Commentaries on health services research

Box 1This study of clinically active PAs and their “intent to retire” breaks new ground; yet leaves much unanswered. The title reminds readers that this relatively young profession is mature enough to consider retirement. The demographics of the surveyed PAs are a little startling compared to PA school classes, which are predominately young women. The sample was near gender parity (54% male) and the average age at graduation was 34 years. As with many workforce issues, it is tempting to compare PAs with physicians. A 2006 study by Landon and colleagues showed a strong relationship between physician job satisfaction levels and leaving practice: dissatisfied physicians were two to three times more likely to retire.1 This study had a large and nationally representative sample of physicians (n=16,581), with a prospective design and well-defined outcome measures, and could serve as a model for PA-focused research. The authors of this intriguing study express concern that recent trends toward decreasing job satisfaction by physicians may exacerbate the projected physician shortage. As the PA profession continues to mature, the issue of PA retirement should be revisited often, ideally with prospective studies that can elucidate the role of multiple factors and help identify workforce trends.2 If increased job satisfaction turns out to predict later retirement age in PAs-–as it appears to do in physicians–-and PAs continue to have high job satisfaction, perhaps PAs will continue to work into their 60s, 70s, and beyond. Commentary by Theresa E. HegemannBox 2Box 3Reading about German physicians' willingness to delegate home visits to PAs, one might get the impression that the German physician assistant profession is well established and growing. However the authors have used an incorrect name for care professionals (to whom specific tasks are sometimes delegated) as PAs: a literal translation from German into English. The potential harm for the PA profession is the loose use of professional nomenclature. This unfortunate use of the term PA is further propagated when the authors insert references of articles about US PAs to support the theoretical grounding, without knowing the content. Even though the Arzthelferin (AH) and Praxis assistentin (P.ast) are long-established German professions, and support the physician's work, they are not comparable to PAs known in the United States, Canada, Australia, the United Kingdom, and the Netherlands. These Medizinisch Fachangestellten (medical assistants) are clinical assistants and are not the medical model PAs.1 However, to confuse matters, Germany is experimenting with formally trained PAs, and training similar to that in the United States and other countries began in 2005.2 PAs in Germany are trained at the bachelor's level and perform medical tasks similar to the scope of practice of their colleagues working in other countries. Although the German PA profession is still in development, German PAs are physician-supervised providers whose tasks are delegated by physicians. The PA workforce in Germany is beginning to take root and the state of Baden Württemberg has adopted a law providing PA training that appears more like the more recognized model. Such legislation may help non-German readers to understand the new movement under way in Germany. Commentary by Luppo KuilmanBox 4The rapid growth in the number of PA educational programs coincides with reports that the PA profession is one of the most desirable careers in the country. In 2013, PA programs had at least three times more applicants than available seats. Does it matter where a student attends PA school? Cawley and Jones have identified a notable difference in tuition at PA schools housed in public versus private institutions. They also discuss the disproportionately higher number of privately-sponsored programs established in recent decades. What remains unanswered is whether the higher debt incurred at private institutions translates into lower rates of new graduates entering primary care. Despite the much-discussed anticipated need for increased primary care clinicians as health reform is implemented, PAs are practicing in primary care at historically low rates. One theory is that the increasing choice of specialty practice by PAs may be more economic than institutionally influenced. The next step in this conversation is to determine whether student debt influences specialty choice. Commentary by Keren H. Wick

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