Learning Needs of Physician Assistants

Physician assistants (PA) have rapidly become an integral component in the United States health care delivery system, including in the field of Hospital Medicine, the fastest growing medical field in the United States.1, 2 Since its induction in 1997, hospitalist providers in North America have increased by 30‐fold.3 Correlating with this, the number of PAs practicing in the field of hospital medicine has also increased greatly in recent years. According to the American Academy of Physician Assistants (AAPA) census reports, Hospital Medicine first appeared as one of the specialty choices in the 2006 census (response rate, 33% of all individuals eligible to practice as PAs) when it was selected as the primary specialty by 239 PAs (1.1% of respondents). In the 2008 report (response rate, 35%), the number grew to 421 (1.7%) PAs.2

PA training programs emphasize primary care and offer limited exposure to inpatient medicine. After PA students complete their first 12 months of training in didactic coursework that teach the basic sciences, they typically spend the next year on clinical rotations, largely rooted in outpatient care.2, 4 Upon graduation, PAs do not have to pursue postgraduate training before beginning to practice in their preferred specialty areas. Thus, a majority of PAs going into specialty areas are trained on the job. This is not an exception in the field of hospital medicine.

In recent years, despite an increase in the number of PAs in Hospital Medicine, some medical centers have chosen to phase out the use of midlevel hospitalist providers (including PAs) with the purposeful decision to not hire new midlevel providers.5 The rationale for this strategy is that there is thought to be a steep learning curve that requires much time to overcome before these providers feel comfortable across the breadth of clinical cases. Before they become experienced and confident in caring for a highly complex heterogeneous patient population, they cannot operate autonomously and are not a cost‐effective alternative to physicians. The complexities associated with practicing in this field were clarified in 2006 when the Society of Hospital Medicine identified 51 core competencies in hospital medicine.3, 6 Some hospitalist programs are willing to provide their PAs with on‐the‐job training, but many programs do not have the educational expertise or the resources to make this happen. Structured and focused postgraduate training in hospital medicine seems like a reasonable solution to prepare newly graduating PAs that are interested in pursuing hospitalist careers, but such opportunities are very limited.7

To date, there is no available information about the learning needs of PAs working in hospital medicine settings. We hypothesized that understanding the learning needs of PA hospitalists would inform the development of more effective and efficient training programs. We studied PAs with experience working in hospital medicine to (1) identify self‐perceived gaps in their skills and knowledge upon starting their hospitalist careers and (2) understand their views about optimal training for careers in hospital medicine.

METHODS

RESULTS

Sixty‐nine PAs responded (response rate, 67%). Table 1 provides demographic characteristics of the respondents. The majority of respondents were 2635 years old and had worked as hospitalists for a mean of 4.3 years.

DISCUSSION

Our survey addresses a wide range of topics related to PA hospitalists' learning needs including their experience with the Core Competencies in Hospital Medicine and their views on the benefits of PA training following graduation. Although self‐efficacy is not assessed, our study revealed that PAs who are choosing hospitalist careers have limited prior clinical experience treating many medical conditions that are managed in inpatient settings, such as sepsis syndrome. This inexperience with commonly seen clinical conditions, such as sepsis, wherein following guidelines can both reduce costs and improve outcomes, is problematic. More experience and training with such conditions would almost certainly reduce variability, improve skills, and augment confidence. These observed variations in experience in caring for conditions that often prompt admission to the hospital among PAs starting their hospitalist careers emphasizes the need to be learner‐centered when training PAs, so as to provide tailored guidance and oversight.

Only a few other empiric research articles have focused on PA hospitalists. One article described a postgraduate training program for PAs in hospital medicine that was launched in 2008. The curriculum was developed based on the Core Competencies in Hospital Medicine, and the authors explained that after 12 months of training, their first graduate functioned at the level of a PA with 4 years of experience under her belt.7 Several articles describe experiences using midlevel providers (including PAs) in general surgery, primary care medicine, cardiology, emergency medicine, critical care, pediatrics, and hospital medicine settings.5, 820 Many of these articles reported favorable results showing that using midlevel providers was either superior or just as effective in terms of cost and quality measures to physician‐only models. Many of these papers alluded to the ways in which PAs have enabled graduate medical education training programs to comply with residents' duty‐hour restrictions. A recent analysis that compared outcomes related to inpatient care provided by a hospitalist‐PA model versus a traditional resident‐based model revealed a slightly longer length of stay on the PA team but similar charges, readmission rates, and mortality.19 Yet another paper revealed that patients admitted to a residents' service, compared with the nonteaching hospitalist service that uses PAs and nurse practitioners, were different, having higher comorbidity burdens and higher acuity diagnoses.20 The authors suggested that this variance might be explained by the difference in their training, abilities, and goals of the groups. There was no research article that sought to capture the perspectives of practicing hospitalist PAs.

Our study revealed that although half of respondents became hospitalists immediately after graduating from PA school, a majority agreed that additional clinical training in inpatient settings would have been welcomed and helpful. This study's results reveal that although there is a fair amount of perceived interest in postgraduate training programs in hospital medicine, there are very few training opportunities for PAs in hospital medicine.7, 21 The American Academy of Physician Assistants, the Society of Hospital Medicine, and the American Academy of Nurse Practitioners cosponsor Adult Hospital Medicine Boot Camp for PAs and nurse practitioners annually to facilitate knowledge acquisition, but this course is truly an orientation rather than a comprehensive training program.22 Our findings suggest that more rigorous and thorough training in hospital medicine would be valued and appreciated by PA hospitalists.

Several limitations of this study should be considered. First, our survey respondents may not represent the entire spectrum of practicing PA hospitalists. However, the demographic data of 421 PAs who indicated their specialty as hospital medicine in the 2008 National Physician Assistants Census Report were not dissimilar from our informants; 65% were women, and their mean number of years in hospital medicine was 3.9 years.2 Second, our study sample was small. It was difficult to identify a national sample of hospitalist PAs, and we had to resort to a creative use of social media to find a national sample. Third, the study relied exclusively on self‐report, and since we asked about their perceived learning needs when they started working as hospitalists, recall bias cannot be excluded. However, the questions addressing attitudes and beliefs can only be ascertained from the informants themselves. That said, the input from hospitalist physicians about training needs for the PAs who they are supervising would have strengthened the reliability of the data, but this was not possible given the sampling strategy that we elected to use. Finally, our survey instrument was developed based on the Core Competencies in Hospital Medicine, which is a blueprint to develop standardized curricula for teaching hospital medicine in medical school, postgraduate training programs (ie, residency, fellowship), and continuing medical education programs. It is not clear whether the same competencies should be expected of PA hospitalists who may have different job descriptions from physician hospitalists.

In conclusion, we present the first national data on self‐perceived learning needs of PAs working in hospital medicine settings. This study collates the perceptions of PAs working in hospital medicine and highlights the fact that training in PA school does not adequately prepare them to care for hospitalized patients. Hospitalist groups may use this study's findings to coach and instruct newly hired or inexperienced hospitalist PAs, particularly until postgraduate training opportunities become more prevalent. PA schools may consider the results of this study for modifying their curricula in hopes of emphasizing the clinical content that may be most relevant for a proportion of their graduates.

Physician assistants (PA) have rapidly become an integral component in the United States health care delivery system, including in the field of Hospital Medicine, the fastest growing medical field in the United States.1, 2 Since its induction in 1997, hospitalist providers in North America have increased by 30‐fold.3 Correlating with this, the number of PAs practicing in the field of hospital medicine has also increased greatly in recent years. According to the American Academy of Physician Assistants (AAPA) census reports, Hospital Medicine first appeared as one of the specialty choices in the 2006 census (response rate, 33% of all individuals eligible to practice as PAs) when it was selected as the primary specialty by 239 PAs (1.1% of respondents). In the 2008 report (response rate, 35%), the number grew to 421 (1.7%) PAs.2

PA training programs emphasize primary care and offer limited exposure to inpatient medicine. After PA students complete their first 12 months of training in didactic coursework that teach the basic sciences, they typically spend the next year on clinical rotations, largely rooted in outpatient care.2, 4 Upon graduation, PAs do not have to pursue postgraduate training before beginning to practice in their preferred specialty areas. Thus, a majority of PAs going into specialty areas are trained on the job. This is not an exception in the field of hospital medicine.

In recent years, despite an increase in the number of PAs in Hospital Medicine, some medical centers have chosen to phase out the use of midlevel hospitalist providers (including PAs) with the purposeful decision to not hire new midlevel providers.5 The rationale for this strategy is that there is thought to be a steep learning curve that requires much time to overcome before these providers feel comfortable across the breadth of clinical cases. Before they become experienced and confident in caring for a highly complex heterogeneous patient population, they cannot operate autonomously and are not a cost‐effective alternative to physicians. The complexities associated with practicing in this field were clarified in 2006 when the Society of Hospital Medicine identified 51 core competencies in hospital medicine.3, 6 Some hospitalist programs are willing to provide their PAs with on‐the‐job training, but many programs do not have the educational expertise or the resources to make this happen. Structured and focused postgraduate training in hospital medicine seems like a reasonable solution to prepare newly graduating PAs that are interested in pursuing hospitalist careers, but such opportunities are very limited.7

To date, there is no available information about the learning needs of PAs working in hospital medicine settings. We hypothesized that understanding the learning needs of PA hospitalists would inform the development of more effective and efficient training programs. We studied PAs with experience working in hospital medicine to (1) identify self‐perceived gaps in their skills and knowledge upon starting their hospitalist careers and (2) understand their views about optimal training for careers in hospital medicine.

METHODS

RESULTS

Sixty‐nine PAs responded (response rate, 67%). Table 1 provides demographic characteristics of the respondents. The majority of respondents were 2635 years old and had worked as hospitalists for a mean of 4.3 years.

DISCUSSION

Our survey addresses a wide range of topics related to PA hospitalists' learning needs including their experience with the Core Competencies in Hospital Medicine and their views on the benefits of PA training following graduation. Although self‐efficacy is not assessed, our study revealed that PAs who are choosing hospitalist careers have limited prior clinical experience treating many medical conditions that are managed in inpatient settings, such as sepsis syndrome. This inexperience with commonly seen clinical conditions, such as sepsis, wherein following guidelines can both reduce costs and improve outcomes, is problematic. More experience and training with such conditions would almost certainly reduce variability, improve skills, and augment confidence. These observed variations in experience in caring for conditions that often prompt admission to the hospital among PAs starting their hospitalist careers emphasizes the need to be learner‐centered when training PAs, so as to provide tailored guidance and oversight.

Only a few other empiric research articles have focused on PA hospitalists. One article described a postgraduate training program for PAs in hospital medicine that was launched in 2008. The curriculum was developed based on the Core Competencies in Hospital Medicine, and the authors explained that after 12 months of training, their first graduate functioned at the level of a PA with 4 years of experience under her belt.7 Several articles describe experiences using midlevel providers (including PAs) in general surgery, primary care medicine, cardiology, emergency medicine, critical care, pediatrics, and hospital medicine settings.5, 820 Many of these articles reported favorable results showing that using midlevel providers was either superior or just as effective in terms of cost and quality measures to physician‐only models. Many of these papers alluded to the ways in which PAs have enabled graduate medical education training programs to comply with residents' duty‐hour restrictions. A recent analysis that compared outcomes related to inpatient care provided by a hospitalist‐PA model versus a traditional resident‐based model revealed a slightly longer length of stay on the PA team but similar charges, readmission rates, and mortality.19 Yet another paper revealed that patients admitted to a residents' service, compared with the nonteaching hospitalist service that uses PAs and nurse practitioners, were different, having higher comorbidity burdens and higher acuity diagnoses.20 The authors suggested that this variance might be explained by the difference in their training, abilities, and goals of the groups. There was no research article that sought to capture the perspectives of practicing hospitalist PAs.

Our study revealed that although half of respondents became hospitalists immediately after graduating from PA school, a majority agreed that additional clinical training in inpatient settings would have been welcomed and helpful. This study's results reveal that although there is a fair amount of perceived interest in postgraduate training programs in hospital medicine, there are very few training opportunities for PAs in hospital medicine.7, 21 The American Academy of Physician Assistants, the Society of Hospital Medicine, and the American Academy of Nurse Practitioners cosponsor Adult Hospital Medicine Boot Camp for PAs and nurse practitioners annually to facilitate knowledge acquisition, but this course is truly an orientation rather than a comprehensive training program.22 Our findings suggest that more rigorous and thorough training in hospital medicine would be valued and appreciated by PA hospitalists.

Several limitations of this study should be considered. First, our survey respondents may not represent the entire spectrum of practicing PA hospitalists. However, the demographic data of 421 PAs who indicated their specialty as hospital medicine in the 2008 National Physician Assistants Census Report were not dissimilar from our informants; 65% were women, and their mean number of years in hospital medicine was 3.9 years.2 Second, our study sample was small. It was difficult to identify a national sample of hospitalist PAs, and we had to resort to a creative use of social media to find a national sample. Third, the study relied exclusively on self‐report, and since we asked about their perceived learning needs when they started working as hospitalists, recall bias cannot be excluded. However, the questions addressing attitudes and beliefs can only be ascertained from the informants themselves. That said, the input from hospitalist physicians about training needs for the PAs who they are supervising would have strengthened the reliability of the data, but this was not possible given the sampling strategy that we elected to use. Finally, our survey instrument was developed based on the Core Competencies in Hospital Medicine, which is a blueprint to develop standardized curricula for teaching hospital medicine in medical school, postgraduate training programs (ie, residency, fellowship), and continuing medical education programs. It is not clear whether the same competencies should be expected of PA hospitalists who may have different job descriptions from physician hospitalists.

In conclusion, we present the first national data on self‐perceived learning needs of PAs working in hospital medicine settings. This study collates the perceptions of PAs working in hospital medicine and highlights the fact that training in PA school does not adequately prepare them to care for hospitalized patients. Hospitalist groups may use this study's findings to coach and instruct newly hired or inexperienced hospitalist PAs, particularly until postgraduate training opportunities become more prevalent. PA schools may consider the results of this study for modifying their curricula in hopes of emphasizing the clinical content that may be most relevant for a proportion of their graduates.

Physician assistants (PA) have rapidly become an integral component in the United States health care delivery system, including in the field of Hospital Medicine, the fastest growing medical field in the United States.1, 2 Since its induction in 1997, hospitalist providers in North America have increased by 30‐fold.3 Correlating with this, the number of PAs practicing in the field of hospital medicine has also increased greatly in recent years. According to the American Academy of Physician Assistants (AAPA) census reports, Hospital Medicine first appeared as one of the specialty choices in the 2006 census (response rate, 33% of all individuals eligible to practice as PAs) when it was selected as the primary specialty by 239 PAs (1.1% of respondents). In the 2008 report (response rate, 35%), the number grew to 421 (1.7%) PAs.2

PA training programs emphasize primary care and offer limited exposure to inpatient medicine. After PA students complete their first 12 months of training in didactic coursework that teach the basic sciences, they typically spend the next year on clinical rotations, largely rooted in outpatient care.2, 4 Upon graduation, PAs do not have to pursue postgraduate training before beginning to practice in their preferred specialty areas. Thus, a majority of PAs going into specialty areas are trained on the job. This is not an exception in the field of hospital medicine.

In recent years, despite an increase in the number of PAs in Hospital Medicine, some medical centers have chosen to phase out the use of midlevel hospitalist providers (including PAs) with the purposeful decision to not hire new midlevel providers.5 The rationale for this strategy is that there is thought to be a steep learning curve that requires much time to overcome before these providers feel comfortable across the breadth of clinical cases. Before they become experienced and confident in caring for a highly complex heterogeneous patient population, they cannot operate autonomously and are not a cost‐effective alternative to physicians. The complexities associated with practicing in this field were clarified in 2006 when the Society of Hospital Medicine identified 51 core competencies in hospital medicine.3, 6 Some hospitalist programs are willing to provide their PAs with on‐the‐job training, but many programs do not have the educational expertise or the resources to make this happen. Structured and focused postgraduate training in hospital medicine seems like a reasonable solution to prepare newly graduating PAs that are interested in pursuing hospitalist careers, but such opportunities are very limited.7

To date, there is no available information about the learning needs of PAs working in hospital medicine settings. We hypothesized that understanding the learning needs of PA hospitalists would inform the development of more effective and efficient training programs. We studied PAs with experience working in hospital medicine to (1) identify self‐perceived gaps in their skills and knowledge upon starting their hospitalist careers and (2) understand their views about optimal training for careers in hospital medicine.

METHODS

RESULTS

Sixty‐nine PAs responded (response rate, 67%). Table 1 provides demographic characteristics of the respondents. The majority of respondents were 2635 years old and had worked as hospitalists for a mean of 4.3 years.

DISCUSSION

Our survey addresses a wide range of topics related to PA hospitalists' learning needs including their experience with the Core Competencies in Hospital Medicine and their views on the benefits of PA training following graduation. Although self‐efficacy is not assessed, our study revealed that PAs who are choosing hospitalist careers have limited prior clinical experience treating many medical conditions that are managed in inpatient settings, such as sepsis syndrome. This inexperience with commonly seen clinical conditions, such as sepsis, wherein following guidelines can both reduce costs and improve outcomes, is problematic. More experience and training with such conditions would almost certainly reduce variability, improve skills, and augment confidence. These observed variations in experience in caring for conditions that often prompt admission to the hospital among PAs starting their hospitalist careers emphasizes the need to be learner‐centered when training PAs, so as to provide tailored guidance and oversight.

Only a few other empiric research articles have focused on PA hospitalists. One article described a postgraduate training program for PAs in hospital medicine that was launched in 2008. The curriculum was developed based on the Core Competencies in Hospital Medicine, and the authors explained that after 12 months of training, their first graduate functioned at the level of a PA with 4 years of experience under her belt.7 Several articles describe experiences using midlevel providers (including PAs) in general surgery, primary care medicine, cardiology, emergency medicine, critical care, pediatrics, and hospital medicine settings.5, 820 Many of these articles reported favorable results showing that using midlevel providers was either superior or just as effective in terms of cost and quality measures to physician‐only models. Many of these papers alluded to the ways in which PAs have enabled graduate medical education training programs to comply with residents' duty‐hour restrictions. A recent analysis that compared outcomes related to inpatient care provided by a hospitalist‐PA model versus a traditional resident‐based model revealed a slightly longer length of stay on the PA team but similar charges, readmission rates, and mortality.19 Yet another paper revealed that patients admitted to a residents' service, compared with the nonteaching hospitalist service that uses PAs and nurse practitioners, were different, having higher comorbidity burdens and higher acuity diagnoses.20 The authors suggested that this variance might be explained by the difference in their training, abilities, and goals of the groups. There was no research article that sought to capture the perspectives of practicing hospitalist PAs.

Our study revealed that although half of respondents became hospitalists immediately after graduating from PA school, a majority agreed that additional clinical training in inpatient settings would have been welcomed and helpful. This study's results reveal that although there is a fair amount of perceived interest in postgraduate training programs in hospital medicine, there are very few training opportunities for PAs in hospital medicine.7, 21 The American Academy of Physician Assistants, the Society of Hospital Medicine, and the American Academy of Nurse Practitioners cosponsor Adult Hospital Medicine Boot Camp for PAs and nurse practitioners annually to facilitate knowledge acquisition, but this course is truly an orientation rather than a comprehensive training program.22 Our findings suggest that more rigorous and thorough training in hospital medicine would be valued and appreciated by PA hospitalists.

Several limitations of this study should be considered. First, our survey respondents may not represent the entire spectrum of practicing PA hospitalists. However, the demographic data of 421 PAs who indicated their specialty as hospital medicine in the 2008 National Physician Assistants Census Report were not dissimilar from our informants; 65% were women, and their mean number of years in hospital medicine was 3.9 years.2 Second, our study sample was small. It was difficult to identify a national sample of hospitalist PAs, and we had to resort to a creative use of social media to find a national sample. Third, the study relied exclusively on self‐report, and since we asked about their perceived learning needs when they started working as hospitalists, recall bias cannot be excluded. However, the questions addressing attitudes and beliefs can only be ascertained from the informants themselves. That said, the input from hospitalist physicians about training needs for the PAs who they are supervising would have strengthened the reliability of the data, but this was not possible given the sampling strategy that we elected to use. Finally, our survey instrument was developed based on the Core Competencies in Hospital Medicine, which is a blueprint to develop standardized curricula for teaching hospital medicine in medical school, postgraduate training programs (ie, residency, fellowship), and continuing medical education programs. It is not clear whether the same competencies should be expected of PA hospitalists who may have different job descriptions from physician hospitalists.

In conclusion, we present the first national data on self‐perceived learning needs of PAs working in hospital medicine settings. This study collates the perceptions of PAs working in hospital medicine and highlights the fact that training in PA school does not adequately prepare them to care for hospitalized patients. Hospitalist groups may use this study's findings to coach and instruct newly hired or inexperienced hospitalist PAs, particularly until postgraduate training opportunities become more prevalent. PA schools may consider the results of this study for modifying their curricula in hopes of emphasizing the clinical content that may be most relevant for a proportion of their graduates.