Physician assistant shortage looms in Iowa

Retirement wave threatens key link in rural health care

Samantha Sparrow (Supplied photo)
Samantha Sparrow (Supplied photo)

IOWA CITY — Iowa’s rural demography and shortage of primary care doctors, especially in smaller towns, has patients heavily reliant on physician assistants — a pool of providers facing a growing threat: age.

New University of Iowa research shows 29 percent of Iowa’s 873 physician assistants in 2015 were over 50 and nearing retirement age, up from just 11 percent a decade earlier.

That coming exodus will only add to the typical attrition rate of about 5 percent annually as physician assistants in Iowa leave the profession or move to other states.

“Iowa faces a challenge to recruit and retain 30 percent of its entire PA workforce in the next 15 years,” said study co-author Tom Gruca, a marketing professor in the UI Tippie College of Business.

Physician assistants are not doctors, but they perform many essential health care duties for patients. In Iowa, they are required to be in communication with a supervising physician but they can examine patients, order tests and provide a variety of treatments, among other things.

In rural areas where there is no primary care physician, they well may serve as the main health care providers.

Sixty-one of the state’s 99 counties, either in whole or in part, are designated “health professional shortage areas” for primary care, according to the research.


Through their research, Gruca and his colleagues make the case that Iowa needs a statewide strategy to not only attract more physician assistants, but keep more of the ones it educates.

“There are certain things you need for healthy living,” Gruca said. “You need a primary care provider, a dentist and a pharmacy.”

Losing those resources could further hamper the ability to get health care in rural Iowa.

“This is a forecast you don’t want to come true,” Gruca said. “The good thing is, we have a chance to change it.”


Samantha Sparrow, a 28-year-old physician assistant student about to graduate from a UI program, illustrates the type of PA the research says Iowa needs more of — someone educated here who intends to stay here, and is willing to serve in a rural community.

Sparrow, who is from Michigan and moved to Iowa for her undergraduate education at Cornell College, chose the PA path over the more drawn-own route to physician because it minimized student debt and offered her a more ideal work-life balance. She is married and would like to have a family.

“I’ll have the ability to practice medicine but make it to kids’ games,” she said.

Making Sparrow an even greater get is her willingness to serve Iowa’s rural communities, although she noted concerns with state requirements for supervision. Advanced practice nurses aren’t required to be supervised by physicians, but PAs are.

In places where communication and supervision are more difficult to arrange, the attractiveness of serving there could be diminished.

“Those things are putting more of a burden on PAs in rural areas,” Sparrow said.

Still, Sparrow and her husband — also taking the PA path with plans to start training at the UI in the fall — hope to end up in rural Iowa, having recently bought a house in South Amana.


Todd Patterson, chief executive of Washington County Hospitals and Clinics in Washington, Iowa, said he’d love to connect with more rural-focused PAs. His facility has none right now.


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“That’s not been a conscious decision at all,” he aid. “We would be very happy with PAs, if we could find them.”

Made with Flourish

Rather, Washington County has supplemented its primary-care physicians with nurse practitioners with more manageable supervisory requirements.

And it’s doing OK, for now. But its seven primary care physicians have been on staff for an average of 15 years, according to Patterson.

“Going forward, restocking our provider pool is a huge challenge,” he said. “We are constantly recruiting, but over the next five years, we are going to have to be able to replace some of those physicians who will be leaving the workforce.”

The staffing situation at the Washington County hospital is borne out by the research: that Iowa is in fairly decent shape — for now.

The state’s tally of physician assistants surged 161 percent from 242 in 1995 to 873 by the end of 2015, the most recent year studied.

And about 30 percent of that total worked in rural areas, twice the national average rate.

More than half of Iowa’s PAs in 2015 practiced in primary care, which includes family medicine, general internal medicine, general pediatrics and obstetrics and gynecology. By contrast, less than a third of PAs nationally are in primary care.

Of Iowa’s primary-care crop, about 44 percent practiced in places designated as primary-care shortage areas.

“There are some very positive findings,” Gruca told The Gazette.


But since 1995, an average of about 33 PAs have departed Iowa’s workforce each year. And it’s going up. In the last five years, the average turnover is 42 a year.

“Unless we start retaining a higher portion of the PAs we train, we won’t be able to maintain the growth and replace the people who will be retiring,” Gruca said.

statewide strategy

Iowa for years offered just two physician assistant training programs — at Des Moines University and at the UI Carver College of Medicine, which launched its program in 1972 and graduates about 25 new physician assistants a year, according to the study.

The Des Moines program graduates about 50 students a year, and Iowa recently multiplied its crop of PA graduates by 73 percent with the launch of programs at St. Ambrose University, which graduates about 30 a year, and the University of Dubuque, which graduates about 25.

But only about a quarter of those trained in Iowa stay in Iowa.

Of the 728 PAs trained in the UI program from 1983 to 2015, about 26 percent — or 187 — were practicing in Iowa in 2015, according to the research. Of the 1,024 PAs trained at Des Moines University during that time, 252 were working in Iowa in 2015, a 25 percent retention rate.

“Despite the increased supply provided by new PA training programs, this historical retention rate may not be sufficient to meet the demands,” according to the UI research. “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.”

As it stands, nearly half of the PAs working in Iowa are recruited from other states.


Suggestions from Gruca and co-author David Asprey, chair of the UI Department of Physician Assistant Studies and Services, include expanding opportunities for students to practice their full scope of training and encouraging local clinics and providers to interact with them while they’re still in school.

“Job fairs and other face-to-face interactions can help encourage students to stay in Iowa before they make their post-graduation plans,” according to a list of suggestions.

Supervising physicians can do more to mentor students by meeting with them outside of reviews and listening to their challenges. Practices can offer funding and time off to help physician assistants complete required continuing education. And the state could consider incentive programs to recruit and retain PAs to high-needs areas — including loan-repayment offerings.


According to the U.S. Bureau of Labor Statistics, the median pay for PAs in Iowa was more than $100,000 annually in 2017. And the demand for more PAs is expected to grow across the nation.

“Employment of physician assistants is projected to grow 37 percent from 2016 to 2026, much faster than the average for all occupations,” the bureau reported.

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