Article
The Military Veteran to Physician Assistant Pathway: Building the Primary Care Workforce Douglas Brock, PhD, Shannon Bolon, MD, MPH, Keren Wick, PhD, Kenneth Harbert, PhD, MCHES, PA-C, Paul Jacques, DHSc, MEd, PA-C, Timothy Evans, MD, PhD, Athena Abdullah, JD, and F.J. Gianola, PA
Abstract The physician assistant (PA) profession emerged to utilize the skills of returning Vietnam-era military medics and corpsmen to fortify deficits in the health care workforce. Today, the nation again faces projected health care workforce shortages and a significant armed forces drawdown. The authors describe national efforts to address both issues by facilitating veterans’ entrance into civilian PA careers and leveraging their skills. More than 50,000 service personnel with military health care training were discharged between 2006 and 2010. These veterans’ health care experience and maturity make them
T
he physician assistant (PA) profession was founded in the mid- to late 1960s on the premise that returning Vietnamera medics and corpsmen offered added value in extending physicians’ and other providers’ ability to meet our nation’s growing need for high-quality health care. PAs are nationally certified health care professionals, who are state-licensed to practice medicine in teams with physicians and other health care providers. Under the direction of a physician they conduct physical exams, diagnose and treat illnesses, order and interpret tests, prescribe medications, counsel on preventive health care, and assist in surgery. This innovative solution originally sought to address physician shortages in primary
Please see the end of this article for information about the authors. Correspondence should be addressed to Dr. Brock, Department of Family Medicine and MEDEX Northwest, 4311 11th Ave. NE, Suite 200, Seattle, WA 98105; telephone: (206) 616-1736; fax: (206) 616-3889; e-mail: [email protected]. Acad Med. 2013;88:1890–1894. First published online October 14, 2013 doi: 10.1097/ACM.0000000000000011
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ideal candidates for civilian training as primary care providers. They trained and practiced in teams and functioned under minimal supervision to care for a broad range of patients. Military health care personnel are experienced in emergency medicine, urgent care, primary care, public health, and disaster medicine. However, the PA profession scarcely taps this valuable resource. Fewer than 4% of veterans with health care experience may ever apply for civilian PA training. The Health Resources and Services Administration (HRSA) implements two strategies to help prepare and
care and within rural and underserved communities.1,2 The number of students graduating from PA education programs has increased from 3, in 1967,3 to approximately 5,886 students in 2010.4 In sharp contrast to the early years, only 4% of the recent entering PA class nationally were military veterans. Today there are over 170 PA education programs,5 and the number of clinically active PAs is expected to grow by about 72% by 2025.6 The growth in the PA workforce is particularly important as the Affordable Care Act is implemented with the potential to exacerbate the shortage of primary care physicians.7,8 Although PAs have recently been following physician patterns in a shift away from primary care,9,10 there is a potential for veterans with health care experience to, once again, help fill gaps in primary care. Military personnel with considerable health care training and experience are separating from military service in large numbers. These veterans are mature, experienced, and report a strong interest in primary care and rural practice.11 They are highly familiar working within
graduate veterans from PA education programs. First, Primary Care Training and Enhancement (PCTE) grants help develop the primary care workforce. In 2012, HRSA introduced reserved review points for PCTE: Physician Assistant Training in Primary Care applicants with veteran-targeted activities, increasing their likelihood of receiving funding. Second, HRSA leads civilian and military stakeholder workgroups that are identifying recruitment and retention activities and curricula adaptations that maximize veterans’ potential as PAs. Both strategies are described, and early outcomes are presented.
interprofessional health care teams, which are the foundation of advanced practice models such as the primary care medical home.12,13 Recruiting and training veterans with prior health care experience, considerable skills, and an interest in primary care to become civilian PAs may help alleviate anticipated health workforce shortages. The vast majority of PA applicants, however, do not have prior military experience,11 and veterans may experience barriers to entering PA training, such as a minority of programs that accept credits earned by veterans for military training; poor PA program understanding of the GI bill and other financial support for veterans; or concerns about PTSD.11,14 In 2011, the Obama Administration announced the Helping Veterans Become Physician Assistants initiative to make it easier for veterans to use the training they have received in the military to become PAs.15 In this article, we will describe national efforts that facilitate the participation of military veterans in PA educational programs by employing qualitative and quantitative approaches to identify, attract, and prepare veterans for the PA profession.
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Veteran Applicants
Veterans who trained as medics and corpsmen in the military have been given real-world, team-focused training focusing on diagnostic procedures, advanced first aid, basic life support, nursing procedures, minor surgery, basic clinical laboratory procedures, and other routine and emergency health care. Veterans’ skills typically include a foundation in emergency medicine; urgent care; primary care for men, women, and children; public health; and disaster medicine. Military training emphasizes leadership skills, crisis management, and critical thinking. Veterans’ clinical skills include assessment, treatment, care coordination, record management, detecting adverse effects, managing incipient epidemics, and rapid risk assessment of health-compromising exposures. Translating military experience to civilian health care careers capitalizes on veterans’ knowledge and skills while responding to national needs. A research collaboration between the University of Washington and the Physician Assistant Education Association (PAEA), including several of us (D.B., K.W.), analyzed veterans’ applications to PA education.11 In 2012, the Centralized Application Service for Physician Assistants (CASPA)—a standardized application process available to PA education programs—provided access to data for 18,510 applicants, representing 143 PA education programs. Veterans accounted for only 3.8% of the total applicants, and over a third of the veteran applicants reported having no military health care experience. A majority of veteran applicants were male (67.7%), whereas a majority of the nonveteran applicants were female (71%). The average age of veteran applicants was 34.0 years, whereas nonveteran applicants were younger, with an average age of 27.1 years. Veteran and nonveteran applicants had comparable overall GPAs, science GPAs, and GRE quantitative and verbal scores.11 In addition to surveying all veteran applicants, these researchers also surveyed a stratified random sampling of nonveteran applicants.16 This survey demonstrated that for these veteran applicants, the hurdles and challenges of PA training were perceived similarly to those of nonveterans.
Veteran and nonveteran expectations for success in all aspects of PA education were not demonstrably different. While patriotism and educational benefits remain principal reasons reported for enlisting in the military,11,17 more than 30% of surveyed veteran applicants also reported health care training and experience opportunities as major influences for joining the military.11 However, only 17% of veterans reported being able to obtain “most” or “all” of their civilian health care training prerequisites while in the service. Fifty-four percent of survey respondents reported a need to obtain an academic degree after separation from the military before applying to PA education. This survey work was approved by the University of Washington institutional review board. The Helping Veterans Become Physician Assistants Initiative
Recognizing the great, underused potential and resource in veterans with military medical experience, the White House announced the Helping Veterans Become Physician Assistants initiative15 in 2011. This initiative challenged the Health Resources and Services Administration (HRSA) to encourage PA education programs to enhance their recruitment and training activities for veterans and disseminate best practices nationally. The initiative’s objective aligns with HRSA’s mission to improve health and achieve health equity through access to quality services, a skilled health workforce, and innovative programs.18 HRSA administers the initiative through the Primary Care Training and Enhancement: Physician Assistant Training in Primary Care program, a competitive funding opportunity supporting PA education, knowledge of primary care and workforce development, and relationships with civilian and military education stakeholders. In addition, HRSA is facilitating the work of a voluntary workgroup of public and private stakeholders in veteran and PA education who are invested in creating a career path for veterans to enter the civilian PA workforce and to improve the quality of education received by veterans. We describe each of these activities below. Primary Care Training and Enhancement Program
HRSA administers the Primary Care Training and Enhancement (PCTE)
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program, authorized by Title VII Section 747(a) of the Public Health Service Act, to develop the primary care workforce through curriculum innovation, faculty development, and infrastructure enhancement for PA and physician education programs. The Physician Assistant Training in Primary Care program, one of six currently available PCTE funding opportunities, helps accredited PA education programs enhance their curricula and develop their faculty so they can graduate more PAs into primary care careers, strengthen the education they provide, and place more graduates in medically underserved communities. As of March 2013, the Physician Assistant Training in Primary Care grant provides funding to 39 PA education programs across 26 states. The 2012 Physician Assistant Training in Primary Care funding opportunity announcement offered additional review points for grant applications that help veterans matriculate, succeed, and graduate. The extra points increased the likelihood that institutional applicants with veteran-targeted activities receive funding. Institutional applicants described how they adjusted curricula to respond to veterans’ skills and experience, as well as their recruitment, retention, support, and mentoring services that are tailored to the unique strengths and needs of veterans. Eleven of 13 Physician Assistant Training in Primary Care grantees that were newly funded in 2012 received these reserved points. Helping Veterans Become Physician Assistants Initiative Work Group
HRSA hosted public webinars in 2011 and 2012 to identify and disseminate strategies employed by PA education programs to adapt curricula for veterans and implement successful veteran recruiting, retention, and mentoring services. The 2011 webinar yielded such rich discussion that a group of self-identified experts in PA, military, and veteran education and career development formed. HRSA hosts the Helping Veterans Become Physician Assistants Initiative Work Group and provides guidance, communication forums, policy expertise, and connection to outside experts and stakeholders. The members represent PA and military educators and researchers, the
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Department of Defense, Department of Veteran Affairs, Department of Health and Human Services, and professional organizations, including the PAEA and the American Academy of Physician Assistants. The work group meets monthly. Participation is voluntary, and members are not compensated for their time and efforts. PAEA provides free logistical support. The Helping Veterans Become Physician Assistants Initiative Work Group applies its members’ collective expertise to guide civilian and military education communities’ efforts to prepare service members and veterans to be excellent applicants, students, and professional PAs. The work group activities are directed by the consensus that service members and veterans often require additional guidance, support, and education to be successful PA applicants and students. To better address these issues, two subwork groups formed: Veterans Education Transition to Physician Assistant (VET2PA) and Recruitment and Training. HRSA disseminates information about the overall work group’s activities and other resources relevant to civilian PA educators via the Helping Veterans Become Physician Assistants Web pages.19 Veterans Education Transition to Physician Assistant VET2PA is identifying existing and new strategies to bridge the educational divide between military training and formal academic prerequisites for PA education program admission. Initial inquiries revealed diverse approaches in community colleges, four-year institutions, and PA education programs. The group is also exploring how academic programs adapt to and address service members’ and veterans’ unique education needs (e.g., schedules that accommodate lengthy deployments and unfamiliar course transcripts). This group is also addressing career counseling, separation planning, and career ladders spanning military and civilian employment. The VET2PA Work Group has identified PA education programs that use modified prerequisite course requirements to accommodate veterans with few or no college courses prior to entering the military. The American Council on Education (ACE) and the Defense Activity
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for Non-Traditional Education Support (DANTES) assessments of college credit equivalency for military training are universally available tools employed by some programs. ACE and DANTES can decrease the number of required additional college credits to be earned and decrease the delay between discharge from the military and eligibility for PA education program admission. VET2PA inquiries reveal creative approaches and commitment to recruiting and educating veterans to be PAs. Recruitment and Training Work Group The Recruitment and Training Work Group is identifying strategies to facilitate outreach to service members and veterans seeking to enter the civilian PA workforce. Successful outreach requires easy access to information about the PA profession, application prerequisites, educational funding, expectations of students while enrolled, and additional resources available to the veteran student. A large, relatively untapped reservoir of prospective veteran applicants exists.20 Examination of current recruitment practices suggests the solution lies in part with the PA education programs themselves—only a minority have veteran outreach plans, and fewer still have support systems for matriculated veterans.14 In addition to summarizing these resources for potential students, the group intends to produce guidelines for PA education programs seeking to reach this pool of applicants. Blending traditional communication methods and social media tools, the work group hopes to reduce barriers—both actual and perceived—for military medical personnel considering the PA profession as a future career goal. Successful outreach to veterans will benefit from multiple factors, illustrated by the work group’s growing collection of best practices. PA veteran faculty and alumni can leverage their knowledge of military experience, and veterans service organizations and veterans administration offices can facilitate collaboration between PA education programs and various service offices on local military bases. Social media networks and academic Web pages can help establish personal connections with veterans and active duty military. On-base presentations can be organized through educational services, transitional
services, counseling centers, clinics, and hospitals. Education fairs and other community-based events that draw on these collaborations increase accessible information about PA educational opportunities. Recruiting efforts should direct prospective applicants to financial aid opportunities and help applying for GI Bill benefits to finance their education. Once matriculated, veteran PA students transitioning to civilian and student life benefit from mentorship by veteran faculty. Veteran colleagues can provide train-the-trainer faculty development to increase nonveteran faculty’s awareness and skills. Academic-supported veteran counseling services can ease the transition to civilian student life. Such opportunities create student coalitions and foster potential employment opportunities after graduation. Discussion
In response to the White House’s Helping Veterans Become Physician Assistants initiative, HRSA committed to take action to help bring qualified veterans into civilian PA education programs and careers. This initiative resonates with earlier calls to train veterans to support physicians and other health care providers in meeting emerging health care workforce needs, simultaneously leveraging existing training while honoring these veterans’ service. Following the establishment of the Helping Veterans Become Physician Assistants Initiative Work Group, two subgroups were formed specifically to address issues of recruitment and training of veterans and also to identify opportunities that address knowledge, skill, and course gaps and support the transition from service to training. Building on the previous work of many, the work groups are describing and analyzing efforts to overcome obstacles to veterans becoming civilian PAs. The work group’s forthcoming products will improve veterans’ preparation for, admission to, and success in PA education programs. Over 52,000 Army, Navy, and Air Force enlisted personnel with military health care experience left military service between 2006 and 2010.20 These veterans already hold some of the experience necessary to apply to PA education
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programs.* Application rates for veterans might increase if veterans are more aware of the profession, have obtained the educational and experience prerequisites, and see PA training as attainable and suitable to their career aspirations. Additionally, service personnel and veterans may face challenges in fulfilling prerequisites—challenges unrelated to their potential to become skilled PAs. This untapped pool of potential PA students presents a potential solution to addressing the increasing need for primary care and rural clinicians, which also offers a career track for veterans as they rejoin the civilian workforce. Comparison of today’s veteran and nonveteran applicants to PA training identified similarities but notable differences. Evidence suggests that veteran applicants hold equivalent or in some cases more advanced skills compared with their nonveteran counterparts.11 PA program veteran applicants demonstrate similar academic ability to nonveterans and share a strong confidence in their achieving success in PA education.11 However, veteran applicants are older, predominantly male, and report more health care experience than their nonveteran peers.11 As PA education programs seek to welcome veterans into their classrooms, a broad range of outreach activities is required to ensure that PA training is accessible to veterans. Collaboration with the military community and local installations, followed by on-campus support for the veteran student, will facilitate the transition from service to civilian PA training and the veteran’s success. Collaboration across PA education programs will strengthen the ability of the educational community to enhance outreach to and services for these potential students. The public has invested significant resources in training members of the military health care workforce. When these men and women are discharged, they face limited opportunities to apply the full depth and breadth of their training and experience to civilian health careers. Veterans commonly have the life and health care experience needed to * These 52,000, however, do not include veterans leaving the service before 2006 or after 2010 or those veterans who acquire prerequisite health care experience after separating from the service.
serve as culturally sensitive, adaptable, and knowledgeable providers. Facilitating the pathway toward civilian PA careers leverages the public’s investment and veterans’ skills to increase access to care for all Americans. Concluding Remarks
As the men and women of our military return home from service, we as a nation seek ways to ensure that these veterans’ service is honored but also that civilian career opportunities are made available. They entered the service for many reasons, but important among those—and one reinforced by military recruiters—is that they would receive training and experience in addition to educational benefits after leaving the service. Veterans do receive GI Bill support and access to VA services, but perhaps the best way to support our veterans is to honor the educational promises while simultaneously meeting growing workforce challenges. The programs we described seek to reinforce and build new pathways between service and practice, support veterans with civilian health care training opportunities, and, for a second time, give these men and women an opportunity to serve the nation’s needs. Acknowledgments: The authors acknowledge the Department of Health and Human Services Health Resources and Services Administration and the Physician Assistant Education Association for helping to facilitate much of the work underlying this article. The authors specifically thank Tony Miller, Sherillyn Crooks, Kendall Williams, and Crecilla Scott for their insights, assistance, and commitment to supporting veterans seeking to train as physician assistants. Funding/Support: None Other disclosures: None. Ethical approval: Not applicable. Dr. Brock is associate professor, University of Washington Department of Family Medicine and MEDEX Northwest, Seattle, Washington. Dr. Bolon is chief, Primary Care Medical Education Branch, Division of Medicine and Dentistry, Bureau of Health Professions, Department of Health Resources and Services Administration, U.S. Department of Health and Human Services, Washington, DC. Dr. Wick is assistant professor, University of Washington Department of Family Medicine and MEDEX Northwest, Seattle, Washington. Dr. Harbert is dean and program director, South College School of Physician Assistant Studies, Knoxville, Tennessee. Dr. Jacques is associate professor, Division of Physician Assistant Studies, Medical University of South Carolina, Charleston, South Carolina.
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Dr. Evans is associate professor, University of Washington Department of Internal Medicine and MEDEX Northwest, Seattle, Washington. Ms. Abdullah is director of government relations, Physician Assistant Education Association, Alexandria, Virginia. Mr. Gianola is lecturer, University of Washington Department of Family Medicine and MEDEX Northwest, Seattle, Washington.
References 1 Soutter R. Allied Health Personnel: A Report on Their Use in the Military Services as a Model for Use in Nonmilitary HealthCare Programs. Washington, DC: National Academy of Sciences; 1969. 2 Smith RA. MEDEX. JAMA. 1970;211: 1843–1845. 3 Dieter P, Strand J. Snapshots in time: Duke University physician assistant classes. J Physician Assist Educ. 2007;18(3):16–23. 4 Twenty-Sixth Annual Report on Physician Assistant Educational Programs in the United States. Alexandria, Va: Physician Assistant Education Association; 2010. 5 Accreditation Review Commission on Education for the Physician Assistant. Accredited entry-level programs. http://www. arc-pa.org/acc_programs/. Accessed August 15, 2013. 6 Hooker RS, Cawley JF, Everett CM. Predictive modeling the physician assistant supply: 2010–2025. Public Health Rep. 2011;126: 708–716. 7 United States Department of Health and Human Servcies Health Resources and Services Administration. The Physician Workforce: Projections and Research Into Current Issues Affecting Supply and Demand. http://bhpr.hrsa.gov/ healthworkforce/reports/physwfissues.pdf. Accessed August 15, 2013. 8 Dill MJ, Salsberg ES. Center for Workforce Studies. The Complexities of Physician Supply and Demand: Projections Through 2025. Washington, DC: Association of American Medical Colleges; 2008. 9 Morgan PA, Hooker RS. Choice of specialties among physician assistants in the United States. Health Aff (Millwood). 2010;29: 887–892. 10 American Academy of Physician Assistants. Physician Assistant Census Report: Results From the 2010 AAPA Census. http://www. aapa.org/uploadedFiles/content/Common/ Files/2010_Census_Report_Final.pdf. Accessed August 13, 2013. 11 Brock DM, Scott C, Abdullah A. Recruiting veterans to be physician assistants: What can CASPA tell us? Paper presented at: Physician Assistant Education Association Education Forum; November 2012; Seattle, Wash. 12 O’Malley AS, Peikes K, Ginsburg PB. Making medical homes work: Moving from concepts to practice. Agency for Heathcare Research and Quality Web site. http://pcmh.ahrq. gov/portal/server.pt/community/pcmh__ home/1483/PCMH_Defining%20the%20 PCMH_Foundational%20Articles_v2. Accessed August 15, 2013. 13 Bodenheimer T, Grumbach K, Berenson RA. A lifeline for primary care. N Engl J Med. 2009;360:2693–2696.
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Article 14 Michaud E, Jacques PF, Gianola FJ, Harbert K. Assessment of admissions policies for veteran corpsmen and medics applying to physician assistant educational programs. J Physician Assist Educ. 2012;23:4–12. 15 Flavin M. We can’t wait: Supporting our veterans. The White House Blog. October 25, 2011. http://www.whitehouse.gov/ blog/2011/10/25/we-can-t-wait-supportingour-veterans. Accessed August 15, 2013. 16 Brock DM, Gianola FS. Selecting military veterans to physician assistant training.
Paper to be presented at: Physician Assistant Education Association Education Forum, October 2013; Memphis, Tenn. 17 Brock DM, Wick KH, Evans TC, Gianola FJ. The physician assistant profession and military veterans. Mil Med. 2011;176: 197–203. 18 About HRSA. United States Department of Health and Human Servcies Health Resources and Services Administration. http://www.hrsa.gov/about/index.html. Accessed August 15, 2013.
19 United States Department of Health and Human Services, Health Resources and Services Administration. Helping veterans become physician assistants. http://bhpr.hrsa.gov/veterans/ physicianassistants.html. Accessed August 15, 2013. 20 Number of enlisted personnel leaving military service with healthcare experience 2006–2010. Freedom of Information Act (FOIA) request. Department of Defense, 2012.
Cover Art Artist’s Statement: Doctor-Patient The art collage entitled Doctor-Patient shows a doctor and a nurse weighing and confirming the height of a male participant in the Tuskegee Syphilis Study. The upper left corner of the collage shows the John A. Andrew Memorial Hospital on the campus of Tuskegee Institute (now Tuskegee University), where the study was conducted. The faces of the doctor, nurse, and study participant are obscured to emphasize that their personal identity is not as significant as their participation in the study. No matter the role of the individual, each person involved in the study—doctor, nurse, participant—is in some way ignorant of the consequences of his or her actions. During the study, which lasted from 1932 to 1972, doctors from the U.S. Public Health Service studied the progression of untreated syphilis in rural African American men who were misled to believe they were receiving free health care. Doctors involved in the study abused their role as medical experts to direct participants, updating records with their weight and physical condition and regularly testing their blood to check the syphilitic status of participants who were in the nonsyphilitic group. Yet, throughout the 40-year span of the study, the participants never provided informed consent nor received any explanation for why they had to endure painful tests, such as spinal taps done without
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then medical doctors could prove that the black male body reacted to a sexually transmitted disease differently than the white male body.
Doctor-Patient
anesthesia, which eventually caused physical harm and even death for some participants. The doctors who conducted the Tuskegee Syphilis Study defended their deceptive actions as necessary for the greater good of society. For example, although penicillin was a known treatment for syphilis in the 1940s, doctors withheld this treatment because they wanted to observe the effects of nontreatment of syphilis in the African American male body. Their justification for nontreatment was based on a belief that if the nontreatment could be observed,
I was inspired to create this art collage because I was born in the John A. Andrew Memorial Hospital. As a young child, I was aware of the study because my parents worked at Tuskegee Institute during the 1960s when the clinical trial was still being conducted. When I grew older, I wanted to learn more about the historical context of the study. The study’s African American male participants were intentionally deceived about their medical treatment and uninformed about the true intent of the Tuskegee Syphilis Study. Why did this happen, and how could it have continued for so long? As an artist and emerging bioethicist, I am driven to pursue these questions and more through my educational and research endeavors, and this pursuit has inspired and enriched my life both professionally and personally. Acknowledgments: Original images provided by the Tuskegee University Archives, Tuskegee, Alabama and the National Archives and Records Administration, Southeast Region, Morrow, Georgia. Obiora N. Anekwe, EdD Dr. Anekwe is a graduate student in bioethics, Columbia University, New York, New York; e-mail: [email protected].
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The Military Veteran to Physician Assistant Pathway: Building the Primary Care Workforce Douglas Brock, PhD, Shannon Bolon, MD, MPH, Keren Wick, PhD, Kenneth Harbert, PhD, MCHES, PA-C, Paul Jacques, DHSc, MEd, PA-C, Timothy Evans, MD, PhD, Athena Abdullah, JD, and F.J. Gianola, PA
Abstract The physician assistant (PA) profession emerged to utilize the skills of returning Vietnam-era military medics and corpsmen to fortify deficits in the health care workforce. Today, the nation again faces projected health care workforce shortages and a significant armed forces drawdown. The authors describe national efforts to address both issues by facilitating veterans’ entrance into civilian PA careers and leveraging their skills. More than 50,000 service personnel with military health care training were discharged between 2006 and 2010. These veterans’ health care experience and maturity make them
T
he physician assistant (PA) profession was founded in the mid- to late 1960s on the premise that returning Vietnamera medics and corpsmen offered added value in extending physicians’ and other providers’ ability to meet our nation’s growing need for high-quality health care. PAs are nationally certified health care professionals, who are state-licensed to practice medicine in teams with physicians and other health care providers. Under the direction of a physician they conduct physical exams, diagnose and treat illnesses, order and interpret tests, prescribe medications, counsel on preventive health care, and assist in surgery. This innovative solution originally sought to address physician shortages in primary
Please see the end of this article for information about the authors. Correspondence should be addressed to Dr. Brock, Department of Family Medicine and MEDEX Northwest, 4311 11th Ave. NE, Suite 200, Seattle, WA 98105; telephone: (206) 616-1736; fax: (206) 616-3889; e-mail: [email protected]. Acad Med. 2013;88:1890–1894. First published online October 14, 2013 doi: 10.1097/ACM.0000000000000011
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ideal candidates for civilian training as primary care providers. They trained and practiced in teams and functioned under minimal supervision to care for a broad range of patients. Military health care personnel are experienced in emergency medicine, urgent care, primary care, public health, and disaster medicine. However, the PA profession scarcely taps this valuable resource. Fewer than 4% of veterans with health care experience may ever apply for civilian PA training. The Health Resources and Services Administration (HRSA) implements two strategies to help prepare and
care and within rural and underserved communities.1,2 The number of students graduating from PA education programs has increased from 3, in 1967,3 to approximately 5,886 students in 2010.4 In sharp contrast to the early years, only 4% of the recent entering PA class nationally were military veterans. Today there are over 170 PA education programs,5 and the number of clinically active PAs is expected to grow by about 72% by 2025.6 The growth in the PA workforce is particularly important as the Affordable Care Act is implemented with the potential to exacerbate the shortage of primary care physicians.7,8 Although PAs have recently been following physician patterns in a shift away from primary care,9,10 there is a potential for veterans with health care experience to, once again, help fill gaps in primary care. Military personnel with considerable health care training and experience are separating from military service in large numbers. These veterans are mature, experienced, and report a strong interest in primary care and rural practice.11 They are highly familiar working within
graduate veterans from PA education programs. First, Primary Care Training and Enhancement (PCTE) grants help develop the primary care workforce. In 2012, HRSA introduced reserved review points for PCTE: Physician Assistant Training in Primary Care applicants with veteran-targeted activities, increasing their likelihood of receiving funding. Second, HRSA leads civilian and military stakeholder workgroups that are identifying recruitment and retention activities and curricula adaptations that maximize veterans’ potential as PAs. Both strategies are described, and early outcomes are presented.
interprofessional health care teams, which are the foundation of advanced practice models such as the primary care medical home.12,13 Recruiting and training veterans with prior health care experience, considerable skills, and an interest in primary care to become civilian PAs may help alleviate anticipated health workforce shortages. The vast majority of PA applicants, however, do not have prior military experience,11 and veterans may experience barriers to entering PA training, such as a minority of programs that accept credits earned by veterans for military training; poor PA program understanding of the GI bill and other financial support for veterans; or concerns about PTSD.11,14 In 2011, the Obama Administration announced the Helping Veterans Become Physician Assistants initiative to make it easier for veterans to use the training they have received in the military to become PAs.15 In this article, we will describe national efforts that facilitate the participation of military veterans in PA educational programs by employing qualitative and quantitative approaches to identify, attract, and prepare veterans for the PA profession.
Academic Medicine, Vol. 88, No. 12 / December 2013
Article
Veteran Applicants
Veterans who trained as medics and corpsmen in the military have been given real-world, team-focused training focusing on diagnostic procedures, advanced first aid, basic life support, nursing procedures, minor surgery, basic clinical laboratory procedures, and other routine and emergency health care. Veterans’ skills typically include a foundation in emergency medicine; urgent care; primary care for men, women, and children; public health; and disaster medicine. Military training emphasizes leadership skills, crisis management, and critical thinking. Veterans’ clinical skills include assessment, treatment, care coordination, record management, detecting adverse effects, managing incipient epidemics, and rapid risk assessment of health-compromising exposures. Translating military experience to civilian health care careers capitalizes on veterans’ knowledge and skills while responding to national needs. A research collaboration between the University of Washington and the Physician Assistant Education Association (PAEA), including several of us (D.B., K.W.), analyzed veterans’ applications to PA education.11 In 2012, the Centralized Application Service for Physician Assistants (CASPA)—a standardized application process available to PA education programs—provided access to data for 18,510 applicants, representing 143 PA education programs. Veterans accounted for only 3.8% of the total applicants, and over a third of the veteran applicants reported having no military health care experience. A majority of veteran applicants were male (67.7%), whereas a majority of the nonveteran applicants were female (71%). The average age of veteran applicants was 34.0 years, whereas nonveteran applicants were younger, with an average age of 27.1 years. Veteran and nonveteran applicants had comparable overall GPAs, science GPAs, and GRE quantitative and verbal scores.11 In addition to surveying all veteran applicants, these researchers also surveyed a stratified random sampling of nonveteran applicants.16 This survey demonstrated that for these veteran applicants, the hurdles and challenges of PA training were perceived similarly to those of nonveterans.
Veteran and nonveteran expectations for success in all aspects of PA education were not demonstrably different. While patriotism and educational benefits remain principal reasons reported for enlisting in the military,11,17 more than 30% of surveyed veteran applicants also reported health care training and experience opportunities as major influences for joining the military.11 However, only 17% of veterans reported being able to obtain “most” or “all” of their civilian health care training prerequisites while in the service. Fifty-four percent of survey respondents reported a need to obtain an academic degree after separation from the military before applying to PA education. This survey work was approved by the University of Washington institutional review board. The Helping Veterans Become Physician Assistants Initiative
Recognizing the great, underused potential and resource in veterans with military medical experience, the White House announced the Helping Veterans Become Physician Assistants initiative15 in 2011. This initiative challenged the Health Resources and Services Administration (HRSA) to encourage PA education programs to enhance their recruitment and training activities for veterans and disseminate best practices nationally. The initiative’s objective aligns with HRSA’s mission to improve health and achieve health equity through access to quality services, a skilled health workforce, and innovative programs.18 HRSA administers the initiative through the Primary Care Training and Enhancement: Physician Assistant Training in Primary Care program, a competitive funding opportunity supporting PA education, knowledge of primary care and workforce development, and relationships with civilian and military education stakeholders. In addition, HRSA is facilitating the work of a voluntary workgroup of public and private stakeholders in veteran and PA education who are invested in creating a career path for veterans to enter the civilian PA workforce and to improve the quality of education received by veterans. We describe each of these activities below. Primary Care Training and Enhancement Program
HRSA administers the Primary Care Training and Enhancement (PCTE)
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program, authorized by Title VII Section 747(a) of the Public Health Service Act, to develop the primary care workforce through curriculum innovation, faculty development, and infrastructure enhancement for PA and physician education programs. The Physician Assistant Training in Primary Care program, one of six currently available PCTE funding opportunities, helps accredited PA education programs enhance their curricula and develop their faculty so they can graduate more PAs into primary care careers, strengthen the education they provide, and place more graduates in medically underserved communities. As of March 2013, the Physician Assistant Training in Primary Care grant provides funding to 39 PA education programs across 26 states. The 2012 Physician Assistant Training in Primary Care funding opportunity announcement offered additional review points for grant applications that help veterans matriculate, succeed, and graduate. The extra points increased the likelihood that institutional applicants with veteran-targeted activities receive funding. Institutional applicants described how they adjusted curricula to respond to veterans’ skills and experience, as well as their recruitment, retention, support, and mentoring services that are tailored to the unique strengths and needs of veterans. Eleven of 13 Physician Assistant Training in Primary Care grantees that were newly funded in 2012 received these reserved points. Helping Veterans Become Physician Assistants Initiative Work Group
HRSA hosted public webinars in 2011 and 2012 to identify and disseminate strategies employed by PA education programs to adapt curricula for veterans and implement successful veteran recruiting, retention, and mentoring services. The 2011 webinar yielded such rich discussion that a group of self-identified experts in PA, military, and veteran education and career development formed. HRSA hosts the Helping Veterans Become Physician Assistants Initiative Work Group and provides guidance, communication forums, policy expertise, and connection to outside experts and stakeholders. The members represent PA and military educators and researchers, the
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Department of Defense, Department of Veteran Affairs, Department of Health and Human Services, and professional organizations, including the PAEA and the American Academy of Physician Assistants. The work group meets monthly. Participation is voluntary, and members are not compensated for their time and efforts. PAEA provides free logistical support. The Helping Veterans Become Physician Assistants Initiative Work Group applies its members’ collective expertise to guide civilian and military education communities’ efforts to prepare service members and veterans to be excellent applicants, students, and professional PAs. The work group activities are directed by the consensus that service members and veterans often require additional guidance, support, and education to be successful PA applicants and students. To better address these issues, two subwork groups formed: Veterans Education Transition to Physician Assistant (VET2PA) and Recruitment and Training. HRSA disseminates information about the overall work group’s activities and other resources relevant to civilian PA educators via the Helping Veterans Become Physician Assistants Web pages.19 Veterans Education Transition to Physician Assistant VET2PA is identifying existing and new strategies to bridge the educational divide between military training and formal academic prerequisites for PA education program admission. Initial inquiries revealed diverse approaches in community colleges, four-year institutions, and PA education programs. The group is also exploring how academic programs adapt to and address service members’ and veterans’ unique education needs (e.g., schedules that accommodate lengthy deployments and unfamiliar course transcripts). This group is also addressing career counseling, separation planning, and career ladders spanning military and civilian employment. The VET2PA Work Group has identified PA education programs that use modified prerequisite course requirements to accommodate veterans with few or no college courses prior to entering the military. The American Council on Education (ACE) and the Defense Activity
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for Non-Traditional Education Support (DANTES) assessments of college credit equivalency for military training are universally available tools employed by some programs. ACE and DANTES can decrease the number of required additional college credits to be earned and decrease the delay between discharge from the military and eligibility for PA education program admission. VET2PA inquiries reveal creative approaches and commitment to recruiting and educating veterans to be PAs. Recruitment and Training Work Group The Recruitment and Training Work Group is identifying strategies to facilitate outreach to service members and veterans seeking to enter the civilian PA workforce. Successful outreach requires easy access to information about the PA profession, application prerequisites, educational funding, expectations of students while enrolled, and additional resources available to the veteran student. A large, relatively untapped reservoir of prospective veteran applicants exists.20 Examination of current recruitment practices suggests the solution lies in part with the PA education programs themselves—only a minority have veteran outreach plans, and fewer still have support systems for matriculated veterans.14 In addition to summarizing these resources for potential students, the group intends to produce guidelines for PA education programs seeking to reach this pool of applicants. Blending traditional communication methods and social media tools, the work group hopes to reduce barriers—both actual and perceived—for military medical personnel considering the PA profession as a future career goal. Successful outreach to veterans will benefit from multiple factors, illustrated by the work group’s growing collection of best practices. PA veteran faculty and alumni can leverage their knowledge of military experience, and veterans service organizations and veterans administration offices can facilitate collaboration between PA education programs and various service offices on local military bases. Social media networks and academic Web pages can help establish personal connections with veterans and active duty military. On-base presentations can be organized through educational services, transitional
services, counseling centers, clinics, and hospitals. Education fairs and other community-based events that draw on these collaborations increase accessible information about PA educational opportunities. Recruiting efforts should direct prospective applicants to financial aid opportunities and help applying for GI Bill benefits to finance their education. Once matriculated, veteran PA students transitioning to civilian and student life benefit from mentorship by veteran faculty. Veteran colleagues can provide train-the-trainer faculty development to increase nonveteran faculty’s awareness and skills. Academic-supported veteran counseling services can ease the transition to civilian student life. Such opportunities create student coalitions and foster potential employment opportunities after graduation. Discussion
In response to the White House’s Helping Veterans Become Physician Assistants initiative, HRSA committed to take action to help bring qualified veterans into civilian PA education programs and careers. This initiative resonates with earlier calls to train veterans to support physicians and other health care providers in meeting emerging health care workforce needs, simultaneously leveraging existing training while honoring these veterans’ service. Following the establishment of the Helping Veterans Become Physician Assistants Initiative Work Group, two subgroups were formed specifically to address issues of recruitment and training of veterans and also to identify opportunities that address knowledge, skill, and course gaps and support the transition from service to training. Building on the previous work of many, the work groups are describing and analyzing efforts to overcome obstacles to veterans becoming civilian PAs. The work group’s forthcoming products will improve veterans’ preparation for, admission to, and success in PA education programs. Over 52,000 Army, Navy, and Air Force enlisted personnel with military health care experience left military service between 2006 and 2010.20 These veterans already hold some of the experience necessary to apply to PA education
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programs.* Application rates for veterans might increase if veterans are more aware of the profession, have obtained the educational and experience prerequisites, and see PA training as attainable and suitable to their career aspirations. Additionally, service personnel and veterans may face challenges in fulfilling prerequisites—challenges unrelated to their potential to become skilled PAs. This untapped pool of potential PA students presents a potential solution to addressing the increasing need for primary care and rural clinicians, which also offers a career track for veterans as they rejoin the civilian workforce. Comparison of today’s veteran and nonveteran applicants to PA training identified similarities but notable differences. Evidence suggests that veteran applicants hold equivalent or in some cases more advanced skills compared with their nonveteran counterparts.11 PA program veteran applicants demonstrate similar academic ability to nonveterans and share a strong confidence in their achieving success in PA education.11 However, veteran applicants are older, predominantly male, and report more health care experience than their nonveteran peers.11 As PA education programs seek to welcome veterans into their classrooms, a broad range of outreach activities is required to ensure that PA training is accessible to veterans. Collaboration with the military community and local installations, followed by on-campus support for the veteran student, will facilitate the transition from service to civilian PA training and the veteran’s success. Collaboration across PA education programs will strengthen the ability of the educational community to enhance outreach to and services for these potential students. The public has invested significant resources in training members of the military health care workforce. When these men and women are discharged, they face limited opportunities to apply the full depth and breadth of their training and experience to civilian health careers. Veterans commonly have the life and health care experience needed to * These 52,000, however, do not include veterans leaving the service before 2006 or after 2010 or those veterans who acquire prerequisite health care experience after separating from the service.
serve as culturally sensitive, adaptable, and knowledgeable providers. Facilitating the pathway toward civilian PA careers leverages the public’s investment and veterans’ skills to increase access to care for all Americans. Concluding Remarks
As the men and women of our military return home from service, we as a nation seek ways to ensure that these veterans’ service is honored but also that civilian career opportunities are made available. They entered the service for many reasons, but important among those—and one reinforced by military recruiters—is that they would receive training and experience in addition to educational benefits after leaving the service. Veterans do receive GI Bill support and access to VA services, but perhaps the best way to support our veterans is to honor the educational promises while simultaneously meeting growing workforce challenges. The programs we described seek to reinforce and build new pathways between service and practice, support veterans with civilian health care training opportunities, and, for a second time, give these men and women an opportunity to serve the nation’s needs. Acknowledgments: The authors acknowledge the Department of Health and Human Services Health Resources and Services Administration and the Physician Assistant Education Association for helping to facilitate much of the work underlying this article. The authors specifically thank Tony Miller, Sherillyn Crooks, Kendall Williams, and Crecilla Scott for their insights, assistance, and commitment to supporting veterans seeking to train as physician assistants. Funding/Support: None Other disclosures: None. Ethical approval: Not applicable. Dr. Brock is associate professor, University of Washington Department of Family Medicine and MEDEX Northwest, Seattle, Washington. Dr. Bolon is chief, Primary Care Medical Education Branch, Division of Medicine and Dentistry, Bureau of Health Professions, Department of Health Resources and Services Administration, U.S. Department of Health and Human Services, Washington, DC. Dr. Wick is assistant professor, University of Washington Department of Family Medicine and MEDEX Northwest, Seattle, Washington. Dr. Harbert is dean and program director, South College School of Physician Assistant Studies, Knoxville, Tennessee. Dr. Jacques is associate professor, Division of Physician Assistant Studies, Medical University of South Carolina, Charleston, South Carolina.
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Dr. Evans is associate professor, University of Washington Department of Internal Medicine and MEDEX Northwest, Seattle, Washington. Ms. Abdullah is director of government relations, Physician Assistant Education Association, Alexandria, Virginia. Mr. Gianola is lecturer, University of Washington Department of Family Medicine and MEDEX Northwest, Seattle, Washington.
References 1 Soutter R. Allied Health Personnel: A Report on Their Use in the Military Services as a Model for Use in Nonmilitary HealthCare Programs. Washington, DC: National Academy of Sciences; 1969. 2 Smith RA. MEDEX. JAMA. 1970;211: 1843–1845. 3 Dieter P, Strand J. Snapshots in time: Duke University physician assistant classes. J Physician Assist Educ. 2007;18(3):16–23. 4 Twenty-Sixth Annual Report on Physician Assistant Educational Programs in the United States. Alexandria, Va: Physician Assistant Education Association; 2010. 5 Accreditation Review Commission on Education for the Physician Assistant. Accredited entry-level programs. http://www. arc-pa.org/acc_programs/. Accessed August 15, 2013. 6 Hooker RS, Cawley JF, Everett CM. Predictive modeling the physician assistant supply: 2010–2025. Public Health Rep. 2011;126: 708–716. 7 United States Department of Health and Human Servcies Health Resources and Services Administration. The Physician Workforce: Projections and Research Into Current Issues Affecting Supply and Demand. http://bhpr.hrsa.gov/ healthworkforce/reports/physwfissues.pdf. Accessed August 15, 2013. 8 Dill MJ, Salsberg ES. Center for Workforce Studies. The Complexities of Physician Supply and Demand: Projections Through 2025. Washington, DC: Association of American Medical Colleges; 2008. 9 Morgan PA, Hooker RS. Choice of specialties among physician assistants in the United States. Health Aff (Millwood). 2010;29: 887–892. 10 American Academy of Physician Assistants. Physician Assistant Census Report: Results From the 2010 AAPA Census. http://www. aapa.org/uploadedFiles/content/Common/ Files/2010_Census_Report_Final.pdf. Accessed August 13, 2013. 11 Brock DM, Scott C, Abdullah A. Recruiting veterans to be physician assistants: What can CASPA tell us? Paper presented at: Physician Assistant Education Association Education Forum; November 2012; Seattle, Wash. 12 O’Malley AS, Peikes K, Ginsburg PB. Making medical homes work: Moving from concepts to practice. Agency for Heathcare Research and Quality Web site. http://pcmh.ahrq. gov/portal/server.pt/community/pcmh__ home/1483/PCMH_Defining%20the%20 PCMH_Foundational%20Articles_v2. Accessed August 15, 2013. 13 Bodenheimer T, Grumbach K, Berenson RA. A lifeline for primary care. N Engl J Med. 2009;360:2693–2696.
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Article 14 Michaud E, Jacques PF, Gianola FJ, Harbert K. Assessment of admissions policies for veteran corpsmen and medics applying to physician assistant educational programs. J Physician Assist Educ. 2012;23:4–12. 15 Flavin M. We can’t wait: Supporting our veterans. The White House Blog. October 25, 2011. http://www.whitehouse.gov/ blog/2011/10/25/we-can-t-wait-supportingour-veterans. Accessed August 15, 2013. 16 Brock DM, Gianola FS. Selecting military veterans to physician assistant training.
Paper to be presented at: Physician Assistant Education Association Education Forum, October 2013; Memphis, Tenn. 17 Brock DM, Wick KH, Evans TC, Gianola FJ. The physician assistant profession and military veterans. Mil Med. 2011;176: 197–203. 18 About HRSA. United States Department of Health and Human Servcies Health Resources and Services Administration. http://www.hrsa.gov/about/index.html. Accessed August 15, 2013.
19 United States Department of Health and Human Services, Health Resources and Services Administration. Helping veterans become physician assistants. http://bhpr.hrsa.gov/veterans/ physicianassistants.html. Accessed August 15, 2013. 20 Number of enlisted personnel leaving military service with healthcare experience 2006–2010. Freedom of Information Act (FOIA) request. Department of Defense, 2012.
Cover Art Artist’s Statement: Doctor-Patient The art collage entitled Doctor-Patient shows a doctor and a nurse weighing and confirming the height of a male participant in the Tuskegee Syphilis Study. The upper left corner of the collage shows the John A. Andrew Memorial Hospital on the campus of Tuskegee Institute (now Tuskegee University), where the study was conducted. The faces of the doctor, nurse, and study participant are obscured to emphasize that their personal identity is not as significant as their participation in the study. No matter the role of the individual, each person involved in the study—doctor, nurse, participant—is in some way ignorant of the consequences of his or her actions. During the study, which lasted from 1932 to 1972, doctors from the U.S. Public Health Service studied the progression of untreated syphilis in rural African American men who were misled to believe they were receiving free health care. Doctors involved in the study abused their role as medical experts to direct participants, updating records with their weight and physical condition and regularly testing their blood to check the syphilitic status of participants who were in the nonsyphilitic group. Yet, throughout the 40-year span of the study, the participants never provided informed consent nor received any explanation for why they had to endure painful tests, such as spinal taps done without
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then medical doctors could prove that the black male body reacted to a sexually transmitted disease differently than the white male body.
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anesthesia, which eventually caused physical harm and even death for some participants. The doctors who conducted the Tuskegee Syphilis Study defended their deceptive actions as necessary for the greater good of society. For example, although penicillin was a known treatment for syphilis in the 1940s, doctors withheld this treatment because they wanted to observe the effects of nontreatment of syphilis in the African American male body. Their justification for nontreatment was based on a belief that if the nontreatment could be observed,
I was inspired to create this art collage because I was born in the John A. Andrew Memorial Hospital. As a young child, I was aware of the study because my parents worked at Tuskegee Institute during the 1960s when the clinical trial was still being conducted. When I grew older, I wanted to learn more about the historical context of the study. The study’s African American male participants were intentionally deceived about their medical treatment and uninformed about the true intent of the Tuskegee Syphilis Study. Why did this happen, and how could it have continued for so long? As an artist and emerging bioethicist, I am driven to pursue these questions and more through my educational and research endeavors, and this pursuit has inspired and enriched my life both professionally and personally. Acknowledgments: Original images provided by the Tuskegee University Archives, Tuskegee, Alabama and the National Archives and Records Administration, Southeast Region, Morrow, Georgia. Obiora N. Anekwe, EdD Dr. Anekwe is a graduate student in bioethics, Columbia University, New York, New York; e-mail: [email protected].
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