A Description of Physician Assistant Postgraduate Residency Training: the Resident’S Perspective

Research Article

A Description of Physician Assistant Postgraduate Residency Training: The Resident’s Perspective

David Asprey, PhD, PA-C; Lelia Helms, PhD, JD

Note: This study was sponsored in part by a grant from the APAP Research Institute. Purpose: Postgraduate residency training is an optional form of education that has existed within the physician assistant profession since 1971. Despite almost three decades of experience, there are no comprehensive data regarding PA residents’ opinions about their residency training. At the time of this study, there were 17 residency programs in 10 different states. This study was undertaken to characterize PA residency training in the United States from the perspective of participants. Methods: This study utilizes a non-experimental, descriptive research design to describe residents’ perspectives of various characteristics, activities and opinions regarding PA postgraduate residency training. Data were collected from a survey instrument reviewed by a select group of residency directors for design and clarity. Standard procedures for gaining approval and clearance for studies involving human subjects were followed. Forty-six (59%) of the 78 enrolled residents responded. Data were entered into a relational database. Descriptive statistical analyses utilized a standard statistical software package. Results: Results from the survey data collected from the PA residents are reported. Data are categorized as follows: resident demographic information, entry-level PA program information, pre-residency program information, residency program information, residency curriculum data, residents’ perceptions of changes in knowledge and skills and residents’ opinions regarding residency. Conclusions: PA postgraduate residency education provides an important educational vehicle for training graduate PAs in specialty care. A substantial proportion of residents proceed directly from entry-level to postgraduate training. Residents report satisfaction with their programs generally and specifically in terms of knowledge and skills acquired. More information comparing the differences between academic and internship models of residency education is needed as is consideration of greater standardization in program record-keeping and support for research into the longitudinal outcomes associated with postgraduate education. (Perspective on Physician Assistant Education 2000;11(2):79–86)

Introduction education beyond the entry level and ing specialization and autonomy has for increased specialty training.1,2 If led greater numbers of PAs to seek for- Physician assistant residency educa- the PA profession follows the pattern mal postgraduate training prior to tion has developed in response to a of physicians and several other health- entering the specialty of their choice or perceived need for standardization of care professions, postgraduate residen- transferring from one specialty to cy education may become an expecta- another. David Asprey is the program director and an associ- tion for practitioners. There are two basic types of PA ate professor for the Physician Assistant Program, The The role of the PA has expanded postgraduate residency programs: College of Medicine, University of Iowa, Iowa City, dramatically over the past 30 years. internship and academic model pro- Iowa. Lelia Helms is a professor of Planning, Policy 5 and Leadership, The College of Education, University Today PAs are practicing medicine grams. Internship model programs of Iowa, Iowa City, Iowa. with substantial autonomy in virtually include a modest, practically oriented, every specialty area of medicine.3,4 didactic curriculum combined with Correspondence should be addressed to: Increased autonomy and specialization intensive clinical rotations and educa- David Asprey, PhD, PA-C have resulted in a need for practical, tional experiences. They lead to a cer- Program Director and Associate Professor postgraduate, specialty education. To tificate of completion. Academic model Physician Assistant Program The College of Medicine date, most PAs accomplish specialty programs combine a highly structured University of Iowa education through extensive on-the- and formalized didactic education Iowa City, IA 52242 job training with one-on-one educa- (through courses taken for graduate Voice: 319-335-8920 Fax: 319-335-8923 tion from physicians practicing the credit) with clinical rotations and lead e-mail: [email protected] specialty.3 The trend towards increas- to a master’s degree (or credit towards

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a master’s degree) upon completion. this study at its general membership sis generally consists of summary statis- Because of the different foci of these meeting in May 1997. tics for each parameter reported. two models of residency programs, this In May 1998, surveys were sent to study reports findings by these two cat- residency program directors for distrib- Results egories as appropriate for identifying ution to all their enrolled residents. The important differences between them. surveys were accompanied by a cover Findings are presented in the follow- letter signed by the study author and co- ing general categories: demographics, Purpose signed by the president of APPAP. To information about entry-level PA pro- provide residents with some measure of gram, pre-residency information, pro- This study reports findings from confidentiality in reporting unfavorable gram selection and enrollment, program the second in a two-part comprehen- comments and to add to the integrity of curriculum, and opinions about residen- sive study inventorying PA postgradu- responses, each resident received an cy training. When appropriate, findings ate residency programs. The first part, envelope in which to seal and, thereby, are subcategorized into respondents in “A Description of Physician Assistant secure the completed survey prior to internship and academic model pro- Postgraduate Residency Training: The returning it to the program director. grams. A total of 46 surveys were Director’s Perspective,”5 inventoried After one month, residency directors returned. Occasionally, respondents did residency programs from information who had not returned surveys from cur- not complete all fields of the question- provided by program directors. This rently enrolled residents were contacted. naire and thus the identified number of study, conducted contemporaneously Problems identified through this proce- responses for the data will vary. in May 1998 with the first, sought dure were addressed and assistance in information from currently enrolled, completing the surveys was provided as Resident Demographic Information postgraduate residents about their appropriate. The method of administer- backgrounds, professional history, and ing the survey via the program directors Currently enrolled residents were opinions regarding the value of their was utilized with the assumption that almost evenly divided between males training. This study does not rely or the directors could more effectively (n=23, 51%) and females (n=22, 49%). build upon on either existing descrip- coordinate the distribution and collec- Respondents (n=44) were predomi- tive information or on well-formulated tion of the survey from busy residents nantly white (86%) with the remainder educational theory as its foundation. and thus improve the response rate. being African-American (14%). No Instead, its purpose is to develop an The method of administering the other ethnic identity was represented in initial inventory of baseline informa- surveys for residents resulted in some this group of respondents. The mean tion about PA postgraduate residency limitations in response rates. In the age reported was 34.4 years (n=44, training as described by PA residents companion study, 16 of the 17 directors SD=8.4, range 24–57). enrolled at the time of this study. of postgraduate residency programs returned their inventories. Of these 16, Entry-Level PA Program Information Methods only 14 directors returned surveys collected from residents enrolled in their As presented in Table 1, 45 (98%) of A survey instrument requesting programs. The two programs that the residents provided the name of their information about residents’ back- returned information from directors, entry-level PA program. The most com- grounds and experiences was devel- but not from residents, enrolled six res- monly reported entry-level PA programs oped and reviewed by a select group of idents. Of the 14 programs that did attended were Alderson-Broaddus PA residents and residency directors to return surveys from their residents, 46 College, George Washington University, identify problems of design and clarity. (64%) of the residents (n=72) enrolled University of Southern California, and The study employed a non-experimen- in May 1998 completed inventories. Western Michigan University. tal, descriptive research design. It uti- These responses comprise the database Residents were asked what creden- lized a questionnaire to ask residents for the information about residents’ per- tial(s) they were awarded from their about their various characteristics, spectives on their postgraduate pro- entry-level PA program. More than one backgrounds, activities, and opinions grams in this analysis. choice could be selected. All respon- regarding PA postgraduate residency Data collected from the survey were dents (n=46) indicated being awarded at training. Approval for the study was entered into a relational database. This least one credential from their entry- sought from the professional organiza- allowed the data to be categorized based level PA program. Seven (15%) received tion representing postgraduate resi- upon various residency characteristics. two credentials, typically a certificate dency programs the Association of In addition, descriptive statistical analy- and an academic degree. Table 2 Postgraduate Physician Assistant sis was conducted utilizing a standard describes the frequency and types of Programs (APPAP). APPAP endorsed statistical software package. Data analy- these credentials.

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Table 1 dency programs was information pro- Entry-Level PA Program Attended by Residents vided by the entry-level PA program the resident attended. Entry-Level PA Program Attended # of Residents Percent of Total Residents were then asked to rank- Alderson-Broaddus College 4 8.9 order the items that influenced their George Washington University 4 8.9 decision to attend a PA residency. The University of Southern California 4 8.9 most commonly reported item influenc- Western Michigan University 4 8.9 ing the resident’s decision to pursue res- Duke University 2 4.4 idency training was the ability to com- Midwestern University 2 4.4 pete for a job in this specialty (89.1%). St. Francis College 2 4.4 Interest in additional clinical knowledge All Other PA Programs 23 51.1 and skills prior to going into practice as Total 45 99.9* a PA (84.%) and improved future earn- * Total less than 100% due to rounding off of individual percentages ing potential (80.4%) were also reported by more than two-thirds of the respon- Table 2 dents. Interestingly, 60.9% of residents identified obtaining an advanced degree Entry-Level PA Program Credential Awarded as an item influencing their decision to Entry-Level PA Program Credential Number Percent attend a residency, yet only three of the Certificate Only 11 20.8 17 residency programs in existence at Associate's Degree 3 5.6 the time of this survey offered a master’s Bachelor's Degree 28 52.8 degree upon completion. Table 5 sum- Master's Degree 11 20.8 marizes residents’ responses. Other 0 0 Information was gathered about the Total 53 100 number of residency programs to which residents had applied, been interviewed, and accepted. Thirty-nine (84.7%) Pre-Residency Information dency program. Table 3 describes the respondents (n=46) applied to a single specialty practice of the 14 responses to residency program; five (10.9%), to two PAs often have experience in the this question. residency programs; one (2.2%), to health-care sector prior to enrolling in three; and one (2.2%), to four residency entry-level PA training programs. Residency Program Selection and programs. In terms of interviews prior Thirty-seven (82%) of the residents Enrollment Information to admission, 42 (91.3%) interviewed (n=45) responding to this question with one program and the remainder reported an average of 57.2 months Residents were asked how they (4) with two. Forty-three (93.5%) resi- (SD=58.7, range 6–240) of such expe- became aware of the PA residencies. dents were accepted by one postgradu- rience prior to their initial PA training. Respondents were instructed to select a ate program and three, by two. Table 6 Residents were asked about the total single response from a menu of choices. provides an overview of these findings. number of months they had spent in Table 4 summarizes answers to this Residents were asked to rank-order practice as PAs prior to entering their question. The most commonly reported factors influencing their decision to residency program. Eighteen (39%) of mechanism for learning about the resi- attend their specific residency program the residents (n=46) reported having practiced as a PA prior to entering resi- Table 3 dency while 28 (61%) had no practice Specialty Practiced as a PA Prior to Residency experience. Residents with PA experience averaged 50.7 months (SD = 60.7, Specialty Prior to Residency N Percent of Total range = 1-209) in practice. Family Practice 9 64.3 The 18 residents who indicated prior Emergency Medicine 2 14.3 practice as a PA were asked about their Internal Medicine 1 7.1 area of specialty practice. Fourteen Internal Medicine Specialty 1 7.1 (78%) residents provided a response. Occupational Health 1 7.1 Nearly two-thirds of the respondents Total 14 99.9* were practicing the specialty of family * Total less than 100% due to rounding off of individual percentages medicine just prior to entering the resi-

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Table 4 programs. The following summaries Mechanism by Which Residents Learned About PA Residency describe residents’ estimates of their allocation of effort in these component Mechanism N Percent areas of postgraduate education. Information provided to me by the PA program I attended 19 41.3 Residents estimated the total num- From a fellow student or colleague 12 26.1 ber of hours of formal didactic curricu- Journal advertisements 4 8.7 lum included in their residency program Other 4 8.7 to be 369.6 hours (SD=212.9, By interactions with a residency graduate 3 6.5 range=40–1000). When program model By a mailing sent to me 2 4.3 differences were examined, residents Web site 1 2.2 (n=14) attending an academic model Journal article about the residency 1 2.2 residency program estimated spending Total 46 100 an average of 413.4 hours (SD=117.2, range=150–795) in didactic curriculum. Table 5 Those (n=32) in internship model pro- Items Influencing Residents’ Decision to Attend a Residency grams estimated spending 350.4 hours (SD=226.7, range=40–1000). Frequency Rank Residents were then asked to esti- Item of Selection Percent Order mate the average number of clinical Increased ability to compete for a job in this specialty 41/46 89.1 1 hours related to patient care spent per Interest in additional clinical knowledge and skills prior week in their residency program. Those to going into practice as a PA 39/46 84.8 2 enrolled in academic model programs Improved future earning potential 37/46 80.4 3 estimated spending approximately 44.1 Current level of competency in this specialty area 34/46 73.9 4 hours weekly (SD=6.5, range=36–60) Provides flexibility to change specialty area practiced 28/46 60.9 5 Obtaining an advanced degree 28/46 60.9 5 in patient care. Internship model pro- Other 4/46 8.7 7 gram residents estimated spending approximately 72.3 hours (SD=28.1, Table 6 range=28–150) in clinical care per week on average. This is an average dif- Summary of Admissions Characteristics of the Enrolled Residents (N=46) ference of 28 additional hours weekly Number of Programs Indicated by Enrolled Residents spent in clinical care between program Admissions Activity 1 2 3 4 Total models. (Author note: It is worth not- Applied to 84.7% 10.9% 2.2% 2.2% 100% ing that the internship respondents var- Interviewed at 91.3% 8.7% 0% 0% 100% ied widely in their estimates of the total Received acceptance to 93.5% 6.5% 0% 0% 100% hours spent in patient care activities (28–150). While it is logistically possi- ble for a resident to spend 150 hours and to leave blank those items not influ- the residents attended internship per week in patient care, it is highly encing their decision. Table 7 provides a model programs with a mean length of improbable that this is an accurate summary of these findings. Program 13.2 months (SD=2.2, range=12–25). reflection. It seems reasonable to con- reputation and the didactic component Eleven (24%) residents were enrolled clude that some residents’ perceptions of the curriculum were the most com- in academic model programs with a of hours worked per week may be over- monly reported items. Salary stipend, mean length of 23.5 months (SD=1.2, stated in their survey responses.) the benefits package, and “other” were range=21–24). Residents next estimated the average the only categories identified by less number of hours per week spent in edu- than 50% of respondents. Program Curriculum Information cational activities related to patient care All residents identified the specialty (reading texts, journals, studying). of the residency program they attended. Residents were asked to provide Residents in academic model programs Table 8 summarizes this information. information regarding the number of estimated that on average they spent Residents provided information hours of 1) formal didactic curriculum, nearly 8 additional hours per week (aver- about the length of their training pro- 2) clinical contact with patients, 3) edu- age=16.1 hours, SD=14.5, range=4–60) grams. The mean length of all residen- cational activities relating to patient on educational activities when compared cy programs is 15.7 months (SD=4.8, care, and 4) participation in research- to the internship model residents (aver- range=12–24). Thirty-five (76%) of related activities during their residency age=8.4 hours, SD=4, range=2–20).

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Table 7 included physician residents, staff physi- Items Influencing Residents’ Decision to Attend Their Residency cians, PA residency program staff, staff PAs, and others, again with a space to Frequency Rank specify other health-care professionals. Item of Selection Percent Order The mean number of different types of Program reputation 36/46 78.3 1 supervisory health professionals was 2.1 Didactic component of curriculum 36/46 78.3 1 (SD=1.0, range=1–4). PA residents Practical clinical education component 31/46 67.4 3 were typically supervised by staff physi- Geographic location 30/46 65.2 4 cians (95.7%). Three residents identified Recommendation from colleague or friend 26/46 56.5 5 other supervisory health professionals, Degree or degree option offered 25/46 54.3 6 specifically community physician pre- Recommendation from PA program faculty member 24/46 52.2 7 ceptors. Impression obtained during application/interview process 24/46 52.2 7 Residents were then asked how their Salary stipend 20/46 43.5 9 Benefits package 15/46 32.6 10 performance was evaluated in their resi- Other 9/46 19.6 11 dency program. Each resident selected methods from a list that included 1) Table 8 written evaluations from rotation preceptors, 2) written evaluations from the Percentage of Respondents by Specialty PA residency staff, 3) verbal evaluations Residency Specialty Frequency Percent from rotation preceptors, 4) written Surgery 15 32.6 clinical examinations, 5) practical clini- Emergency Medicine 10 21.7 cal examinations, and 6) other with Primary Care 6 13.0 space to specify the specific other evalu- Orthopedics 5 10.9 ation method. A summary of these Internal Medicine 4 8.7 responses is presented in Table 10. Pediatrics 2 4.3 CVT Surgery 1 2.2 Residents’ Opinions About Dermatology 1 2.2 Training Programs Obstetrics and Gynecology 1 2.2 Occupational Health 1 2.2 Residents were asked their percep- Total 46 100 tions about program benefits through a series of questions requiring them to Finally, residents were asked to esti- medical students, PA students, den- compare their pre- and post-program mate the total number of hours spent tists, nurse practitioners, pharmacists, learning in several areas. participating in research-related activities and others. Space was provided to First, each resident assessed changes and research-related education during specify other groups of health profes- in his or her knowledge about clinical their program. Those attending academ- sionals. The most commonly reported activities (beyond their entry-level edu- ic model residency programs estimated health professionals for PA residents cation) as a result of their residency that they received (on average) approxi- to be trained with are PA students training. Table 11 summarizes these mately 186 additional hours of research- (73.9%), followed by physician resi- findings. Each clinical activity is listed related education (average=215.7 hours, dents (63%) and medical students first with the complete breakdown by SD=155.4, range=0–500) more than (54.3%). The uncommonly reported percentage and then by categories col- residents in the internship model pro- professions included dentists (17.3%), grams (average=29.4 hours, SD=40.2, nurse practitioners (17.3%), and phar- Table 9 range=0–150). macists (6.5%). Other health profes- Residents were then asked a series sionals (6.5%) encountered in training Summary of Resident’s Clinical of questions about program opera- programs included physical therapists Supervisors (N=46) tions in several important areas. They and nursing students. Health Professional Percent Rank were questioned about interdiscipli- Table 9 summarizes responses from nary exposure to other health profes- residents who were asked to specify the Staff Physicians 95.7 1 Staff Physician Assistants 56.3 2 sionals during their residency pro- different health professionals responsi- Physician Residents 39.1 3 gram. Each resident identified other ble for supervising their clinical work PA Residency Program Staff 32.6 4 health professionals in training from a during their residency program. The list Other 6.5 5 list including physician residents, of choices for health professionals

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Table 10 interview skills (21.7%), and physical Summary of Evaluation Methods (N=46) examination skills (19.6%). Table 13 presents findings about res- Evaluation Method Percent Rank idents’ levels of satisfaction with various Written evaluations from rotation preceptors 60.9 1 aspects of their training. It also com- Verbal evaluations from rotation preceptors, 50.0 2 bines the data on satisfaction into high Written evaluations from the PA residency staff 34.8 3 and low categories for broader compar- Written clinical examinations 34.8 3 isons. Other 4.3 5 All residents reported satisfaction in Practical clinical examinations 2.2 6 their summary evaluation of their residency training experience and substan- Table 11 tial satisfaction in the areas of degree of Residents’ Perceptions of Change in Knowledge of Clinical Activities (N=44) responsibility, didactic and clinical education. Residents were least satisfied Percent with the salary and benefits packages. Clinical Activity Unchanged Increased Greatly Increased When asked if they would recommend History taking and interviewing skills 29.5 36.4 34.1 their residency program to other PAs Unchanged versus increased 29.5 70.5 interested in their specialty, 33 (71.7%) Physical examination skills 20.5 50.0 29.5 answered ‘definitely’ and 13 (28.3%), Unchanged versus increased 20.5 79.5 ‘probably.’ None replied that they Ability to develop a differential diagnosis 4.5 36.4 59.1 would not recommend their training Unchanged versus increased 4.5 95.5 Ability to establish a diagnosis 2.3 36.4 61.2 program. Unchanged versus increased 2.3 97.6 Procedural and technical skills 20.5 29.5 50.0 Study Limitations Unchanged versus increased 20.5 79.5 Interpreting laboratory and diagnostic data 11.4 59.1 29.5 This study was designed as a descrip- Unchanged versus increased 11.4 88.6 tive inventory utilizing a survey instru- Research skills 52.3 25.0 22.7 ment to collect data about residents’ Unchanged versus increased 52.3 47.7 perceptions of their postgraduate PA Critical thinking skills 4.5 45.5 50.0 programs. Survey research methodolo- Unchanged versus increased 4.5 95.5 gies have limitations applicable to this Appropriate referral and consultation 18.2 50.0 31.8 study. First, descriptive studies are not Unchanged versus increased 18.2 81.8 Ability to recognize disease and pathology 4.5 45.5 50.0 designed for hypothesis testing or iden- Unchanged versus increased 4.5 95.5 tifying causal relationships but rather to inventory and classify. The present study is exploratory. It is limited to an initial lapsed into two: increased and Next, residents assessed changes in systematic description of various ele- unchanged. Forty-four (95.7%) of the their skills (beyond their entry-level ments of residency education. 46 residents provided usable responses education) resulting from their residen- Further, studies utilizing survey to this item. cy training. Using the same format as methodology are susceptible to errors In decreasing order of frequency, the Table 11, Table 12 presents these find- caused by the participants’ imperfect clinical activities in which the residents ings both for each item and in combined memory, by limited accuracy in obser- identified increased knowledge with the categories. vation, by problems of record-keeping, greatest frequency were ability to estab- The clinical skills where residents and by the respondents’ desire to give lish a diagnosis (97.6%), ability to rec- identified the greatest growth in their what they believe to be acceptable or ognize disease and pathology (95.5%), skills were ability to develop a differ- desired responses. Response rates less critical thinking skills (95.5%), and abil- ential diagnosis (100.0%), ability to than 100% are a common problem ity to develop a differential diagnosis recognize disease and pathology associated with questionnaires, espe- (95.5%). Clinical activities they most (100.0%), critical thinking skills cially those administered via mail. commonly identified as unchanged (97.8%), and ability to establish a Respondents’ motivations may directly included research skills (52.3%), history diagnosis (95.5%). The clinical skills influence the validity and reliability of taking and interview skills (29.5%), that residents most commonly identi- the collected data. Further, because physical examination skills (20.5%), and fied as unchanged included research these surveys are administered at a sin- procedural skills (20.5%). skills (54.4%), history taking and gle point in time, they reflect only a

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Table 12 commitment of time by residents. Residents’ Perceptions of Change in Their Clinical Skills (N=46) Finally, PA residents may seek to por- tray their respective programs positive- Percent ly and present opinion-oriented infor- Clinical Activity Unchanged Increased Greatly Increased mation only in a favorable manner. History taking and interviewing skills 21.7 45.7 32.6 Unchanged versus increased 21.7 78.3 Conclusions Physical examination skills 19.6 45.6 34.8 Unchanged versus increased 19.6 80.4 Several educators have called for Ability to develop a differential diagnosis 0.0 47.8 52.2 greater standardization of the postgrad- Unchanged versus increased 0.0 100.0 uate residency education process.1,6,7 Ability to establish a diagnosis 4.3 41.3 54.4 Nevertheless, except for the develop- Unchanged versus increased 4.3 95.7 ment of the academic model programs, Procedural and technical skills 17.4 23.9 58.7 PA residency education continues to Unchanged versus increased 17.4 82.6 Interpreting laboratory and diagnostic data 10.9 52.2 36.9 exist in much the same format as it did Unchanged versus increased 10.9 89.1 approximately twenty years ago. To Research skills 54.4 23.9 21.7 date, PA postgraduate residency training Unchanged versus increased 54.4 45.6 programs have not objectively docu- Critical thinking skills 2.2 45.6 52.2 mented their value, standardized their Unchanged versus increased 2.2 97.8 curricula, legitimized their educational Appropriate referral and consultation 17.4 54.4 28.2 processes and outcomes through Unchanged versus increased 17.4 82.6 research, or implemented an accredita- Ability to recognize disease and pathology 0.0 58.7 41.3 tion and/or certification process for Unchanged versus increased 0.0 100.0 postgraduate education. Table 13 Nonetheless, the information collected from residents does provide an Summary of Residents’ Satisfaction Levels initial characterization of demograph- Educational Experience Very High High Low Very Low ics, motivations, and program opera- tion as well as some evaluation of pro- Clinical supervision received 15=32.6% 24=52.2% 6=13% 1=2.2% grams from the residents’ perspective. • high versus low satisfaction High=84.8% Low=15.2% This study provides evidence that, Degree of responsibility 19=43.2% 24=54.5% 1=2.3% 0=0% although most PA residents had sub- • high versus low satisfaction High=97.7% Low=2.3% stantial experience in health care, in Degree of autonomy 14=31.8% 22=50.0% 8=18.2% 0=0% 1998 almost three-fifths of PA resi- • high versus low satisfaction High=81.8% Low=18.2% dents had matriculated directly from Salary or stipend 3=7.3% 20=48.8% 14=34.1% 4=9.8% their entry-level training into postgrad- • high versus low satisfaction High=56.1% Low=43.9% uate programs. Two-thirds reported Benefits package 10=24.4% 17=44.7% 7=18.4% 4=10.5% having learned about residency options • high versus low satisfaction High=69.1% Low=28.9% during entry-level programs both from Didactic education 15=32.6% 25=54.4% 3=6.5% 3=6.5% information distributed by those pro- • high versus low satisfaction High=87.0% Low=13.0% grams and from fellow students. Clinical education 16=35.6% 23=51.1% 3=6.7% 3=6.7% Certainly residents felt that residency • high versus low satisfaction High=86.7% Low=13.4% education increased their knowledge, Overall residency training 16=34.8% 30=65.2% 0=0% 0=0% competence, and ability to compete for • high versus low satisfaction High=100% Low=0.0% more desirable positions. While these findings are suggestive, it is not yet clear whether entry-level programs are single reference point and do not pro- there are no existing data that can be beginning to emphasize the value of vide any indication of how the findings used for purposes of direct comparison. additional training. Likewise it is not may change over time (trends). The survey instruments were uniquely yet clear whether an expectation for Issues unique to this particular developed for this study and had not postgraduate credentials (as experi- study also may be identified. The pro- been specifically tested for reliability enced in other health-care professions) grams in this study have not been pre- and validity. Moreover, completing the may be developing; this question is viously surveyed or reviewed. Thus, questionnaire required a substantial beyond the design of this survey.

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The survey describes residents’ self- directors, some inconsistencies may be postgraduate education system to serve assessments of the effects of a residency identified. These occur when residents the interests of all stakeholders broadly. program on their knowledge and skills. estimate the portion of their program Better record-keeping and careful evalu- Generally, residents reported substantial devoted to the didactic curriculum as ation of programs, as well as outcomes gains. These included both clinical activ- compared with information provided of programs and graduates, would be an ities and skills where residents most fre- by program directors.5 Residents both important starting point. quently identified increases in their abil- overestimated (internship model pro- ities to establish a diagnosis, to recog- grams) and underestimated (academic References nize disease and pathology, think criti- model programs) the hours devoted to 1. Timmer S. Call for uniform guidelines for cally, and to develop a differential diag- instruction by their programs. Similar postgraduate surgical residency programs. nosis. Fewer gains were reported in discrepancies were identified in minor- JAAPA. 1991;4(6):453-454. activities and skills related to areas of ity enrollments. 2. Stanhope W. Postgraduate training: who research, history taking and interview- Educators, policymakers, employers, needs it? Physician Assistant. ing, physical examination, and proce- and members of the profession still have 1991;15(11):14-16. dures. relatively little systematic information 3. Hooker RS, Cawley JF. Physician Assistants PA residents appear to be quite sat- on which to formulate opinions regard- in American Medicine. New York, NY: isfied with their residency programs and ing and make judgments about the value Churchill Livingstone; 1997. training generally and with most specif- of PA postgraduate residency education 4. Cawley JF. Physician assistants in the health ic aspects related to their education. programs. The data presented in this care workforce. The roles of physician assistants and nurse practitioners in primary The economics of residency education study provide an initial inventory of care. Association of Academic Health were more problematic, although this information about these pioneering pro- Centers, 1993. item was not fully developed in the sur- grams from the perspective of one 5. Asprey D, Helms L. A description of physi- vey instrument. All residents indicated cohort of enrollees. In their view, resi- cian assistant postgraduate residency train- that they would recommend their residency education appears to be con- ing: the director’s perspective. Perspective dency to other PAs interested in the tributing to their professional knowl- on Physician Assistant Education. same specialty. edge and development. A next step 1999;10(3):124-131. This study, in combination with the would be a study to identify long-term 6. Association of Postgraduate Physician previously published data gathered outcomes of postgraduate education Assistant Programs. Recognition of from program directors, serves as a and compare and contrast these out- Postgraduate Physician Assistant Programs starting point and baseline for compre- comes to those of on-the-job training. to the APAP Board of Directors and the AAPA Education Council. Paper presented hensively describing and assessing post- Postgraduate residency education is at: Association of Physician Assistant graduate residency education for PAs. now well established and may grow in Programs Educational Forum; October 23, However, the results raise many ques- popularity over the next several years. 1994; Albuquerque, NM. tions yet to be answered. For example, The PA profession should take a more 7. Katterjohn KR. Legislation: the increasing although there is minimal overlap in active interest in this form of education interest by hospitals in substituting PAs for the information gathered in this study and work with the residency programs housestaff. Physician Assistant and Health with that in the survey of program to develop more systematically their Practitioner. 1979;3(9):8.

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