In total 72 PA postgraduate programs directors were sent a set of questions along with an introduction for participation. Thirty-four program directors (47% rate of return), responded to the survey questions. On several occasions, the respondent opted to skip a question and the (per question response rates varied between 20 and 100%). Additionally, the survey also included several open-ended questions, which provided respondents the opportunity to give additional feedback. The 34 postgraduate programs are spread across the US in 13 states. Most programs are associated with an academic medical center. Because some directors oversee more than one specialty track within an institution, the total number of postgraduate programs represented in the answers varied.
The majority (82%) of the 34 respondents represent a single-track program, meaning they provide postgraduate training in one discipline such as orthopaedics; 18% are multi-track programs. The disciplines most represented are surgical (39%), Emergency Medicine (33%), Critical Care (30%), and Orthopaedics (24%). (Fig. 1).
All represented postgraduate programs are focused on the education of PAs, and 12 (35%) include nurse practitioners (NPs). The duration of most postgraduate PA education is 12 months (79%), with two at 18 months, and one two-year program. All award a certificate of completion. Some programs include research and award a postgraduate degree [12]. A majority (89%) of 33 responses reported PA fellows received education alongside physician residents in the same specialty.
The techniques used by postgraduate programs in PA role development varies. The most common education delivery methods are case studies, bedside clinical teaching, in-person didactics, specialty rotations, grand rounds, online learning modules, simulation, and journal clubs (Fig. 2).
Beyond a focus on the education about the particular medical or surgical specialty involved, the program incorporates a wide variety of skill development activities such as procedure training, professionalism and emotional intelligence, roles in team-based care, and interpersonal communication. (Fig. 3) Nearly all programs provide continuing medical education credits for maintenance of national certification and state licensure. Programs identified using electronic systems to deliver education (91%). All PAs must be licensed in the state where employed.
Evaluations and assessments of PA fellows incorporate various methods. The more common techniques are one-on-one observations by a mentor or preceptor, instructor evaluations, through regular reviews with the program director or supervising (e.g., attending) physician, completion of program requirements, and achieving clinical milestones (Fig. 4).
Institutional affiliation
Administratively half (55%) of PA postgraduate programs reside in medical schools, with (40%) in health science colleges, and one (5%) in a nursing school. Three-quarters (76%) of the hospitals that sponsor PA postgraduate programs are affiliated with an academic medical center. The others are vertically integrated multi-hospital systems such as The Mayo Clinic (located in three states) (15%), community hospitals (6%), and one in an ambulatory clinic. Nearly all PA postgraduate programs (94%) credentialed and privileged the PA fellows similarly to other PAs and NPs in the organization. Almost all PA postgraduate programs (97%) award a certification of completion or a diploma (3%). The combined Army/Air Force – Baylor University program awards a Doctor of Science (DSc) for active-duty members and Arrowhead Orthopedics, in collaboration with University of Lynchburg, offers a Doctor of Medical Science (DMSc) track [12].
Nomenclature
PAs in postgraduate training are referred to as “Fellows” (59%) or “Residents” (41%). One respondent commented, “We refer to them as fellows, but our program is HRSA grant-funded which is NP only and requires the name resident.”
Applicant pool
Most programs (88%) draw on a national applicant pool with the remainder relying on regional or local applicants. All PAs accepted into a program are graduates of an accredited program and all are nationally certified by the National Commission on the Certification of Physician Assistants (NCCPA). Entry into a postgraduate PA program most commonly occurs within 2 years of graduation.
Employment of PA postgraduate graduates
Upon graduation from a postgraduate training program, the respondents reported that (96%) were employed within 2 months. When asked about the employment opportunity for graduates from the postgraduate programs, and (78%) reported the demand was “high.”
Administration
The majority of postgraduate programs (90%) reported that the chief administrator was a PA. One PA reported being a full-time administrator of multiple tracks, with the remainder varying from 4 h to 20 h a week of single-track programs (63%). Most (80%) of the PA administrators reported 5 years or more of clinical experience before assuming the program director role. In addition, a medical director was assigned to all PA postgraduate programs. The role of the medical director serves as the main medical supervisor of the PA fellow with involvement in educational assessment and program advocacy. The majority (76%) of physician medical directors are not allocated additional administrative time outside their clinical responsibilities. In most cases, physician supervision is a requirement of PA state licensure. A majority of programs have administrative support. Programs differed administratively by clinical department (38%), office of Graduate Medical Education (29%), office of ‘advanced practice’ (13%), medical group (13%), or other (7%). Figure 5.
Organizational costs associated with the PA postgraduate programs
The majority of costs associated with the PA postgraduate education were derived from the medical group (42%) or the hospital system (46%) with the remainder from graduate medical education or a private donor (12%). Also, 90% postgraduate programs reported that they do no pay an honorarium or stipend to clinical faculty to supervise postgraduate APP trainees in the clinical setting. Lastly, administrative costs to keep the program operational were not studied.
Billing for PA postgraduate trainee services
PAs enrolled in postgraduate education are NCCPA-certified, licensed in the state where the program resides, and eligible for billing of their services. Billing is done by the hospital, medical group, or academic medical center and most (79%) reported billing for services provided by the PA fellow. Additionally, four program directors said they intended to begin billing for services rendered by their PAs. It should be noted that not all PA postgraduate programs bill for first assist services. Billing for these services typically requires an attestation from the surgeon that no qualified medical resident is available to assist with eligible operative cases. Medicare reimbursement for a PA/NP assisting in surgery is 13.6% of the primary surgeon’s allowable fee and some surgeries are ‘restricted’ from reimbursement.
PA postgraduate trainee compensation and benefits
All programs provide a stipend for the PA fellow. The amount varied between $50,000–80,000 (2019 dollars). Omitted were the wages for federal employees (e.g., military and VHA) which are government scheduled and at a higher rate than civilian stipends. Employment benefits (not reported) include paid time off (2–4 weeks), health insurance, CME, liability insurance, and clothing/uniforms.
ARC-PA accreditation
Accreditation of PA postgraduate programs has been evolving in various forms since 2010 but the process was put in “abeyance” in 2014. One reason for suspension was that not all programs participated in accreditation, and none were bound by the accreditation process. The following survey question was about an accreditation process. “If ARC-PA accreditation becomes available for your program will you pursue it?” Two-thirds (67%) said they would decline. Another two-thirds (68%) said they had discussed ARC-PA accreditation funding with their institution. The main reason for declining accreditation was cost (48%), as well as lack of support (18%), and other (joint PA/NP program or cost of multi-track programs). A plurality (37%) would be interested in applying for joint accreditation (not yet available) if it included NPs.
Including nurse practitioners in APPAP (selected comment)
“There is an undeniable need for a JOINT accreditation process … as more programs are accepting NP and PA applicants.”
Value of postgraduate programs at sponsoring institutions
To probe the reasons why programs have developed and remain operational, a series of questions were asked. Almost all agreed that recruitment and retention of postgraduate trainees are part of meeting workforce demands (83%), and retention of career staff (55%). Most program directors (76%) believed their program improved decision making and autonomy of PAs/NPs in the clinical setting. Additionally, (93%) of respondents believed their postgraduate program fostered interprofessional collaboration. Lastly, (34%) of respondents felt their postgraduate training program improved compliance with physician resident regulated work hours.