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A topic of increasing interest and importance in the PA profession is the trend of specialization. In a health profession that once comprised mostly generalist clinicians, and for several decades was roughly evenly balanced between primary care providers and specialists, the trend has now gradually shifted to a majority of PAs in specialties. This trend brings with it good and bad aspects for the PA profession. It is worth exploring a few of the implications of these trends as they affect PAs.
In an historic sense, specialization in medicine would appear to be an inexorable phenomenon. Medical specialization emerged in 19th century as a result of expanding medical knowledge and the notion that patients could be best managed through grouping patients, providers and diseases into specific categories.1 Specialization was influenced by factors such as disease prevalence, advances in medical knowledge and the use of technology, and it became well established throughout the 20th century as more and more groups of physicians formed specialty societies and formal certification processes.
Among the first of these was ophthalmology, emerging in 1916.2 Later, between 1974 and 1992, 28 new specialties and subspecialties came to be recognized by the Accreditation Council for Graduate Medical Education. Today ACGME recognizes 26 physician specialties and 84 subspecialties.3 The point here is that specialization is a compelling force in medicine and medical practice, and it is not at all surprising that the PA profession has been influenced by this movement.
PAs and Specialization
Within the PA profession, specialization began at an early stage marked by the founding of specialty-focused educational programs in pediatrics and surgery in the late 1960s and the establishment of a surgical postgraduate program in 1972. For many years, largely due to the influence of federal funding dollars, the direction of the profession took a marked turn toward primary care, and in the late 1970s a majority of PAs worked in family medicine. But as the profession evolved and grew in the 1980s and 1990s, specialization increased as increasing numbers of PAs entered specialty practices. This in turn led to the formation of an increasing number of specific specialty and subspecialty societies within the AAPA and increasing numbers of postgraduate educational programs.
These trends have continued, and as the number of PAs in specialties has increased, the numbers in primary care have consequently declined. A majority of practicing PAs are now in specialties. According to the 2004 AAPA census, the percentage of PAs working in primary care specialties has fallen to the lowest levels recorded in the past several decades. Only 40.8% of the nation's 55,000-plus PAs in active clinical practice work in the areas of family medicine (29.5%), general internal medicine (7.8%), or general pediatrics (2.5%); less than a third of all new PA graduates now enter primary care fields. This is in contrast to the fact that nearly a quarter (23.9%) of PAs work in surgery and the surgical subspecialties and almost 10% work in emergency medicine.4
As Physicians Go, So Go PAs
The decline in interest of PAs in primary care practice parallels that of physicians, whose numbers in primary care also have been falling. Fewer medical school graduates are selecting residencies in the primary care specialties, and physicians worry aloud that in the future primary care will be lost to other types of providers.
For the PA profession, the decline in the percentage in primary care runs counter to long-held traditions and priorities for PAs to serve in generalist practice and in medically underserved communities. It is difficult for PA educational programs to maintain an emphasis on primary care practice for PAs when the economic and market forces pull increasing numbers of graduates to specialties.
Organizationally, specialization within the PA profession has, as would be expected, spurred the founding of a number of specialty and subspecialty organizations, most of which are still closely aligned with the AAPA. The challenge is to retain these groups under the big tent of the academy, since many of these specialty groups hold their own meetings and CME programs and possibly even have their own certification structure.
PA Postgraduate Accreditation
A flashpoint for the debate related to specialization is the recent discussion of the accreditation of PA postgraduate programs, so-called PA residencies. Specialty groups within the academy support the notion that PA postgraduate programs should develop a formal accreditation process. The AAPA has opposed the accreditation of postgraduate PA programs, primarily on the basis that such a step would give status to such education and lead to circumstances where specialty certification would be the norm and thus become a requirement for employment, practice, licensure and reimbursement.5
Central to the AAPA's argument against accreditation of postgraduate programs is that such a move could limit a cherished aspect of PA practice, that being the capability to move into and out of different practice specialties. PA career flexibility is a major advantage for many in the profession, and the academy is acting in what it believes is the best interest of the profession to protect that set of options. In doing so, however, it encounters the increasing forces of professional specialization that universally continue to affect modern medical practice.
A key question for the future will be whether the PA profession can maintain a balance between primary care and specialty practice, and manage the consequent influences that specialization brings to organizational and educational structures.
James F. Cawley is director of the PA/MPH program and professor and vice chair of the Department of Prevention and Community Health, School of Public Health and Health Services at The George Washington University in Washington. He also is professor of health care sciences at the university's School of Medicine and Health Science.
References
1. Weisz G. The emergence of medical specialization in the nineteenth century. Bull Hist Med. 2003;77:536-575.
2. Ludmerer KM. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. New York, NY: Oxford University Press; 1999.
3. Accreditation Council for Graduate Medical Education. Available at: http://www.acgme.org/acWebsite/newsRoom/newsRm_acGlance.asp. Accessed September 14, 2005.
4. American Academy of Physician Assistants. 2004 AAPA Physician Assistant Census Report. Available at: http://www.aapa.org/research/04census-intro.html. Accessed September 14, 2005.
5. American Academy of Physician Assistants. Maintaining professional flexibility: the case against accrediting physician assistant postgraduate programs. JAAPA. 2005;18(8):14-16.
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