PAs, the High-Up Front Cost of Becoming a Physician, and the Future of Hospital Care

by Reihan Salam

Ever since I read the Chen-Chevalier paper on physician labor supply, I’ve been thinking about how we use physicians and physician assistants in the practice of medicine, and in particular in the practice of hospital medicine. To refresh your memory, Chen and Chevalier, whom we’ve discussed in this space before, observed the following:

Our estimates suggest that the median man in our sample with 10 years experience earns apremium of over $25 per hour as a physician rather than as a PA with 10 years experience. The corresponding median female in our sample earns a premium of only $16 per houras a doctor rather than a PA. However, a larger part of the difference in male vs. female returns to entering medical school stems from differences in hours worked. The median male physician in our sample with 10 years of experience works 11 hours more per week than the median female physician in our sample with 10 years of experience. Simply put, the majority of women physicians do not appear to work enough hours earning the physician PA wage premium to amortize the higher up-front investments in becoming a physician. [Emphasis added]

Two thoughts immediately leap to mind: (1) the high up-front investment in becoming a physician is perhaps than it should be and (2) we should make better and more extensive use of PAs. The two points are related.  There has been an ongoing controversy over limiting duty hours for medical residents, which have been associated with extreme exhaustion and other maladies. Duty hours for U.S. medical residents are unusually high when compared to those of medical residents elsewhere in the developed world. It is also true, however, that U.S. physicians tend to earn more in their peak earning years, and that the distribution of specialties, etc., varies across countries. Certain specialties demand more specialized training-by-doing. Moreover, the reduction of duty hours has been associated, for obvious reasons, with staffing shortages. 

That is why there has been increasing interest in relying more heavily on the combination of PAs and hospitalists to replace medical residents. In 2009, the American Journal of Medical Quality published a paper that concluded as follows:

Our study shows that the combination of PAs and hospitalists can meet the clinical inpatient needs of a diverse inner-city population that relies on a public hospital for acute care. Most outcomes remained equivalent between the 2 periods, including adverse events, readmission rate, patient satisfaction, and quality issues related to mortality and readmissions. All-cause mortality was actually lower during the PA-hospitalist period, although this difference may have been owing to the on-site direct attending supervision. Although our model may not suit every institution, we maintain that it is practical and generalizable. Long-term viability of the new model must be evaluated by including a cost analysis of the replacement model.

PAs are being deployed much more widely across the health system, and we’re likely to see more of this rather than less. Ultimately, I think the goal is to deploy physicians for an increasingly narrow range of medical services, focused on the diagnosis of complex problems. The kind of routine medical care that is so often the purview of physicians now will increasingly be delegated to allied health professionals and, whenever possible, machines.