Postgraduate clinical training programs for physician assistants

Introduction

Employment opportunities and clinical roles for physician assistants (PAs) have rapidly expanded to include positions in a wide variety of specialty areas. Postgraduate curricula are designed to build on the knowledge and experience acquired in PA school, enabling individuals to assume roles as well-prepared PAs on specialty health care teams more rapidly than those without formal training or prior specialty experience. Many postgraduate programs have pioneered the role of PAs in these specialty areas and offer experienced role models, as well as expert clinical instruction. Although this training is optional for PAs and only a small percentage of PAs elect to participate in residency programs, they can provide PAs with an opportunity to receive formal clinical training, typically in academic medical centers, giving PAs a strong foundation in specialty practice not available as part of entry-level PA education.

The education model of physician assistant residencies

In the early days of the PA profession, a model of providing postgraduate specialty clinical training, similar to the residency model used for physician graduate medical education, was established for PAs. In 1971 the first postgraduate program to train PAs in surgical practice was established at the Montefiore Medical Center in affiliation with the Albert Einstein School of Medicine in New York. These PA residents were trained alongside physician surgical residents to expand the number of house officers. In 1975 the Norwalk Hospital and the Yale School of Medicine established a second PA surgical residency program, this one designed for PAs only. By the 1980s, several other PA residency programs were developed, providing training opportunities in a variety of specialties, including surgery, emergency medicine, and pediatrics. As time passed, other residencies were developed until programs were established in most surgical and medical specialties and in nearly every state in the United States. Although the number of residency programs have expanded over the years, the total number of PAs participating in such programs has remained low and is no more than a small percentage.

Although PA residency programs were modeled after physician residency programs, some important differences exist. First, postgraduate training is not required for PA practice, licensure, or certification. Therefore PA enrollment in residency programs has been completely optional and guided by the unique professional interests and goals of individual PAs. Next, until recent years, only a few residency programs have existed in any particular discipline and consequently a standard curriculum for each discipline has not been established. Because PA residency programs are shorter than physician residencies, PA programs cannot simply adopt a physician residency curriculum in its entirety. Instead, each PA residency program has needed to identify its own goals and objectives to guide the training of PAs to develop the clinical competencies identified by the program as relevant to PA practice within the identified specialty. Another unique difference from physician programs has been the lack of an established accreditation process (discussed in further detail later) guiding the development, implementation, and evaluation of such programs. Furthermore, although most PA residency programs have provided only a certificate of completion, as do physician residency programs, some programs have awarded academic credit and some graduates have earned academic degrees. ^, Finally, given the similar scope of practice of nurse practitioners (NPs) and PAs in many practice settings, an increasing number of PA residency programs also enroll NPs and therefore these programs represent a unique model of interprofessional education. ^, Given these important differences from physician residencies, these programs have faced unique opportunities and challenges during the nearly 50 years of their existence.

Association of postgraduate physician assistant programs

With the growth in the number of PA residency programs in the 1980s came the desire for program leaders to network with others involved in PA postgraduate education. The American Academy of Physician Assistants’ (AAPA’s) annual conferences provided this opportunity. During the AAPA Annual Meeting in May 1988, and after several years of informal meetings, a group of representatives from seven postgraduate PA residency programs established a new organization—the Association of Postgraduate Physician Assistant Programs (APPAP). Since that time, the APPAP has been the primary organization representing PA residency programs. Its primary purpose is to support established and developing PA residency programs, and it is also a source of information for PAs, PA students, and entry-level PA programs regarding postgraduate clinical education. In addition to active and provisional program membership, the APPAP allows for the individual membership of PAs and students. Individual members may participate in APPAP business meetings and serve on committees. Although program membership in APPAP is voluntary, APPAP membership data has provided the most comprehensive information to date regarding existing programs. The APPAP holds membership meetings biannually, including during the AAPA annual conference when they typically also have information sessions for those wishing to learn more about PA residency training opportunities. In addition, the APPAP has recently begun collaborating with the Association of Postgraduate Advanced Practice Registered Nurse (APRN) Programs to provide workshops in the development of advanced practice provider (APP) postgraduate training programs.

Program accreditation

Program accreditation has not been widely adopted for PA residency programs as it is for other types of educational programs, including entry-level PA programs and physician residencies. Accreditation is a process of ensuring educational institutions or programs meet established quality standards as determined by an external body and is intended to foster program improvement. Accreditation is intended to be voluntary and because residencies are not required for PA licensure, certification, or practice, there have been no significant drivers for accreditation, such as those for physician residency programs. Although interest in the accreditation of PA residency programs dates back decades, it was not until in 2006, when the Accreditation Review Commission on the Education for the Physician Assistant (ARC-PA) voted in favor of offering accreditation to qualified PA residency programs. The ARC-PA accreditation standards for PA postgraduate clinical training addressed a wide range of educational administration issues, including ensuring programs have adequate faculty and staff, funding, and patient care experiences. Programs were required to be full-time and to last at least 6 months in duration, offering in-residency clinical training and didactic instruction. The curriculum had to be reviewed by a medical review committee of experts in the discipline to determine whether program objectives could be met by the established curriculum. The first two PA residency programs were granted accreditation in March 2008, and as of 2014, only eight programs had been accredited. In August 2014, however, the ARC-PA announced that the accreditation process of residency programs would be held in abeyance and a work group would be formed to “discuss alternative methods of recognition of educational quality for Clinical Postgraduate PA Programs.” After some delays, in 2019 the ARC-PA voted to approve a revised accreditation process and set accreditation standards. At the time of this writing, it is expected that programs will be able to apply for accreditation by 2020. Because accreditation will remain optional and given the time typically required to apply for and be granted accreditation, it is unlikely that accreditation of PA residencies will be widespread in the near future.

Currently available programs

The exact number of residency programs is unknown because of the lack of a required accreditation that would ensure all programs were identified. Nevertheless, membership data from the APPAP have been valuable sources of information regarding available programs and trends in program growth. The use of APPAP membership data has important limitations because of membership being optional. Further limitations exist in the use of the APPAP membership roster as a source on information about residency programs because membership does not ensure consistency in the type of education offered and may be inclusive of programs not actively enrolling PAs. Nevertheless, the use of APPAP membership data has provided important information regarding the scope of postgraduate education and has been a means of contacting programs to request participation in survey research.

The most recent membership roster of the APPAP includes approximately 100 member programs with about half in surgical specialties and emergency medicine ( Fig. 38.1 ). It should be noted that PA residency programs in the military and in Veterans Affairs are not members of the APPAP and many other residency programs are known to exist. The authors estimate that only approximately half of all residencies are member programs of the APPAP. Therefore there are likely 200 or more programs in existence across the United States. Although there has been a rapid growth in the number of residency programs, particularly in recent years, programs typically enroll small numbers of residents, and given the concurrent growth of entry-level programs, it is likely that the percentage of PAs participating in residency programs has not substantially increased in recent years.

Historically, studies of PA residency training have primarily used the APPAP membership roster to survey programs and residents. More recently, investigators have attempted to identify non-APPAP members as well to provide more comprehensive data on programs. Nevertheless, with the lack of a comprehensive source for all programs, limitations to reported data exist. The authors’ understanding of the scope and characteristics of postgraduate programs is informed by data available from published studies along with online information, most notably from the APPAP website, as well as anecdotal information obtained from professional involvement in PA residency programs dating back to the 1990s. Therefore, while reading the following available program information, readers should consider the limitations of available data in understanding the full landscape of PA postgraduate residency programs.