work experience, so PA students can get started. These certifications include:
- Basic Life Support: The American Heart Association trains participants to recognize cardiovascular emergencies and administer proper chest compressions and when to use AED
- Certified Physician Assistant – Orthopaedic Surgery: This is for PAs who want to showcase their expertise and advanced knowledge in orthopedic surgery beyond the entry-level or generalize approach. Candidates need at least 4,000 hours of experience, and the test covers areas such as anesthesia, advanced wound management, and all levels of operative care.
- Orthopedic Physician’s Assistant Certification: This is a certification that promotes growth in the specialty of orthopedics. Candidates need at least five years of experience in orthopedics, including surgical and physical assessment.
- Healthcare CPD Associate: New PAs with at least one year of experience and experienced professionals whose dedication to continuous professional development with the certification. It’s a 90-minute exam that covers such topics as leadership, adult learning principles, and collaboration.
- Certified Physician Assistant – Nephrology: This demonstrates advanced knowledge and expertise in nephrology.
- Vascular Access-Board Certified: This is a multidisciplinary certification that demonstrates the basic knowledge of vascular access.
- Certified Physician Assistant – Cardiovascular and Thoracic Surgery: PAs show their commitment to the specialty by achieving an added qualification that demonstrates advanced knowledge of either or both cardiovascular and thoracic surgical specialties.
- Certified Physician Assistant – Pediatrics: PAs who want to show their expertise in pediatrics can go for this added qualification certificate which accompanies augmented education.
- Certificate of Added Qualifications: Electronic Fetal Monitoring: PAs in U.S. and Canada can interpret electronic fetal monitor data and provide qualified care for obstetrics patients.
- Wound Care Certification: The National Alliance of Wound Care provides certification in skin and wound care management, which can be particularly useful in burn centers and other trauma environments.
- Emergency Medicine: PAs specializing in internal medicine, as well as students with more than two years of work experience, can get this certification to showcase their mastery of emergency medicine. It needs to be renewed every eight years.
In what states can PAs practice independently?
The scope of practice among PAs is complex. While they can do many of the things that physicians can do, the American Medical Association (AMA) has stated that they don’t support legislation that gives PAs the sole authority to make medical judgments. Twenty states require a certain number of PA charts to be co-signed by physicians and 39 states have limits on the number of PAs physicians can collaborate with.
So far, physician assistants can prescribe Schedule II through IV drugs, but in Alabama, Arkansas, Georgia, Hawaii, Iowa, and West Virginia, PAs can’t prescribe Schedule II drugs, which include oxycodone. Kentucky is the only state where PAs are not allowed to prescribe medications despite being trained to do so.
To understand how states are changing how autonomous PAs can be, it’s important to define the six key elements of a modern PA practice and how they contribute to an environment where the physician assistant has more autonomy:
- They are denoted as licensed professionals instead of certified because being licensed means that they demonstrate the highest level of professional qualifications.
- Their extensive pharmacology training gives them the knowledge and expertise to prescribe medications. States that grant full prescriptive authority provide better care and have fewer costs.
- The scope of practice is determined by the PA, collaborating physicians, and the health team, providing flexibility and the ability to tailor clinical services to patient needs.
- The relationship between PAs and physicians is adaptable considering state laws and regulations. Adaptable collaboration provides more efficient and expanded patient care
- Ideally, the co-signature requirements should be dictated by the needs of the patient and not as a way for the positions to showcase their authority. Regulated agreements at the practice level enhance communication and coordination between members of the healthcare team.
- The number of PAs physicians can collaborate with should also be done at the practice level. Physicians may need to collaborate with multiple PAs on a complex case in this cannot be regulated by a statute. It should be dictated by the practice.
Here are some states that are have adopted a majority, if not all, of these elements as a way of facilitating better patient care:
- Alaska calls medical doctors “collaborating physicians,” and they are there to be a resource to the PA. At a minimum, communication must be once a month or two days each quarter.
- Wyoming states that the supervision agreement is required between physician and PA and the physician’s physical present is not required. PAs have their prescriptive authority and their scope of practice matches that of the physician.
- Michigan recognized PAs as fully-prescribers meaning that the state acknowledges their ability to prescribe medication to patients and doesn’t limit their care. Additionally, physicians become full participants in their relationships with physician assistants, instead of supervisors.
- Vermont requires physicians and PAs to enter into a practice agreement with an individual physician whose specialty matches that of the PA, or with a physician group where at least one physician’s specialty matches that of the PA.
- North Carolina PAs need to meet with their supervising physician every month for the first six months of their new assignment and every six months after that. PAs must submit an Intent to Practice (ITP) form via the North Carolina Medical Board.
- North Dakota’s rural geography makes PAs vital to its health care. There is no limit to the number of PAs a physician can collaborate with, and as of April 2019, physician assistants are allowed to open their own practices.
- Minnesota PAs will no longer need to be attached to a single physician as of May 2020. Scope of practice depends on the physician assistant’s individual qualifications, experience, and training. Full prescriptive authority is now in Minnesota statute.
Job outlook for physician assistants
Over the next few years, the physician shortage will be felt and the causes are attrition, an increasingly aging population, and burnout. Physician assistants can ease the shortage and fill that gap. Their attrition rate is much lower and the average age of PAs skews younger, meaning they have the energy to give to the medical profession.
With PAs now able to take their assessments online, the NCCPA exam becomes a real-time exercise that lessens the time between licensure and practice. More states will update their legislation, giving more power to the practice and the state medical board to craft the relationship between physicians and assistants in addition to the PAs scope of practice. A few states, such as North Dakota and Utah, have created a path for PAs to work independently and even open up practices. As PAs become more specialized, they are able to expand their care and maintaining their core medical knowledge and skills.
Physician assistant jobs and salary expectations
Physician assistants are in high demand, because the PA profession is rewarding, flexible, and offers significant financial benefits. The median salary for a PA is over $100,000, which is about $30,000 higher than many individuals with a master’s degree.
One of the reasons why it’s easier to get a job as a PA is because they are licensed and skilled professionals who are able to work in multiple specialties. Their unemployment rate is below one percent, and physicians understand the need for these professionals who, on average, see about 9 million patients weekly. PAs reside in that professional gap between nurses and doctors and are some of the biggest advocates for improved legislation that expands the PA scope of practice.
Here are some of the most popular specializations:
- Emergency departments: This is pretty common especially in rural and remote areas, because it offers a rush of excitement. It does provide a level of autonomy especially in smaller communities where physicians aren’t readily available. The annual salary for this specialization falls between $110,000 and $140,000.
- Urgent care: In clinics and medical centers, urgent care is a lot like a hospital’s emergency care. PAs have the chance to work independently in a highly active environment. In this specialty, the average is about $130,000 annually.
- Surgery: While they may not be able to conduct surgery, they are skilled in all aspects of operative care, diagnostic tests, and surgical procedures. There are many subspecialties, but they take their core learning wherever they operate. Physician assistant salary expectations are around $115,000 a year.
- Dermatology: PAs who specialize in dermatology not only get to treat patients with a variety of ailments, but they are also heavily involved with the surgical aspects. Dermatologists rely heavily on these PAs and with their level of experience, they are some of the highest-paid professionals, making about $130,000 or more.