PA students often ask whether or not they should consider a PA residency or PA fellowship after graduating. The decision to pursue postgraduate training for PAs is like any other decision where the potential benefits should be measured against the opportunity costs. In the end, it is a personal decision individuals must make based on personal goals and preferences.
While there are many factors to consider, several advantages and disadvantages hold more weight than others. The primary benefits most often cited in favor of postgraduate education are additional focused training, a potential advantage to securing a job in a preferred specialty, and the potential for a higher income as a result of increased training and experience. The primary disadvantage of a PA fellowship or residency is loss of time and income.
Before examining each of these factors in more detail, a look at the history and current state of postgraduate education for PA students may be helpful.
A History of PA Postgraduate Training Accreditation
The field of PA postgraduate training is a little bit of the wild wild west. Unlike postgraduate training for physicians, there is currently no governing or accrediting body required to oversee PA postgraduate education. This does not mean these programs are substandard or inadequate. Most programs are associated with an academic medical center or medical residency and include intensive learning experiences through bedside teaching, lectures, mentorship, assigned reading, procedures, simulation and conferences all facilitated by well-seasoned physicians and PAs (1). But because postgraduate training is not required for PAs, most of these programs have not sought out voluntary credentialing. This allows these programs the flexibility to customize their programs and save cost.
Prior to 2000, there was no governing authority offering accreditation for postgraduate PA programs. The Accreditation Review Commission on Education for the Physician Assistant (ARC-PA), whose primary responsibility is to assess and accredit PA education programs, initiated the process to accredit postgraduate PA programs in the early 2000s. This was met with some resistance, including by AAPA. But eventually they approved a set of voluntary accreditation standards and went on to accredit a handful of programs (2).
In 2014, ARC-PA placed its postgraduate PA accreditation process in abeyance until alternative methods were developed to establish quality metrics for these programs. In 2017, interest resurfaced and by 2020 ARC-PA developed and approved new standards and a process for credentialing postgraduate PA programs. This accreditation process is still voluntary. At the time this article is published, there are currently 12 programs from nine medical centers accredited by ARC-PA. To put that in perspective, there are currently more than 140 postgraduate programs.
Accreditation is not a bad thing. It ensures an agreed-upon set of standards are met. When used appropriately it protects all parties involved including programs, students, potential employers and the public. Universities, hospitals, and many other industries require accreditation to ensure safety to the public. But it is no secret accreditation is a money-making institution. For example, a single postgraduate PA program would spend $19,500 in the first three years of the accreditation process (3). It is a fair question to ask why a program that is not required to receive accreditation, and has potentially been training PAs for years often under the umbrella of an established medical residency, would voluntarily submit for accreditation because ARC-PA has finally decided to be part of the process.
The bottom line at this point is a program’s accreditation status is not necessarily indicative of its strength or value.
Comparing the Data
Because there is no single central accreditation body, there is unfortunately a lack of comparable data to compare programs and outcomes. It is difficult to compare things like application requirements, salary and benefits, and curriculum among different programs. Additionally, there is no great research available on factors like job satisfaction, salary comparison, and employment rates between PAs who complete postgraduate training and those who do not.
The Association of Postgraduate PA Programs (APPAP) is probably the best source for PA students considering a residency or fellowship. They maintain a list of current programs and a database with the ability to filter by specialty and location, as well as compare aspects of individual programs such as start date, duration, class size, etc.
A review of available literature confirms a lack of investigation into many of the questions PA students want to know. The best study available, which reviewed the responses from 34 different PA postgraduate programs, provides some insight into these topics, but barely scratches the surface. While information is lacking, a look at what is available may help PA students identify potential pros and cons of pursuing postgraduate training.
Do PAs with postgraduate training make more money?
A common argument for postgraduate training is the potential to be hired on at a higher salary based on experience and a higher level of training. An attempt to find data supporting this has been unsuccessful. Not necessarily because it is not true, but because it simply has not been thoroughly researched.
PA fellowship and residency stipends range from $50,000-80,000 per year and average program length is 12 months (1). In comparison, the average starting salary of a recently certified PA in 2021 was $100,961 (4). A PA choosing to pursue postgraduate training accepts an opportunity cost in salary of $20,000-$50,000.
There is no definitive evidence showing PAs with postgraduate training make more than those without. A national survey analyzing this would be greatly appreciated.
Many employers maintain pay scales for physician assistants and nurse practitioners, and base starting salaries on years of experience with new graduates starting near the bottom. Many also have salary caps. It would be generous to assume employers would count educational training as years of experience. Some might. Assuming they did, it would be generous to assume an employer would start a PA with one year of experience at, say, $5,000 more than their new graduate counterpart. With this generous assumption, it would still take 2-10 years to make up for lost income from choosing a residency or fellowship. This is of course a single scenario, and there are many potential calculations. But it seems safe to conclude completing a PA residency or fellowship for the sole purpose of making more money is not a wise decision.
Are PAs with postgraduate training more likely to find a job in their desired specialty?
There are more than 150,000 PAs currently certified in the US, working in every subspecialty of medicine, and only a very small percentage of them have completed postgraduate training. In 2021, only 6.5% of recently certified PAs were in the process of or planned to complete a residency program. Only 5.2% of all PAs have completed a postgraduate residency or fellowship. Logically, the number of residency-trained PAs could not possibly fill the void of open positions in all specialties of medicine across the country, and 95 times out of 100, positions are filled by PAs without postgraduate training. There will absolutely still be job opportunities in every specialty for PAs who do not complete a postgraduate training program.
One argument worth considering is healthcare facilities who offer PA postgraduate training programs may only hire PAs who have completed a fellowship or residency, and likely hire the majority of their APPs internally out of training. In this situation, if a PA strongly desires to work at such a facility, they may have little choice but to complete a fellowship. Limiting job searches by location or specialty will always narrow employment opportunities.
Do PAs with postgraduate training find jobs faster?
90% of PAs who complete a residency are hired within two months of completing their training, presumably in the specialty they desire (1). 90% of all recently certified PAs have accepted a position after four months, a difference of only two months (4). It would be fair to say giving up 12 months in order to save two months of unemployment does not make sense.
Why Consider a Postgraduate PA Residency or Fellowship?
If not solely for the employment opportunities or salary potential, why consider a postgraduate training?
Most would say they desire to have more comprehensive training, mentorship, and supervision in the specialty they desire prior to practicing as a traditional PA. For some, this reason alone is enough to sacrifice time and income potential.
It has been my experience talking with dozens of PAs that those who complete postgraduate training highly recommend it, and those who have not say they do not feel like it held them back and do not regret their decision to immediately enter the workforce.
I have heard a few reports from PAs who regretted completing postgraduate training, usually stating it was not well organized and felt like they were utilized as cheap labor. One PA who completed a surgical residency reported her first surgical job after completing her training provided a much better on-boarding which she found more valuable than her residency.
Once again, an extensive survey of PAs who have completed postgraduate training would be extremely valuable for future PAs considering residencies or fellowships. Anyone looking for a master’s thesis, please consider this.
How Much Training is Too Much?
One of the most attractive attributes of the PA profession is program duration. Many choose PA over medical school for the chance to start practicing clinical medicine in fewer than three years. Despite this, PA students are now offered and encouraged to consider multiple paths to extend their education beyond PA school. Every year more Doctor of Medical Science and similar doctoral programs targeting PAs are opening across the country. These doctoral degrees come at the cost of years and dollars that, like postgraduate training programs, are hard to justify when looking at them from a purely financial standpoint when their goal is to become a clinician.
PAs have to ask if postgraduate training and doctoral degrees are expected to become the norm, why not spend an extra 18 months and go to medical school? PA programs already meet credit requirements that surpass most doctoral programs (the discussion on whether current PA master’s degrees should be doctoral degrees will be saved for another time). The PA program strikes a near perfect balance between effort and time required (a competitive application process and rigorous 2.5 years of education), and value (salary, job satisfaction, work/life balance, etc). As more time and effort become required, for the same value, the equation no longer makes sense.
While there is a lot of discussion about postgraduate training programs and doctoral degrees becoming “the way PAs are moving,” I suggest not letting that motivate you one way or the other. We are still years from that. We can also look to other medical professions who already ventured in that territory. Ask any of your nurse practitioner colleagues with a DNP who practice clinically if they are making significantly more money. Ask veteran pharmacists or physical therapists with master’s degrees if not having a doctoral degree has held them back after working for 20+ years. Unless you plan to teach, in most cases it will not make a difference even if PA eventually becomes a doctoral degree.
At this time I feel comfortable advising anyone considering postgraduate PA education should do so based on personal preference for advanced training, supervision and mentorship prior to entering the workforce. That is it. And if that is enough for you, I encourage and support you.
Did you complete a residency or fellowship? Please share your comments.