Already facing a shortage of primary care physicians, the state of Iowa also may soon face a shortage of physician assistants, according to a new study from the University of Iowa.

The study found that 32 percent of the state’s 873 physician assistants (PAs) were age 50 or older in 2015, says co-author Tom Gruca, professor of marketing in the Tippie College of Business. He says the dropout rate already averages 5 percent per year, a number that will increase significantly as PAs retire, if the trend continues.

“Iowa faces a challenge to recruit and retain 30 percent of its entire PA workforce in the next 15 years,” Gruca says. He points out that a higher proportion of Iowa’s PAs practice in primary care—56 percent—when compared to the nation as a whole—30 percent.

Iowa has become increasingly dependent upon PAs to provide primary care services in recent decades, filling the gaps as the number of practicing primary care physicians has declined in most parts of the state. This is particularly true in rural counties, many of which have such a severe shortage they have too few primary care physicians to meet the growing needs of an aging population. Gruca says 30 percent of Iowa’s PA workforce practice in rural areas, compared to 15 percent nationwide. Also, 44 percent of the state’s PAs practice in the 61 counties the federal government designates as underserved by primary care physicians.

Many of those underserved counties also have high percentages of elderly residents who require additional health care services, and a shortage of PAs would significantly affect that population. PA retirements would have an outsized impact on these counties as well because new graduates will have more lucrative opportunities in urban areas or in specialized care, making it harder to replace those who retire from rural practices, according to the study.

“It seems apparent that Iowa depends heavily on its PA workforce to provide primary care to its most vulnerable citizens,” Gruca says.

The state for years had only two schools with PA training programs—the UI Roy J. and Lucille A. Carver College of Medicine and Des Moines University—that trained about half of all PAs who provide care to Iowans. But Gruca’s study found only about 25 percent of graduates from those programs were still practicing in Iowa in 2015, the remaining having either moved to another state, left their practice, or retired.

Two other Iowa universities recently started training programs—St. Ambrose University in Davenport in 2016 and the University of Dubuque in 2018—but Gruca says those programs may not produce enough graduates to offset the anticipated losses in coming years.

“Despite the increased supply provided by the new training programs, the historical retention rate may be not be sufficient to meet the demands due to shifts in care models and retirements or relocations,” Gruca says. “A statewide strategy is needed to recruit PAs into primary care, especially in rural or underserved areas, as well as to retain PAs already practicing in the state.”

The Carver College of Medicine has offered a Physician Assistant program since 1972 and graduates 25 new PAs every year.

The program takes 28 months to complete, and David Asprey, chair of the Department of Physician Assistant Studies and Services, says students must have some level of hands-on health care experience before applying, such as EMT, military medic, nurse or nursing assistant, or physical aide. About half stay in Iowa to practice, he says.

While about one-third of the 240 PA training programs in the country are affiliated with a medical school, Asprey says none are as deeply integrated into an existing MD program as the UI’s. For instance, UI has the only program in which PA and MD students take identical coursework and study together for their first three semesters.

“Our PA graduates might work alongside doctors more effectively in a clinical setting since they have so much shared education,” Asprey says. “At the same time, the innovative curriculum prepares students to move far beyond simple memorization of facts and figures to developing skills designed to prepare them as lifelong learners.”

The UI’s program is consistently ranked among the best in the country by U.S. News & World Report and was ranked No. 2 in the most recent survey.

What policy changes can be made to avoid a future shortage? Asprey and Gruca say several options could be considered:

• Increase retention of PAs trained at Iowa institutions by encouraging practices to interact with them while they’re still students. Job fairs and other face-to-face interactions can help encourage students to stay in Iowa before they make their post-graduation plans.
• Supervising physicians can help by interacting more with PAs through mentoring, listening to the challenges they face, or just meeting with them outside of chart reviews.
• Practices can provide funding and time off to help PAs complete the considerable amount of required continuing professional education, which demonstrates a commitment to their assistants as valued professionals.
• Ensure that PAs are allowed to practice to the full scope of their training.
• Consider incentive programs to recruit and retain PAs in high-need areas of the state, such as student loan repayments.

Gruca’s study, “The Workforce Trends of Physician Assistants in Iowa (1995–2015),” was co-authored by Gregory Nelson, Linda Thiesen, and David Asprey of the Carver College of Medicine, and Sean Young of the University of Arkansas for Medical Sciences. It was published in the October 2018 edition of the journal PLOS ONE.