Meeting Rural America's Needs:
PA Presence Remains Strong

DIRE PREDICTIONS PROVE UNFOUNDED

A decade ago researchers feared that the number of PAs serving rural communities would dwindle as the demographics of the profession began to change and as significant barriers to rural practice appeared to be firmly rooted in place.

An article in the September 1990 Journal of the American Academy of Physician Assistants reported that a typical rural PA was an older male with many years of clinical experience. At the same time, increasing numbers of young, female PAs were entering the profession. The author concluded that if those two scenarios continued, the numbers of PAs in rural practice would decline.[1]

Those fears have not been borne out. The most recent data from the AAPA show that 22 percent of PAs identify themselves as practicing in rural communities. Real numbers of PAs in rural areas has steadily climbed - from 6,700 in 1996 to over 10,000 in 2002.[2]

These PAs who are serving the needs of rural America represent a significant percentage of the profession. In addition to supporting the work of physicians who might otherwise leave rural practice, in many cases PAs enable the health care system to reach rural communities that cannot support a physician. Rural PAs also impact the profession by maintaining an important tie to one of its original tenets, increasing access to primary care in underserved areas.

BARRIERS TO RURAL PRACTICE FALL

None of the data used to frame these scenarios reflect why PAs practice in rural communities, but many incentives and barriers to rural practice have been identified in other studies. Lack of prescriptive authority has been a major barrier to rural PA practice in the past — a barrier that has fallen with spectacular regularity in the past few years. In 1989, PAs had prescriptive authority in 24 states and the District of Columbia; today they have prescriptive authority in 47 states and the District of Columbia. Restrictive state laws requiring on-site physician supervision -- rather than off-site supervision by telecommunication — were another enormous barrier to rural PA practice.

Rural practice in Texas provides a dramatic example of how access to care opens when practice barriers are removed. In 1989, fewer than five percent of the PAs in Texas practiced in small communities. State law did not permit PAs to work in sites remote from their supervising physicians, nor did it allow PAs to write prescriptions. In 1989 Texas law was amended to allow off-site physician supervision of PAs and delegated prescriptive authority in underserved areas. By 1992 the number of PAs in rural communities in Texas had tripled. The number of federally certified rural health clinics grew from zero in 1989 to nearly 400 by the end of 1995. [3-4]

THE RURAL PICTURE IN 2002

The researchers in 1990 made some educated guesses about why the number of PAs in rural areas was dropping. By examining the demographics, they thought fewer PAs might enter rural practice in the future because more women were entering the profession and they were believed to prefer urban practice. Rural PAs tended to be men, were older than average, and had more clinical experience than the general PA population. Finally, substantially fewer graduates from 1985 through 1989 had entered rural practice.[1]

Data from the 2002 AAPA Census, the most recent available, has not borne out those predictions. For example, the 2001 data show that among rural PAs, the gender split is 52-48- not so far off the 57-43, female-to-male, split in the total practicing population. The 1990 data reflected that older PAs favored rural areas and younger ones urban settings. The 2002 data show that the age distribution among rural PAs is virtually identical to the age distribution across all practicing PAs. The median age of rural PAs is 43; the median age for all PAs is 40. Current data show that there is no difference in median years of clinical practice between rural and urban PAs. The median for both is 6.0 years.

Further research would be required to identify what factors influence PAs to choose rural practice. However, it is likely that some of the reasons have to do with state practice acts that allow maximum utilization of PAs, efforts to recruit students from rural areas, improvements in the availability of student financial aid through the National Health Service Corps, and improvements in the national Rural Health Clinic Services Act that have increased the number of rural health clinics and the demand for rural PAs.

REFERENCES

  1. Willis JB. Is the PA Supply in Rural American Dwindling? J Am Acad Phys Asst; 1990;3:433-5.
  2. American Academy of Physician Assistants. 2002 AAPA Physician Assistant Census Report. October 6, 2002.
  3. American Academy of Physician Assistants. Testimony of the American Academy of Physician Assistants to the Physician Payment Review Commission. November 29, 1993.
  4. Health Care Financing Administration, US Department of Health and Human Services. Federally Certified Rural Health Clinics by State. Unpublished data. September 1995.

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Last Revised: 7/16/03