To understand the roles of physician associates [PAs] and nurse practitioners [NPs] in rheumatology care delivery, we examined the pharmacoepidemiology of disease-modifying antirheumatic drug [DMARD] prescriptions among Medicare beneficiaries. The intent was to inform regulatory decisions, optimize prescribing, and better manage risk in older populations. An observational, retrospective cohort study of Medicare Part D claims from 2013 to 2023 compared rheumatologist prescribers with primary care providers (family practice [FP] and internal medicine [IM]) and with PAs and NPs. Trends in DMARD prescriptions and prescriber counts were reported as absolute numbers and percentages and presented graphically. Over the 10-year period from 2013 to 2023, 13 of the most commonly prescribed DMARDs in Medicare Part D claims were tracked. Methotrexate was the most frequently prescribed, followed by hydroxychloroquine. The share of DMARD claims by rheumatologists remained relatively steady (58-60%) during this period, whereas the shares for PAs and NPs increased. Expressed as unique prescriber counts, the trends are even stronger: in 2013, NPs and PAs represented 6.7% and 4.2% of DMARD prescribers, respectively, increasing to 19.2% and 8.9% by 2023, while the percentages of IM and FP physicians declined from 45.7% to 35.8% to 32.7% and 30.0%, respectively, during this same period. DMARD prescriptions for the Medicare population increased from 2013 to 2023, with NPs and PAs assuming a growing role in prescribing.

BACKGROUND:There is a significant shortage of psychiatrists compared with the demand for their services. We studied Medicare Part D claims of psychiatrists and similar clinician prescribers to identify possible shifts in medication prescribing to address this gap. OBJECTIVE:This pharmacoepidemiology study aimed to identify prescribing patterns among psychiatrists, family physicians, internists, physician associates/assistants (PAs), and nurse practitioners (NPs), as well as trends. DESIGN:An observational, retrospective cohort study of Medicare Part D claims from 2013 to 2022 was conducted. Psychiatrists' prescription patterns were compared with those of non-psychiatrists, using the National Provider Identifier (NPI). Diagnosis information was not available in the dataset. PARTICIPANTS:In 2022, more than 32,400 psychiatrists' prescriptions were submitted for more than 36.6 million Medicare Part D claims for various medications. MAIN MEASURES:Prescribers and medication claim counts were analyzed to determine the most commonly prescribed drugs by psychiatrists. Total psychiatrist prescription counts and trends were compared with those of primary care physicians, PAs, and NPs. KEY RESULTS:Family practice physicians wrote more than 55 million prescriptions in 2022, nearly twice the number written by psychiatrists. From 2013 to 2022, prescriptions written by PAs and NPs showed a strong upward trend. In 2020, prescription claims by NPs surpassed psychiatrists, and by 2022, they had exceeded those of internal medicine physicians. CONCLUSIONS:Claims by NPs increased from 8.6% to 24.8%, whereas psychiatrists' claims decreased from 24.4% to 18.0%. As of 2023, NPs and PAs comprise a significant portion of the workforce that addresses gaps in mental health medication care for Medicare patients.

ABSTRACT Objective: To compare the characteristics and dynamics of physician associates (PAs) aged 65 years and older with PAs younger than 65. Methods: A descriptive, quantitative study compared demographic and practice attributes of PAs aged 65 and older with those younger than 65, utilizing a 2023 national dataset (n = 149,909). Results: In 2023, 4.1% of board-certified PAs were 65 years and older. Among PAs 65 and older, 75.3% reported working clinically. Compared with PAs under age 65, a higher proportion of PAs 65 and older were male (50.2% vs 28.0%; P < .001), resided in rural/isolated areas (12.1% vs 6.9%; P < .001), and provided telemedicine services (44.5% vs 42.7%; P = .014). Older PAs were also less satisfied with their current job and reported lower burnout rates. Conclusions: Amid persistent physician shortages, understanding the practice patterns of PAs 65 and older is crucial for developing targeted policies and practices that support their retention.

OBJECTIVE:Physician assistants/associates (PAs) serve as commissioned medical officers in the uniformed services, supporting readiness, global health operations, and domestic response. Despite their critical contributions, limited data exist to inform strategic workforce planning, recruiting, and retention efforts. MATERIALS AND METHODS:A cross-sectional quantitative analysis was conducted using a 2023 national workforce dataset. We compared the demographic and employment characteristics of PAs on active duty with those not on active duty (N=12,146), using descriptive statistics and bivariate analysis (Pearson chi-square tests for categorical variables and Mann-Whitney tests for continuous variables). RESULTS:The PA Professional Profile data identified 12,146 PAs who reported their armed forces status, with 2,508 (20.6%) indicating they were on active duty, although 9,639 (79.4%) were inactive (retired and veterans). As of 2023, 2,508 active duty PAs served in the Army (52.0%), Air Force (25.8%), Navy/Marines (20.1%), USPHS/NOAA (5.9%), and Coast Guard (3.0%). In terms of demographics, PAs in active duty report a median age of 41, with 29.9% female and 11.6% indicating Hispanic/Latinx ethnicity. Compared to PAs not on active duty, PAs on active duty were more likely to complete a postgraduate fellowship/residency (17.6% vs. 13.9%). Over half of active duty PAs participate in telemedicine. More than a third (37.2%) of active duty PAs report symptoms of burnout, compared to 30.1% of PAs not on active duty. CONCLUSIONS:PAs occupy unique roles in the U.S. government's uniformed services. Federal agencies should enhance PA retention initiatives by addressing workload demands, aligning compensation with responsibilities, expanding leadership and fellowship opportunities, and incorporating flexible, nonclinical career pathways into retention packets. Such strategies are essential to sustain a resilient, skilled, mission-ready uniformed PA workforce.

OBJECTIVE:To compare the characteristics and dynamics of physician associates (PAs) aged 65 years and older with PAs younger than 65. METHODS:A descriptive, quantitative study compared demographic and practice attributes of PAs aged 65 and older with those younger than 65, utilizing a 2023 national dataset (n = 149,909). RESULTS:In 2023, 4.1% of board-certified PAs were 65 years and older. Among PAs 65 and older, 75.3% reported working clinically. Compared with PAs under age 65, a higher proportion of PAs 65 and older were male (50.2% vs 28.0%; P < .001), resided in rural/isolated areas (12.1% vs 6.9%; P < .001), and provided telemedicine services (44.5% vs 42.7%; P = .014). Older PAs were also less satisfied with their current job and reported lower burnout rates. CONCLUSIONS:Amid persistent physician shortages, understanding the practice patterns of PAs 65 and older is crucial for developing targeted policies and practices that support their retention.

The entry-level physician assistant/associate (PA) education offers a solid foundation for general medical knowledge and clinical skills. Yet, there has been an increasing trend for PAs to complete a postgraduate (PG) fellowship/residency to gain specialized expertise in specific medical disciplines. We analyzed national data and compared PAs' annual income, educational attainment, background, and professional attributes with a PG fellowship/residency and those without. Descriptive and bivariate statistics, along with quantile regression, were conducted. We found distinct differences in demographic/practice characteristics of the two groups (all p<0.001). PAs with PG fellowship/residency vs those without were older (median age, 42 vs 38), identified as male (42.4% vs 29.4%), Black/African American (4.8% vs 3.3%), and Hispanic/ Latino(a/x) (8.0% vs 6.6%). Most PAs completed their PG fellowship/residency in emergency medicine and worked in hospitals. Furthermore, income levels between PAs with a PG fellowship/residency and those without, revealed a significant gap of $10,000 in favor of those with a fellowship/residency. However, after adjusting for confounders, quantile regression analysis estimated a narrowed gap ($1,500.60). These findings indicate that additional education may not be associated with a substantial income increase. Further research should investigate the income growth trajectory of a PG fellowship/residency, providing a deeper understanding of the economic implications.

Objective: Physician assistants (PAs) are employed in endocrinology, but little is known about their roles and activities. The study aimed to assess PAs' employment characteristics in endocrinology compared to those in all other specialties. Methods: This descriptive observational study used the 2022 National Commission on Certification PAs dataset. The study includes 117 748 board-certified PAs who indicated a clinical specialty in 2022. The characteristics of PAs in endocrinology were examined using descriptive statistics, including counts and percentages for categorical variables; means (with standard deviations), and medians (with interquartile ranges) for continuous variables. Bivariate analyses (chi(2) and Mann-Whitney tests) were used to determine statistical differences between PAs practicing in endocrinology versus PAs in all other specialties. Results: This study found that as of 2022, 685 PAs reported practicing in endocrinology. PAs endocrinology, compared to PAs in all other specialties (all P < .001), were more likely to identify as female (82.0% vs 69.6%), work in an office-based private practice (61.3% vs 37.0%), and participate telemedicine (70.8% vs 40.1%). Conversely, PAs in endocrinology were less likely to work in a secondary position, saw slightly fewer patients weekly, and earned $10,000 less yearly than their PA colleagues in all other specialties. Conclusion: Examining the PA endocrinology workforce is essential due to the shortage of endocrinologists and the increased prevalence of diabetes as the U.S. population ages. Understanding where PAs in endocrinology are employed and their attributes could assist efforts in specialty modeling address supply and demand projections. (c) 2024 AACE. Published by Elsevier Inc. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

ABSTRACT:The American physician associate (PA) profession is evolving and now includes the potential for postgraduate doctorates that align with other healthcare disciplines. This educational trend is expanding: The number of PA doctoral degree programs doubled between 2022 and 2024. A census assessment of postgraduate doctoral degrees was conducted to document this movement. In 2024, we identified 28 postprofessional PA doctoral degree programs, most conferring a Doctor of Medical Science. Tuition for an online PA doctorate ranges from $15,240 to $47,880, and most programs require at least 12 months to complete. Nearly all are online and designed for working PAs. Within these 28 doctoral programs for PAs, the most common areas of study include PA education, healthcare administration, leadership, management, and several clinical and administrative concentrations. All programs are accredited by one of six federally recognized agencies. The social, professional, economic, and financial factors pertinent to a PA considering a clinical doctorate are of interest to PA graduates, educators, and social scientists.

The growth of physician assistants/associates (PAs) in hospital medicine is due to increased demand and insufficient physician-house staff. We compared the demographics and practice attributes of 4074 PAs in hospital medicine to 111,430 in all other specialties. Hospitalist PAs were younger (median age, 36 vs. 39), female (73.4% vs. 68.9%), resided in urban regions (93.3% vs. 92.4%), and worked in secondary positions (18.7% vs. 15.1%). However, hospitalist PAs indicated a higher burnout rate than all other specialties. The growth of PAs in hospital medicine makes them part of the strategy to meet the demand for specialized service delivery.

PURPOSE Procedures are manual technical skills clinicians perform for their patients. Family physicians (FPs) acquire these skills during residency; most are undertaken in outpatient settings. We performed a retrospective observational cohort study to describe the extent to which FPs perform the core procedures recommended by the Council of Academic Family Medicine (CAFM) and how this might have changed over time. METHODS The CAFM recommended a list of procedures all FP residents should perform competently after graduation. We modified this list for Medicare beneficiaries to enable matching with Current Procedural Terminology codes. We probed Medicare Part B databases for modified CAFM procedure claims submitted by FPs in 2021 and how these claims changed from 2014 to 2021. RESULTS In 2021, there were 904,278 modified CAFM procedures filed by 9,410 FPs in the outpatient setting. All procedures were clustered with respect to organ system (eg, musculoskeletal, skin, pulmonary). Beginning in 2014 and continuously through 2021, there was a 33% decrease in outpatient procedures filed and a 36% decrease in the number of FPs filing them. CONCLUSIONS Office -based procedures are integral to a primary care physician's role, although the activity is rarely analyzed. At a time when the Medicare population is growing, the number of available FPs and the number of procedures they perform are not. This decrease might result from the changing scope of FP practice, new referral patterns, task shifting, and/or increased delegation to physician associates and nurse practitioners.

Background Physician assistants/associates (PAs), due to their broad medical education and certification, have the flexibility to change specialties throughout their careers. Prior studies suggest that between half and three-quarters exercise this option at some point in their career, and a third do so within the first decade. However, more research is needed to understand the factors associated with PAs changing vs. remaining in the same specialty throughout their professional journey. Methods A cross-sectional analysis using a 2023 national dataset was conducted to examine specialty transitions throughout PAs' careers. We analyzed responses (N = 121,947 [81.3% response rate]) to a question asking how many times PAs changed specialties throughout their careers. Our investigation included specialty changes overall and separately within career-stage subgroups. We also explored demographics and practice attributes associated with specialty change patterns. Results Most PAs change specialties at least once during their careers, with some making this transition as many as six or more times. The highest proportion of change occurs in the first, followed by the second decade of practice. In the first 10 years, 40.3% of PAs changed specialties. In multivariate analysis, duration of practice was the strongest factor associated with increased odds of transitioning. PAs practicing for 31 or more years had over four-fold higher odds of changing specialties than PAs practicing for 10 or fewer years. Other factors strongly linked to specialty changes included working in critical care medicine or psychiatry, holding two or more clinical positions, practicing in urgent care, being an independent contractor, female gender, serving in the military, and possessing a doctorate. The pattern of significant PA characteristics linked with specialty changes was largely consistent when comparing the overall cross-sectional analysis with separate subgroups of PAs within different career stages. Conclusion PAs exhibit a high degree of career flexibility when it comes to changing specialties. Our research demonstrates that by the late-career stage, three-fourths of PAs have transitioned between at least two disciplines; however, most changes occurred in the first decade of practice. This study further substantiates the PA profession's attributes, highlighting its unique characteristics, such as its adaptability and capacity for career flexibility.

OBJECT:Physician associates (PAs) and nurse practitioners (NPs) are distributed across 70 medical and surgical specialties. A central role is to provide outpatient care. Urology is a significant employer of PAs and NPs, but their scope of practice in the ambulatory setting needs to be better delineated. DATA SOURCES AND STUDY SETTING:We conducted a retrospective cohort analysis of frequently performed ambulatory urological procedures identified by the American Urological Association, drawing on Medicare Procedure Summary master files. STUDY DESIGN:We analyzed Part B Medicare outpatient urology procedure claims from 2014 through 2021. The analysis compared the procedural reimbursable claims filed by urologists, PAs, and NPs. PRINCIPAL FINDINGS:From 2014 to 2022, urologists, PAs, and NPs filed over 35 million outpatient urology procedural claims. In 2021, ultrasound measurement of bladder capacity after voiding, endoscopic examination of the bladder and urethra, and electronic assessment of bladder emptying were the most performed procedures. The number of urologists filing claims for the 15 most common outpatient procedures decreased slightly by 0.66% between 2014 and 2021, while the number of PAs and NPs who did so increased by 109% and 156%, respectively. Although urologists performed nearly 13 times as many commonly performed outpatient procedures, the number performed by urologists declined by 15%. In contrast, the number of urologic procedures performed by PAs and NPs increased by 130% and 162%, respectively. CONCLUSIONS:This analysis of mostly older Americans receiving urological care illustrates a broadening scope of practice for PAs and NPs in this specialty. The results exemplify team-based care and the economic principle of task transfer in urology. This shift in ambulatory proceduralist roles occurred as the demand for urological care increased while the supply of urologists lagged.

OBJECTIVE:We hypothesized that physician associate (PA) and nurse practitioner (NP) procedural roles are expanding. We sought to describe ambulatory procedures these professionals performed in 2021 for older adults. STUDY DESIGN:Retrospective observational cohort study of Medicare Part B data. US Bureau of Labor Statistics data were used to provide overall PA and NP employment context. METHODS:Medicare Part B databases were probed for outpatient events by PAs and NPs using a modified list of the Council of Academic Family Medicine's recommended clinical procedures that focused on 29 procedures organized into 9 categories called procedure clusters. These procedures were linked to Current Procedural Terminology codes and PA and NP National Provider Identifier codes in Medicare Part B and then tabulated and analyzed for 2021. The Bureau of Labor Statistics provided NP and PA employment trends for context. The trend of the procedures and providers spanning 2014-2021 was analyzed. RESULTS:In 2021, 23,581 NPs and PAs filed 9.6 million Medicare Part B enrollee procedure claims. Most procedures (96%) involved skin or the musculoskeletal system. PAs filed more than twice as many claims for skin and musculoskeletal procedures as NPs, and NPs filed 1.25 times as many as PAs for the eye, ear, nose, and throat; pulmonary; genitourinary; gastrointestinal-colorectal; and women's health categories. From 2014 through 2021, the number of PAs and NPs in clinical practice increased by 72%, and the number of those who filed procedure claims increased by 74%. CONCLUSIONS:Overall, PAs performed more skin and musculoskeletal procedures than NPs, and NPs performed more procedures in the other 7 procedure clusters than PAs. PA and NP employment growth does not fully explain these observations. We suggest that outpatient procedural task-shifting activity presents an area for further research.

Prescribing is a significant activity undertaken by physicians, physician associates/assistants (PAs), and nurse practitioners (NPs). We analyzed prescribing data to understand better the growing presence of PAs and NPs in older adults. A trend in frequently prescribed medications was compared with other physicians. All prescriptions in Medicare Part D were grouped into broad categories of drugs and linked to each type of provider. The analysis spanned 9 years (2013-2021). The results revealed that all five providers similarly prescribed the top three main drug classes (antacids, antihypertensives, and statins). In addition, there was a decline in the number of unique prescribers and prescriptions for all three types of physicians (family medicine, internal medicine, and general practice physicians). Concurrently, the number and share of prescriptions for NPs and PAs increased yearly. The findings are consistent with data that PAs and NPs are backfilling physician shortages in treating older adults.

As of 2020, maternal and infant health in the US has worsened. At the same time, the number of health professionals available to manage female health issues is changing; the number of physicians in obstetrics and gynecology (Ob-Gyn) and midwives is decreasing, whereas the number of Ob-Gyn physician associates (PAs) is growing. We analyzed PAs practicing in the Ob-Gyn discipline, drawing on the PA Professional Profile, a database maintained by the National Commission on Certification of PAs. In 2021, there were 1,322 Ob-Gyn PAs (1.2% of all clinically active PAs). This health profession has grown by 66.9% since 2013, when only 792 PAs practiced in this specialty. As of 2021, their median age was 38, and 98.0% were female (70.1% of all PAs were female). The practice setting was between office (54.7%) and hospital (34.0%) employment, with 11.3% described as “other.” In 2021, the median annual income of Ob-Gyn PAs was $105,000. With the reduction of obstetrician-gynecologists, the relative growth of PAs in this area of medicine and surgery is a natural part of the solution to the projected obstetrical physician deficit.

Figure: Ruth M. Ballweg, February 29, 1944-November 20, 2022Photograph courtesy of the PA History SocietyWe remember the remarkable life and legacy of Ruth M. Ballweg, a trailblazing PA, student-turned-educator, and influential leader. Ruth spent her life in the Pacific Northwest, from her early days in Southern Oregon to a distinguished faculty career at the University of Washington in Seattle; however, her work had a global effect on healthcare and the PA profession. Her professional accolades and accomplishments are many, but we remember her most as a loyal friend, proud parent, dedicated teacher and mentor, global ambassador for the PA profession, and fearless change maker. Ruth was many things to many people, and there is no way we can, or wish, to define her in so few words. Drawing from our collective experiences with Ruth, we share three key lessons we each learned from her with our PA colleagues as a starting point for a professional life well lived. Ruth Ballweg retired in 2016 as professor emeritus of family medicine at the University of Washington after leading its MEDEX Northwest PA program and its regional campuses for many years. During her career, Ruth drove effective change in healthcare workforce issues across Washington, Wyoming, Montana, Idaho, Nevada, and Alaska. Her work included chairing the Group Health Cooperative of the Puget Sound Board of Directors and partnering with the Alaska Native Tribal Health Consortium to develop the dental health aide therapist program to ensure routine dental healthcare in rural Alaska. Beyond the Pacific Northwest, Ruth served the National Commission on Certification of Physician Assistants as a board member, founding member of the nccPA Health Foundation, and director of international relations. Ruth traveled the globe, helping expand the PA profession internationally while learning from her experiences abroad and bringing back insights and new innovations to share with PAs in the United States. Wherever Ruth was in the world, she always made time to connect with her colleagues, family, and friends. This inspired Ruth's first lesson: Build and nurture relationships. She availed herself to offer advice, share a caring ear with a friend in need, coach a new mentee, encourage a colleague, or help others make important connections. Nurturing relationships is an indelible part of her legacy as a leader, clinician, educator, scholar, and friend. With an open heart and tactful but sometimes unfiltered mouth, she was the best of friends and cherished getting to know others from diverse backgrounds and interests. Ruth developed professional and personal relationships with leaders, innovators, and thinkers inside and outside the PA profession and across the globe. At conferences and meetings, she prioritized her time to find those who could effect change. Her ability to drive change was supported by an expansive network she cultivated during her life and career and was influenced by thoughtfully listening to and learning from the people and communities she served. Her dominant professional identity was as an educator. She strived to create the next generation of clinicians, educators, scholars, leaders, and global citizens. Like many exceptional teachers, Ruth had a remarkable sense of humor and talent for storytelling. Ruth always had an opinion to share, but one endearing trait was her openness to and curiosity about others' points of view, perspectives, suggestions, and ideas. When Ruth encountered need, such as a gap in healthcare for vulnerable populations, she acted. One word that Ruth rarely spoke was “no.” This inspired Ruth's second lesson: Never say no. In fairness, it wasn't that she never said no; rather, she rarely turned down any opportunity to help a friend or colleague, support a meaningful cause, expand her professional network, or advocate for and support the PA profession or PA educators in the United States and beyond. If she could not be there herself, she was quick to help find someone who could or help make connections among interested colleagues. Testament to this quality is her role in supporting the expansion of PA education and practice in other countries, including India, Ireland, and Israel. The Dentex program is a prime example of how Ruth never said no to acting when she observed a community in need. When the dental therapist movement was started in Alaska to serve Iñupiat, Yupik, Aleut, Eyak, Tlingit, Haida, Tsimshian, and Northern Athabaskan tribes and communities, the American Dental Association objected to the creation of this lesser-trained clinician, regardless of the service provided and in the absence of dentists. Ruth moved the nascent Dental Therapist Association into her department to offer an academic sanctuary and promoted dental therapists as a national asset. Today the dental therapist movement thrives across several states, serving many remote and underserved communities. Many will remember Ruth for her tenacity and skill in working through the complexities of PA leadership in an academic health center and among the national PA organizations as well as the groundbreaking advancements she achieved for the profession through her service. We also note that Ruth rarely encountered a rule she couldn't bend, break, or rewrite if the situation called for it. These qualities and her track record of trailblazing inspired Ruth's third lesson: Never take no for an answer. Ruth overcame numerous hurdles to document our profession in the book Physician Assistant: A Guide to Clinical Practice. This seminal text for PA education now bears her name and is in its seventh edition, with each chapter written by notable scholars in the field. Ruth had a vision for the future of the PA profession and was an early promoter of PAs' potential to make a substantial effect on domestic and global healthcare. Her record of accomplishment in policy and social change as well as the global expansion of PAs stemmed from her unwillingness to accept no for an answer. Her perseverance as a leader and later president of the PA Education Association also drove important policies and practices that are the mainstays of PA education. As any successful researcher knows, failure is part of the process. Ruth never gave up as a grant writer and scholar and, through her collaboration on grants and fellowships, produced an impressive record of extramurally funded research projects and peer-reviewed scholarship. We all asked Ruth at one time or another about the secret to her seemingly endless supply of energy and determination in the face of significant resistance. Her answer was: “It's all about the students.” In particular, it was the experiences she shared with students of the MEDEX Northwest PA program that inspired her work and fueled her drive to advance the PA profession. She often quoted her colleague, friend, and founder of MEDEX, Richard “Dick” Smith, MD, who said that shifting his own career from clinical practice to education was like multiplying his hands 10,000-fold. Ruth said, “Being a PA faculty person and a director especially, you get the chance to do that, and nothing will take that energy away from you.” Ruth recalled the experiences of her MEDEX students, who often were older and embarking on new careers; they faced different challenges than other PA students in balancing their personal lives and education. “Sometimes you get involved in the most wonderful and incredibly sad aspects of their lives,” Ruth recalled, “and the bonds that are created through those experiences will never dissolve.” As Ruth and her colleagues who founded the PA History Society knew, the preservation of our history is critically important. Looking back and seeking to understand our choices and the effect PAs have made can help us face the future and take action. Ruth remains an inspirational force for PAs across the world, and she will be missed. To honor her legacy and learn from her life and work, we share Ruth's three lessons for a professional life well lived to those who aspire to be their own force of change in the world. For more on Ruth Ballweg's extraordinary contributions to the PA profession, please visit her biography on the PA History Society website: https://bit.ly/3UgZlJT.