Federally employed physician assistants

MILITARY MEDICINE, 173, 9:895, 2008

Federally Employed Physician Assistants Roderick S. Hooker, PhD PA ABSTRACT The federal government is the largest single employer of clinically active physician assistants (PAs) in the United States, with ⬎3,000 PAs in 2008. PAs are present within the Departments of Defense, Veterans Affairs, Health and Human Services, Justice, and Homeland Security. Most are civil servants or hold a commission in the uniformed services. Most employing agencies have expanding needs for PAs. This overview presents a framework of how PAs are being used and the critical roles they play in the federal health care system. Because civilian job opportunities for PAs are plentiful, the federal system is seeking strategies for recruitment and retention. A centralized plan may be one useful recommendation.

INTRODUCTION The U.S. government is the largest employer of physician assistants (PAs). Understanding the federal system of health care and its role as utilizer is important for historians and policy makers. Within the federal system, many agencies are grappling with mounting demands for health care access. Health workforce shortages are nearly universal problems, and many solutions have been proposed or are pending; PAs provide one strategy. Outside the United States, various governments are interested in how four decades of experience have produced adaptable providers of medical care.1 Because information about the role or number of federally employed PAs does not reside in any one location, a systematic approach to identifying PAs in the U.S. government was undertaken. The intent was to be descriptive and to serve as a foundation to document four decades of medical deployment and experience. Because data on the utility, competence, and roles of PAs (as well as advanced practice nurses) reside in a large body of publications, that discussion is considered beyond the scope of this article. One common denominator is that all PAs are dependent practitioners and must maintain a relationship with a supervising physician. A review of the literature and the annual census by the American Academy of Physician Assistants were probed for information on government PAs. Because a federal registry of health care workers is not available, communication with senior leaders in various departments and branches of the federal government was also undertaken, to create a data set on federally employed PAs. RESULTS As of 2008, there were ⬃65,000 PAs in clinical practice; ⬎3,000 have a professional relationship with the U.S. government.2 They serve in the armed forces, Department of Veterans Affairs (VA), U.S. Public Health Service (USPHS), Department of Veterans Affairs, Medical Services, Dallas, TX 75216-7191. This manuscript was received for review in November 2007. The revised manuscript was accepted for publication in May 2008. Reprint & Copyright © by Association of Military Surgeons of U.S., 2008.

and many federal agencies. Most federal PAs provide primary care services and work in positions previously occupied by physicians. Exact numbers are difficult to determine, because many agencies and branches of the government, including the military, are constantly recruiting PAs for health care roles among uniform, civilian, and contract jobs. The largest concentrations of PAs are in the Department of Defense (DoD) (military) and the VA (civilian) (Table I). DEPARTMENT OF DEFENSE Military Approximately 1,500,000 uniformed personnel are on active duty, with an additional 1,260,000 personnel in seven reserve/National Guard components; all are under the DoD. A large cadre of personnel is needed for domestic medical management, and this need increases in theater. Consequently, the military must remain in a constant state of recruitment and training of PAs. As of 2008, ⬃1,300 PAs serve on land or sea or in the air, with many in special hardship situations. In addition, ⬎400 civilian PAs serve in the Ready Reserves and National Guard in 50 states and four territories.3 The majority of uniformed PAs started as medics and hospital corpsmen and received their training in the military. At one time, typical military PAs were male, trained at an older age than their civilian counterparts, and assigned a primary care role. In the new millennium, the female:male PA ratio is closer to 1:5 and the roles are more diverse. PAs were introduced in the Army, Navy, and Air Force in 1971 and in the Coast Guard in 1975; initially, all were noncommissioned officers, usually with senior enlisted rank.4 –7 Their numbers swelled throughout the 1970s, and most PAs were promoted to warrant officers as a career ascension strategy.8 In the 1990s, all services commissioned their PAs.5 The primary reason the use of PAs took hold in the military was largely because of termination of the draft for physicians.9 After the removal of obligated service for physicians (and after the abolishment of the draft for military duty), those with little time invested tended to leave. The

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Federal PAs TABLE I.

U.S. Federally Employed PAs in 2008 No. of PAs Branch

DoD U.S. Air Force Active duty Reserve Air National Guard U.S. Army Active duty Reserve National Guard U.S. Navy (including Marine Corps) Active duty Reserve Department of Homeland Security U.S. Coast Guard Active duty Reserve Immigration and Naturalization Service Immigration Health Service Department of Transportation Federal Aviation Administration National Oceanic and Atmospheric Administration Department of Justice Bureau of Prisons Federal Bureau of Investigations Department of Health and Human Services USPHS Indian Health Service Food and Drug Administration Centers for Disease Control and Prevention Federal Occupational Health National Institutes of Health Health Resources and Services Administration NHSC Department of State Peace Corps VA VHA Other agencies Smithsonian Institution Central Intelligence Agency

Active Duty

Billetsa

270 30 24

298 60 20

610 180 350

754 286 831

235 44

275 80

42 10 30

60 18 40

2 3

2 3

60 8

NA NA

140 25 2 1

NA NA NA NA

4 6 2

NA NA NA

36

40

30

NA

1,680

NA

2 4

NA NA

Data were derived from various personal sources in the different agencies and branches in 2008. The numbers are likely to be different at the time of printing. NA, data are not available or do not exist. a A billet means an available position, although all are subject to change.

unplanned departure of more junior physicians than expected created a deficit of general medical officers and more difficulty recruiting them, largely because of the expanding feefor-service marketplace and substantial economic opportunities in civilian roles. With a shortage of medical officers, the military turned to PAs to fill the gap.10 The integral role of combat-ready troops in the Army, Navy, Air Force, Marine Corps, and Coast Guard has enhanced PAs in a number of ways, from deployment in various theaters to policy-making roles. After 35 years, senior PAs

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are colonels in the Air Force and Army and captains in the Navy and Coast Guard. These services tend to share guidelines regarding qualifications, ranks, and promotions, standardizing to some extent the salaries and job descriptions. Domestic options for military PAs include reserve and National Guard units, which are available for mobilization in times of disasters such as floods, tornadoes, hurricanes, and wildfires, as well as combat overseas. For example, many reservist PAs were called up after the September 2001 terrorist attack on the World Trade Center in New York City and the Hurricane Katrina disaster in New Orleans in 2005. PAs in reserve and National Guard units may be assigned to special duties in medical units, prisoner of war units, harbor defense, port security, and training. Air Force The Air Force has ⬃270 PAs on active duty as members of the Biological Sciences Corps, serving principally in primary care clinics. In addition, there are PAs in the Air Force Reserve and the Air National Guard. Some Air Force PAs are specialized in orthopedics, head and neck surgery, emergency medicine, bone marrow transplantation/oncology, and cardiac perfusion. Army Approximately 610 active duty PAs, 350 National Guard PAs, and 180 PAs in the Army Reserve are part of the Medical Specialist Corps and holds the largest contingent of uniformed PAs. From 2004 to 2006, the number of PAs in the Army doubled because of the wars in Iraq and Afghanistan; this number continues to grow as more battalions are formed. Approximately 1,140 PAs serve in Army/National Guard/reserve role, one-third less than the 1,871 total billets available. Army PAs are in the field with operational forces, as well as in primary care settings.11 In addition, Army PAs have opportunities to specialize in occupational medicine, aviation medicine, orthopedic surgery, emergency medicine, cardiac perfusion training, and other specialties.12 In the field, advanced trauma teams may be overseen by a PA, a sergeant medic, and two junior medics.13 Eighty percent of Army PAs are in maneuver units at the division level, such as in the demilitarized zone between North Korea and South Korea, or in acute care settings, surgical units, or hospital units, such as in Iraq or Afghanistan. In garrison, the battalion medical officer may be a PA instead of a physician. To meet the demand for medical personnel in the new century, Army PAs tend to relocate and to deploy frequently. When Army medical units are sent to war-torn areas, they are there not only to care for their own troops but also to provide medical assistance in villages and to set up clinics to assist the citizens. In Bosnia, Iraq, and Afghanistan, they provide civilian health care to refugees. Navy Approximately 180 active duty and 80 reserve Navy PAs are part of the Navy Medical Services Corps. They are used in

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Federal PAs

diverse positions that include shore and overseas hospitals and clinics at home and in foreign lands. Some operational billets are available for deep-water vessels such as carriers and cruisers, but most PAs are attached to medical centers and shore stations. Navy PAs are deployed with Marine Corps units around the world and undergo additional training in field medicine. In the Iraq and Afghanistan theaters, they were deployed in surgical roles. The majority of Navy PAs are graduates of the interservice program, but some PAs are directly recruited from the civilian sector. Scholarships for students in civilian PA programs produce some PAs with obligated service. Coast Guard Because the Coast Guard can be transferred to the Navy in times of war, it is included in the DoD section. However, the Coast Guard resides in the Department of Homeland Security, rather than the DoD. PAs operate domestically more than overseas, some at independent duty stations.14 They serve on large ice breakers when deployed to the polar regions and on cutters when positioned outside U.S. waters. There are 42 PAs on active duty, 18 PAs in the Coast Guard Reserve, and 24 contract civilian PAs. The USPHS supplies some PAs to the Coast Guard, but most PAs are former enlisted personnel trained through the interservice PA program. Approximately one-half of the medical staff members in the Coast Guard are PAs, and the rest are physicians.15 Because there is no specialty corps in the Coast Guard, PAs are line officers and must compete with operational line officers for promotion.15 This is in contrast to the promotion process for USPHS commissioned corps physicians, PAs, and nurse practitioners. Interservice PA Education Education for military PAs is through the tri-service PA program at the U.S. Army Academy of Health Sciences in San Antonio, Texas. Known as the interservice PA program, this is the largest PA classroom in the world. More than 200 students are enrolled annually, drawing from four services (including the reserves). This program represents a substantial investment in PA education, and the value is that most continue their careers as PAs once they graduate.16 NONMILITARY FEDERAL AGENCIES Numerous agencies within the federal government use medical personnel. The following sections list some of the main agencies utilizing PAs. VA One of the principal employers of PAs is the VA, more specifically, the Veterans Healthcare Administration (VHA). From the very beginning of the PA profession, the VA saw PAs as potentially useful workers; in 1968, the VA was the first government agency to employ a PA.17 The VA also plays a supporting role in education. For example, the VA Medical

Center in Durham, North Carolina, has provided clinical education sites dating back to the first PA students at Duke University in the 1960s. The St. Louis University PA program was initially funded by the VA in 1971. In 1972, the VA standardized the role of PAs, defined the areas of the hospital in which PAs could be used, and specified the type and level of tasks assigned to them.17 This seems to have opened the door for PAs; ⬎1,680 PAs work in 130 VA locations.18 The VHA system is the largest medical care system in the United States and includes 172 hospitals, 68 satellite outpatient units, and 127 nursing homes. When community-based outpatient clinics are included, there are ⬎1,330 VA facilities available for veterans.19 Contract physicians and PAs staffing community-based outpatient clinics represent another level of personnel outside this federal health worker count. Despite high demand across all VA facilities, the PA presence is mixed, with each center determining the rate of PA use. Between 2000 and 2008, the number of PAs increased from 1,100 to ⬎1,600 and the pay grades of PAs within the VHA overall were adjusted upward. No policy or analysis regarding the ideal PA:beneficiary ratio has been developed. A senior VA PA reports to the undersecretary of the VA.

Department of Health and Human Services The USPHS has 11 operating divisions in the U.S. Department of Health and Human Services; ⬎6,000 personnel are uniformed commissioned officers. As of 2008, there are 136 PAs in the USPHS, filling clinical and administrative positions; two PAs in the USPHS hold the rank of rear admiral.20 Roles for PAs are expanding because of community health initiatives, and the Department of Homeland Security may deploy them for disasters. The National Health Service Corps (NHSC) is part of the Department of Health and Human Services, a division of the Health Resources and Services Administration Bureau of Health Professions. The NHSC has professionals in ⬎500 areas (both urban and rural) that have critical shortages of primary health care providers. The Health Resources and Services Administration Bureau of Primary Health Care administers the NHSC. Approximately 20 PA students qualify for scholarships each year.21 Recruitment funds support programs that offer financial help for PAs and other medical care professionals in exchange for obligated service. These include scholarships, the Federal Loan Repayment Program, the NHSC State Loan Repayment Program, and the Commissioned Officer Student Extern Program. Agencies within the U.S. Department of Health and Human Services that employ PAs include the Centers for Disease Control and Prevention, National Institutes of Health, Food and Drug Administration, Federal Occupational Health, and Indian Health Service.

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Federal PAs

Other Federal Agencies The following federal agencies employ PAs in various capacities and at various levels of care (Table I): National Oceanic and Atmospheric Administration, Federal Aviation Administration, Federal Bureau of Prisons, Federal Bureau of Investigation, Peace Corps, Immigration and Naturalization Service, Smithsonian Institution, and Central Intelligence Agency. DISCUSSION The federal government remains the largest single employer of PAs, with ⬎3,000 in 18 agencies. As of 2008, the recruitment of PAs in various agencies is growing. Despite this growth, there is no central body that directly recruits PAs for federal service and no PA works in the Health Resources and Services Administration Bureau of Health Professions. All military branches of the DOD, as well as federal agencies such as the VHA, Indian Health Service, and Bureau of Prisons, have recruitment strategies to ensure an adequate number of PAs to care for their members or to fulfill their missions. However, this work is uncoordinated from one agency to another and even within agencies. The military, with its broad-based missions on diverse fronts, requires more medical services in theater than when concentrated stateside. The VHA has been hiring more medical staff members, including PAs, to meet its obligations to beneficiaries. In the aggregate, federal agencies have doubled their PA numbers since 1999. A number of social factors are pressuring the federal government to employ more health workers, including PAs. These factors include population growth, increasing numbers of elderly individuals, sustainability of chronic diseases, and innovative technology. A chief factor driving the employment of PAs is their availability and labor costs, compared with physicians.22 Because PAs are able to improve access to care and are adaptable for a diversity of roles, their utility appears to be sought. However, debates about overutilization and overextension of medical services through employment of PAs have not been seriously undertaken since the 1990s (when they failed to reach any consensus). As the literature on PA deployment has grown, significant debates about the utilization of PAs waxed in the 1990s and have waned in the new century.23–25 Some observers think that the 141 PA programs that graduate 5,500 PAs annually cannot compete with the demand of domestic employers.26 –28 The private sector is offering salaries higher than those the government offers. Embedded in this market activity is the need to meet the demands of a society that is aging, growing, and technologically sophisticated. It is also a society that seems to be facing a physician shortage.29 Although medical school output is predicted to grow from 1,600 in 2000 to 19,500 by 2020, some argue that this is not likely to be adequate to meet the growing demands of the U.S. population.27 Also, it does not appear that the immigration of internationally trained physicians will be as available as it

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once was.30 The world is facing a physician shortage that exceeds 4.5 million and is growing.31 Available overseastrained physician immigration policies may be changing.32 There may be problems with the supply side of the PA equation as well. PAs who are younger and female are making lifestyle tradeoffs that do not include working in one place more than a few years, perhaps with a shorter career span. One unforeseen external factor is global recruitment of PAs, which may reduce the available national PA pool.33 To date, no national discussion has mentioned any national approach to training and retaining PAs. Developing a centralized strategy for training adequate numbers of PAs may be necessary if the federal government remains obligated to maintain a supply of PAs to meet the demand. Although competitive salaries are called for, other ideas should be discussed. Models such as the Uniformed Services University of the Health Sciences, which produces physicians for federal roles, could produce federally obligated PAs if expansion is needed. The Canadian version of a “purple suit,” which deploys uniformed PAs from all three services for a national defense mission, appears to work well.34 Such models (along with other innovations) may be ideas worth considering if a population of qualified PAs for federal employment is to be ensured. CONCLUSIONS The U.S. federal system has a rich history of medical workforce innovations and counts the PA as one of its creations. PAs are used in a wide variety of agencies and environments. Their numbers are growing; however their roles have yet to be delineated. Economic, labor, and organizational research may be useful for understanding how they are deployed (along with the value they provide). Understanding the federal initiatives to train, employ, and retain PAs requires policy analyses which have not been undertaken despite decades of use. A centralized PA program with obligated service may be one useful recommendation. REFERENCES 1. Jolly R: Health Workforce: A Case for Physician Assistants? Report 24. Canberra, Australia, Parliamentary Library, 2008. 2. American Academy of Physician Assistants: Demographics and Characteristics of Physician Assistants: Results of the 2007 Census. Alexandria, VA, American Academy of Physician Assistants, 2007. Available at http://www.aapa.org; accessed September 15, 2007. 3. Salyer SW: Continued growth for military PAs. JAAPA 2002; 15: 35–9. 4. Gwinn DH, Keller JE: Military medicine. In: Physician Assistant: A Guide to Clinical Practice, Ed 2, pp 724 –32. Edited by Ballweg RM, Stolberg S, Sullivan E. Philadelphia, PA, Saunders, 1999. 5. Hooker RS: The military physician assistant. Milit Med 1991; 156: 657– 60. 6. Robinson HA Jr, Thompson HW: Tri-service physician’s assistants programs. Milit Med 1977; 142: 353– 6. 7. Stuart RB, Robinson HA Jr, Reed RF: The training and role of physicians’ assistants in the Army Medical Department. Milit Med 1973; 138: 227–30. 8. Chitwood J: Military physician assistants. In: Physician Assistants in Clinical Practice, Ed 4, pp 851– 60. Edited by Ballweg RM, Sullivan E, Stolberg S, Philadelphia, PA, Elsevier, 2008.

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Federal PAs 9. Gaudry CL Jr, Nicholas NC: The USAF/USN physician assistant program. Milit Med 1977; 142: 29 –31. 10. Hooker RS: A comparison of rank and pay structure for military physician assistants. JAAPA 1989; 2: 293–300. 11. O’Hearn CJ: Physician assistants’ role in combat medicine [letter]. Postgrad Med 1991; 90: 48. 12. Herrera J, Gendron BP, Rice MM: Military emergency medicine physician assistants. Milit Med 1994; 159: 241–2. 13. Henson KE: In Kosovo, making a difference. JAAPA 1999; 12: 77–9. 14. Hooker RS: Coast Guard physician assistants. Am Acad Physician Assist News 1987; 7: 4. 15. Hooker RS: The Coast Guard medical service. Navy Med 1991; 82: 18 –21. 16. Colver JE, Blessing D, Hinojosa J: Military physician assistants: their background and education. J Physician Assist Educ 2007; 18: 40 –5. 17. Fox DP, Whittaker RG: PAs in the Veterans Administration: a report of a national survey. Physician Assist 1983; 7: 106 –12. 18. Alexander BJ, Lipscomb J: Nonphysician practitioners panel report. In: Physician Staffing for the VA, Vol II, Supplementary Papers, pp 421– 65. Edited by Alexander BJ, Lipscomb J. Washington, DC, National Academy Press, 1992. 19. Oliver A: The Veterans Health Administration: an American success story? Milbank Q 2007; 85: 5–35. 20. Zarychta WA, Milner MR, Hunter-Buskey RN: PAs in the U.S. Public Health Service. ADVANCE Physician Assist 2008; 16: 52– 4. 21. Philpot RJ: Financial Returns to Society by National Health Service Corps Scholars Who Receive Training as Physician Assistants and Nurse Practitioners. University of Miami, Doctoral dissertation, Miami, FL, 2005.

22. Hooker RS: Physician assistants in occupational medicine: how do they compare to occupational physicians? Occup Med (Lond) 2004; 54: 153– 8. 23. Owens WD: Nonphysician clinicians in the health care workforce. JAMA 1999; 281: 511. 24. Druss BG, Marcus SC, Olfson M, Tanielian T, Pincus HA: Trends in care by nonphysician clinicians in the United States. N Engl J Med 2003; 348: 130 –7. 25. Cawley JF: The obsolete physician? Clin News 2000; 4: 9 –10. 26. Grumbach K, Bodenheimer T: Can health care teams improve primary care practice? JAMA 2004; 291: 1246 –51. 27. Cooper RA: Scarce physicians encounter scarce foundations: a call for action. Health Aff (Millwood) 2004; 23: 243–9. 28. Catlin AJ, McAuliffe M: Proliferation of non-physician providers as reported in the Journal of the American Medical Association (JAMA) 1998. Image J Nurs Sch 1999; 31: 175–7. 29. McKinlay JB, Marceau LD: The end of the golden age of doctoring. Int J Health Serv 2002; 32: 379 – 416. 30. Mullan F: The metrics of the physician brain drain. N Engl J Med 2005; 353: 1810 – 8. 31. Dal Poz MR, Kinfu Y, Drager S, Kunjumen T, Diallo K: Counting Health Workers: Definitions, Data, Methods and Global Results. Geneva, Switzerland, World Health Organization, 2006. 32. Mullan F: Physicians for the underserved: 1980. Public Health Rep 2006; 121(Suppl 1): 265–7. 33. Hooker RS, Hogan K, Leeker E: The globalization of the physician assistant profession. J Physician Assist Educ 2007; 18: 76 – 85. 34. Hooker RS, MacDonald K, Patterson R: Physician assistants in the Canadian forces. Milit Med 2003; 168: 948 –50.

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