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- [00:00]
Andre
Foreign.
- [00:06]
Podcast Host
Welcome to the Java Podcast. Listeners can now earn CME by listening to the podcast. To receive your CME credit, access your certificate. You just listen to the podcast, then complete the post test and evaluation in AAPA's Learning Central at cme.aapa.org Educational debt is a Hot Topic Knowing that our listeners are both Prospective and practicing PAs, many of you are considering or have experienced the effects of taking student loans. Recently, a team of researchers at the NCCPA examined the impact of educational debt on PA specialty selection. We are thrilled that they are joining us to discuss their work as recently published in japa. Andre is a Senior Director of Research at the NCCPA and holds a PhD in Applied Organizational Psychology. Impressive. He's an extremely talented researcher who has contributed to our understanding of our profession. Alicia is the Director of communications in a PA relations at the NCCPA, a PA and PhD. She was an early graduate of the AAPA PA EA Research Fellowship and has experience as a PA educator, a PA Program director, and if that's not enough, she's been very active in state PA associations. Mirella is also a PA and PhD. You may already know her for the Med State article on the predictors of PA work Life balance. Definitely came around to my phone many times and she is known for her commitment of advocating for PA research that has resulted in a large volume of NCCPA studies. So welcome to the podcast all.
- [01:36]
Andre
Thank you, thank you for having us.
- [01:38]
Podcast Host
Before we dive into discussing educational debt, can y' all share more about your background, your path to joining the nccpa, and what inspired you to research the PA profession?
- [01:47]
Andre
It was just good luck I guess. I worked at Northwell Health for almost a decade as a researcher, so working on patient outcomes research, health services research. And I remember we were ahead of vacation and this recruiter kept on reaching out to me for over a decade. I wasn't searching for a new position or anything like that, but because I was on vacation I kind of just let me check my Gmail and kind of burst the information and it was, you know, it was something from nccpa. So I kind of like what's nccpa? It's a board certification organization. Kind of dove a little bit deeper into it. It was about the PA profession and I remember looking at the reports that NCCPA had generated, the core reports, and I was super impressed with the quality of that data set and I just saw a huge opportunity in terms of conducting more in depth analyses with that data. So not just providing reports but also diving deeper into topics such as the one that we're going to talk about today. But I just saw a huge opportunity there. So that's how I kind of just by sheer luck, I guess, that one time I looked at that email. But that's my story.
- [02:50]
Alicia
I also attributed a lot to luck. So during the pandemic, I was a PA educator, but also I worked in primary care. And I started looking at jobs more on the national level. And so I came across this position which at the time required a lot of travel. But my, you know, family was at the point where I could travel a lot.
- [03:12]
Mirella
And.
- [03:12]
Alicia
And so I thought, huh, traveling around to speak with PA state specialties sounds really attractive. And so again, I just found the job listing and I applied. It was a very rigorous process, but I luckily was chosen. So that's how I got here.
- [03:29]
Mirella
I think you're going to hear another story of luck. So just a little bit of my background. I've been a PA for about 18 years and I still practice clinically, mostly in primary care and endocrine. And then I was a PA educator for 10 years. And then as I was transitioning from clinician to education, I realized that I was not familiar with certain aspect of my role. And I did a lot of assessment and program evaluation. So I pursued a doctorate in higher ed and policy with a concentration in research and assessment. And then I realized that I fell in love with research. Believe it or not, nobody does. So that led me to the path of nccb. And I actually wasn't looking for a specific job, but it was one of those things that somebody introduced me and I was gonna work on things that had to do with our profession, which I still practice clinically. Cause I love it and research. And I'm like, what's the best place to like, blend the two things I love? So that's how I got here.
- [04:31]
Listener/Interviewer
That's very interesting. And to learn how you guys get into this path. As the sole organization certifying pas in the U.S. the NCCPA owns a rich database of information on all of the practicing PAs. Can you briefly describe how the NCCPA collects data on pas and also how the NCPA utilizes that data?
- [04:52]
Mirella
A lot of people are not familiar. Sometimes I remember when my students used to ask me questions like, how do I know how much PA is? Can I Google it? I used to always send them to the website because I was very familiar with the website before I even started working here. So we do have a lot of information. And NCCPA has been collecting data on board certified PA since 2012. And it has three main modules that we collect data. It's about me that talks mostly about demographic composition of our profession, my practice, that is practice characteristics, you know, what specialty PAs work, what's the income they make, how many hours they work, what state they live, and so on. And also recently certified, which actually collects information about the recently graduated PAs that have just been board certified. And that's actually the module that we conducted this research because that particular module stays open for about a year or whenever the PA is completed. The other two modules are more flexible and PAs can complete it and revise it and update it at any point. So having that huge information about our profession, we utilize the data to monitor the PA workforce composition and growth. We use the data to conduct this particular research that we're discussing today about our profession, which is very, very valuable. We also use the data to go to conferences and publish our research in peer review journals because we want to promote our profession and we hope that through the research we can not only promote our profession, but also we can use this to advocate our profession. So those are some of the aspects. Another thing that probably most of our viewers do not know is that we actually do conduct research in collaboration with external researcher. So if anybody's interesting or has a study that we have the data, they can always contact us in our website. And we work very, very closely with them to kind of guide them through the research. So that's if anyone is interesting and promoting collaboration.
- [07:11]
Andre
Yeah, that's an excellent point Marla just made. So particularly since she started, just the number of studies and external collaborations that we've had is just sky reckoning. So we definitely welcome any kinds of PAs that are interested in research to submit their applications. It's a very quick process and there's help also with any questions on how to fill up the application. And like Marla said, it's a very collaborative kind of study. So we work very closely with the researchers to, you know, to analyze the data, to draft the manuscripts, to submit it to peer reviewed publications, revisions and all that stuff.
- [07:45]
Listener/Interviewer
So that's very interesting. Until I started volunteering for NCCP and going to the office, I always thought of NCCP as our board certified certifying organization. I never even knew they did research or collected all this data. And that's when I realized how much data they have. Like, it's incredible. I would not know that until going there to their office and see everything that they do. And I find very interesting. I thought you guys, you know, they were just administering exams to certify pa. So that's very interesting to me and that's why I also volunteer Fantasy pa. So you began your article with a few jaw dropping statistics about increasing educational death among healthcare providers. Those numbers were really eye opening to me because I graduated PA school like more than 10 years ago and those were not the death that we were collecting back then. So the association of American Medical Colleges reported medical school debt increased by 25% from 2009 to 2019 and that the percentage of new graduate PAs with more than $100,000 in debt rose from 51.9% in 2013 to 63.6% in 2022. You also describe the complex and nuanced relationship between educational depth and specialization among medical students and residents. As accomplished academics, researchers and clinicians, you have experienced the growing costs associated with higher education. How did your experience influence your research? Question.
- [09:14]
Mirella
Those statistics are pretty eye opening. I think whenever we focus on a topic or something that is a high interest to the profession, we always look at the statistics because it kind of guides you like where things started and where we are right now. And educational debt has increased substantially in the past decade, not only for the healthcare profession but also for other higher education in general. But those particular statistics have been more significant in medical and PA education. And the other thing that sometimes we, I mean as a pa, we probably know, but maybe some of our listening that PE students typically use or to finance their education by loans and they usually are not able to get institutional or federal funds or if they are, they're pretty limited at that point. So as you mentioned earlier, there is plethora of research on medical students, MPA students on educational debt, but there is limited information on PAS and PA student education. At the same time when we looked at their literature because we were interested in this particular topic, there is a lot of controversial studies on educational debt and specialty choices for physician. Also Alicia, I think mentioned earlier that she's had a lot of experience in primary care. And then we also noticed that the proportion of PAs that are selecting primary care as a specialty has decreased over time and that's the area of greatest need for our nation. So as going back to our roots as the PAs as PAs, the PA profession was developed to fill the gaps in healthcare, especially in primary care setting and underserved and those trends have changed over time. So by going back to our prior research looking at our profession, we wanted to explore if the same educational debt factors that affected physician or medical students to change their career tracks or their specialist choice. Was it the same for PAs as well? So that's what guided our research question.
- [11:34]
Additional Interviewer
I thought this was super interesting because researchers have been working to identify which factors contribute to a PA's specialty choice for some time, and I think we can all agree. And as your article pointed out, it's a really complicated question. It involves a lot of individual goals for the pa, experiences in PA school, job availability for each of the different locations, compensation levels of debt that are accrued in that training. So in designing your study, how did you incorporate the many factors that could influence a practicing PA's specialization?
- [12:08]
Mirella
I know Andre is going to go later and talk a little bit more on the specific, but we typically choose a study by looking, like I said earlier on prior research and the review of literature, and seeing what factors have influenced either physician or medical students or other healthcare professions. And we also look at our database and what information we have that we can contribute and if it's anything else extra. For instance, like prior research on medical students and medical resident has shown that educational debt and specialty choices among physicians differs by age, gender, race, and geographic locations. So by taking some of these factors that we included, we wanted to explore if there were the similar factors that influences specialty choices among PAs. And Andre will probably go in more details on that as primary author, so I'm going to leave that privileges to him.
- [13:09]
Andre
Essentially, our strategy is always we kind of look at the data that we have available first. And every study that we conduct, that always leads to more questions. There's never one study that can account for every single factor in the entire universe, but each study kind of leads to some answers and then further questions. So that's essentially what we tend to do. And what we also do is we kind of scoured the literature to kind of add topics to the PE profile. So, for example, this year we've added quite a few questions, probably more than 15 questions, that specifically look at some of those determining factors for specialty choices among all PAs. So we're certainly looking forward to collecting that data in 2025 and conducting another study, maybe in 2026.
- [13:52]
Additional Interviewer
Yeah. Thank you. So to address your research question, you utilized data from the NCCPA's recently certified PA module, which captured reports from 11,762 PAs who were certified for the first first time in 2023. Can you tell us more about the module? You kind of have mentioned it earlier as well. How did you begin to analyze this massive data set that included both quantitative and qualitative measures?
- [14:18]
Andre
So as Mirella mentioned the recently certified module. That specific module is available for about one year for pas. We specifically want to explore new pas to the profession about their experiences with their job search, their preferences for their positions and the attributes of those positions. So in that module we asked PAs who accepted a position, a variety of questions such as what were the types of specialties that they accepted if they're student debt influenced their choice, if they were offered incentives such as loan repayment and their starting salary and kind of similar questions for PAs who haven't accepted yet, but the preferences for those specialties and as well as if the educational debt impacted the preferences. And we also, this was quite important, but we had asked PAS open ended questions and this was really just critically important because talking about statistical significance all day long is, is great, but not until you, you read the comments. So we had quite a few comments, thousands of comments that we culled through. And that rich data set provided quite a bit of insights into many of the strategies that payees rely on to pay off their educational debt. But also student loan debt has received considerable national attention in the past few years. So we wanted to examine this important topic specifically in the PE profession. We first looked at it actually in 2021 and presented a abstract poster at the PA EA forum in 2022. And then we had quite a few people kind of, you know, approach us at the poster session and kind of ask us questions and is there a paper coming out of this? And when are you going to write a paper? So we had some pressure too. I'm not going to name any names, but some people from JAPA also said we have to publish this study. So, so we had some pressure and incentives ourselves, but we did decide to kind of explore a newer data set. So we looked at the 2023 data set instead of the 2021 just to kind of, you know, maybe eliminate confounding factors because the pandemic and the influence of that and whatnot. So we wanted to kind of take a look at a fresher data set. And also in that poster we didn't include open ended questions, as I mentioned, which were critical for this particular study.
- [16:25]
Podcast Host
Well, I'm glad you got some strong hints to look into this. So the results of your study were quite substantial and impactful. You found that only 12% of PAs graduate without educational debt and then analyzed a range of data accrued by age, sex, ethnicity, US region. They were in an urban or rural setting and their employment status. What themes did you identify and did anything surprise you about these Results, especially when considering underrepresented racial and ethnic groups in medicine.
- [16:54]
Andre
Yeah, as you mentioned, factors associated with higher educational debt included older age, so mean age of graduates, Hispanic ethnicity, African American race, residing in the western US region, and not having accepted a position at the time of the data collection. So those were the factors associated higher debt levels among PAs from underrepresented racial and ethnic groups in medicine, as Mirella mentioned, certainly in line with findings from studies on medical students and physicians, so pretty much on par findings there. This finding is certainly concerning because PAs from these groups underrepresented in medicine are more likely to provide care in underserved populations and also working primary care. And this is a finding that's consistent in a wide variety of studies that we've conducted in the past couple years, one of which was with Morala as the first author just I believe one year ago that looked at this specific topic. But further research is certainly needed, particularly longitudinal research. Again, our research was cross sectional, so this was a limitation. And the more we understand these challenges, the better we can develop effective solutions.
- [18:00]
Podcast Host
Very interesting. So Alicia and Mirella both mentioned that the part of the inspiration was to understand incentives to go into primary care, or lack thereof. Given that we have a declining number of PAs choosing to go in primary care, you looked at some incentives that might promote people to go into primary care. Has the availability of loan repayment programs influenced these patterns in new graduate PAs?
- [18:21]
Andre
I think the biggest thing our study kind of highlights is just the resourcefulness of PAs and the practicality of their specialty choices. So for example, PAs who chose primary care, they frequently mentioned the National Health Service Corps Scholarship Program, which can significantly reduce or even eliminate educational debt. So those who pick primary care, that was a major theme among that data set. And the National Health Service Core Scholarship Program is definitely a win win for both PAs as well as underserved communities that benefit from these types of services. And PAs have had a long standing tradition of participating in these programs. Many also mentioned working in community health centers to benefit from public service loan forgiveness programs. This was also frequently mentioned by PAs who chose non primary care specialties such as emergency medicine, where they could work in nonprofit hospitals. So just a wide variety of strategies. Our data was said just a wide range of different strategies to pay off educational debt among PAs.
- [19:19]
Listener/Interviewer
That's great. I know choosing a specialty for me involved basically mostly flexibility or burnout. Because in primary care, you know how like you guys mentioned your article working long hours or how the PAS felt burnout pretty early on. And I know some Specialties can offer more flexibility of the schedule. So when you are conducting this research, what were some of the major things you identified that attracted PAs to choose a specialty?
- [19:46]
Andre
Definitely burnout came up in a sense of work life balance was one of the big ones, but by far just the passion for the specialty was I would say the number one. So this particular study didn't really dive in too much. Like I mentioned, we're definitely going to look at this in a future study. But passion for the specific specialty was a common theme, particularly in the open ended comments. But starting pay and earning potential were also important, particularly for those who are starting families that were considering cost of living considerations. As I mentioned, the work life balance was important for some. Some bas felt that primary care didn't have the best work life balance working hours and other specialties such as dermatology that had more fixed working hours were better suited for their life circumstances. But other factors such as availability of specialties in specific geographic areas and preferences for those specific geographic areas were also important. So some PAs just they prefer to live in large cities such as New York City, LA, Austin, those kinds of larger cities and others prefer more quiet life in rural areas. So those were also kind of factors. Some mentioned opportunities for fellowships, so and non primary care specialties often mentioned opportunities for fellowships residencies to further sub specialize in those areas being important and that's why they picked specialties that were not primary care related. And he also mentioned the ability to change specialties. So shameless plug. We just published a study on PAs changing specialties just recently. But this is a critically important feature of the PA profession, a very unique and just a really helpful feature. And our particularly comments it was mentioned quite often that this ability to change specialties is hugely beneficial. So for example some PAs and tenants work in primary care applying for the National Health Service Core Scholarship program, kind of eliminating their debt and then after that maybe changing to a different specialty that they were a little bit more passionate about. But others interestingly had the opposite perspective. So they wanted to just aggressively attack their debt by just going 10 years of hard work and a high paying specialty, pay off the debt, don't worry about it, and then seek what they're really passionate about which is primary care. So just a wide variety of strategies that we saw in our dataset.
- [22:02]
Listener/Interviewer
I like that the common theme was passion for the specialty because that shows the dedication of pa. So it's not just, you know, paying their debt or work life balance or flexibility, but also the passion for the profession for the Specialty. And I really like that finding. How does educational death influence when you graduate PAs, then a new graduate PA's decision to pursue a fellowship, then what
- [22:26]
Alicia
our research demonstrated is that there are PAs because of educational debt, decide to go into primary care setting versus a specialty or fellowship specialty setting. And I again, I agree this is very multifactorial, this decision. And it probably most likely has to do with with job availability. What jobs are available to students as that really key last three to six months when they're graduating and then after that they pass their pants. What is available and open to them? Are they able to find the jobs? Does it involve a move or not? You know, if some of the fellowships may be in areas that are more suburban versus some of the primary care fellowships, there's not very many. There are a couple out there, maybe in different parts of the country that they don't want to move to. But I think this is good news for employers because especially primary care employers that there are still newer PAs that are attracted to primary care. And so it's really important for them to remember keeping a competitive salary, maybe a sign on bonus, really offering some kind of loan repayment or the option to apply for a loan repayment is always attractive. And we talk a lot about work life balance. But what does that actually mean in a primary care setting? Could it mean a four day work week or maybe making sure that you have a very supportive team that works around you, you know, a dedicated medical assistant or nurse, a collaborative physician that's open to, you know, lots of questions right when a person starts out in primary care. And so those are important factors to really attract those newer PAs into the primary care setting. I know when I worked in primary care that was some something that we really worked on is making the job very attractive so that once we got a new provider in a new PA boy we'd also be able to retain them for years in a supportive setting. So I think those are important factors.
- [24:27]
Additional Interviewer
Obviously your research has been very comprehensive and you've kind of alluded to a little bit of this. The answer to this next question. What do you specifically think that PAS and PA educators can do to encourage PAS to pursue specialties? Where are provider shortages actually exist?
- [24:46]
Alicia
This is complex, but it starts really early. And this really for PA educators to introduce primary care and the benefits of primary care, almost like really early in their training. Not just the clinical year, but it starts in the didactic year, bringing in preceptors for lectures, small groups. When I was a PA educator, we used to have students rotate a day, a week, even really early in their training in primary care settings. So they really get that foot in the door. And this is in the medical research as well. Medical student research is really. And any experience they have in primary care settings need to be positive. So programs establish really good relationships with preceptors. And what does that mean? They could have academic titles, a financial incentive to take to precept students, access to medical libraries. You know, they're recognized as long term preceptors for students. And when students have that really good experience in primary care, they're more likely to consider it as they're looking for jobs. I know, I've also written primary care training grants where the state health department really supports training in rural and underserved areas. So that could mean travel expenses, lodging, but also offers incentive for preceptors in those rural areas to continue kind of a pipeline of students and offer them really good experiences. And so as a student is there, it benefits them. They can have first pick. It's almost like a pre interview, right for a new provider. But also for students, the good experience really opens their eyes to, you know, I could really see myself growing here, building a foundation of knowledge in primary care. And so I think really actively pursuing that type of experience is probably one of the most important items as you're kind of pulling in the newer PA into these roles.
- [26:44]
Additional Interviewer
Earlier we asked how the NCCPA uses its data set. Your research has shown us how this data can inform PA education, clinical practice and advocacy efforts. So looking forward to what are areas of study that are important to the NCCPA and what do you think would be interesting areas of future research?
- [27:04]
Mirella
For nccpa it's very important to conduct high quality and useful research. Our criteria is usually pretty broad, but we typically focus on research topics that are based on GAAP on prior literature. For instance, we are working on quite a few studies. Like last year we published information on PAs practicing in different specialties and their importance in contributing to the healthcare. We also looked at unique attributes of PAs that and their ability of how to change specialty throughout their career. And this year some of the areas that we're focusing on has been on leadership, which is very essential, like PA leadership. That has been one of the hot topics in not only in education but also in clinical PAs. PAs specifically working in PA programs because there is a lack of educators in those programs. Work life balance, like Alicia mentioned is very, very important and how the PAS are contributing on mental health and that's also a high priority for our nation. So those are some of the things that we are currently working on at this point.
- [28:19]
Listener/Interviewer
Great. That's awesome. Well I don't know if anyone has anything else to add. It was a pleasure having you guys today. Mirella, Alicia and Andres thank you so much for your insights and for really educating us on the work of NCCPA. I think most VAs like me will not receive NCPA just as you know where you the organization administering their board but there's more work going on into that and the research part of the NCCP is very interesting and I think that will help the profession. So I thank you all for your work and for this research and for our listeners. Don't forget you guys can now earn CME by listening to our podcast. To receive your CME credit and access your certificate you just listen to the podcast then complete the post test and evaluation in AAPA's Learning Central at cme.aapa.org until next time thank you.