Tailoring Career Ladders for Medical Assistants in Primary Care: A Qualitative Assessment


 Background: Growing demand for medical assistants (MAs) in team-based primary care has led health systems to explore career ladders as one solution to improve MA recruitment and retention. The practical implementation of career ladders remains a challenge for many health systems, and an improved understanding of MA perspectives on career ladders is needed. Methods: Semi-structured focus groups were conducted August to December 2019 in primary care clinics based in three health systems in California and Utah. MA perspectives of existing career ladders, including acceptability, appropriatness and impact on career intentions were discussed, recorded, and qualitatively analyzed.Results: Ten focus groups conducted with 59 participants showed the MA employment decisions were influenced by a number of factors, with opportunities for economic and professional growth predominating. MA career aspirations varied, with “stepping stone” MAs using their role to advance into other health professions and “contented career” MAs hoping to grow within their MA career. Career ladders were acceptable in theory but MAs felt current implementations could benefit from clear and transparent expectations for advancement, consistent recognition of training, experience and work responsibilities, the ability to advance in place, and career counseling. Conclusion: MAs held positive perceptions of career ladders, yet recommended a number of improvements to their practical implementation across three institutions. The emergence of two distinct clusters of MA professional needs and desires suggests an opportunity to further optimize career ladders to provide tailored support to MAs in order to strengthen the healthcare workforce and talent pipeline.


Background
Primary care practices have increasingly turned to team-based primary care models in their efforts to e ciently provide high quality care. 1,2 As work processes shift in these multi-disciplinary teams to allow each member to perform "at the top of their license" 3,4 , medical assistants (MAs) have seen their responsibilities expand to include panel management, health coaching, scribing, translating, phlebotomy, and other multi-functional roles, which vary by site and state licensing. [5][6][7] Demand is skyrocketing for MAs; growth projections exceed the average for all occupations by over four-fold. 8 Factors contributing to demand include the relative value of MAs in health systems (2019 median salary $34,800 8 ), short training periods, scope of work exibility, and contribution to positive patient outcomes. 5,9 Efforts to employ and retain such a valuable workforce are of considerable interest to healthcare organizations, given the shortage of available MAs, annual turnover rates of 20-30%, and replacement costs that reach 40% of MA yearly salary. 10,11 Research around these challenges is limited; lack of career advancement opportunity 10,12 and negative perceptions of organizational culture may contribute to MA turnover. 13 Given these challenges, many organizations are exploring novel solutions to recruit and retain the MA workforce with the goal of ultimately improving patient outcomes and workforce e ciency. One such solution is the implementation of career ladders-paths of professional advancement that provide employees with greater compensation as they cultivate and demonstrate additional skills and increase job responsibilities. 14 Formal MA career advancement opportunities have been associated with improved quality of care, teamwork, employee satisfaction and intent to stay with current employer. 5,9,15,16 An evaluation of 15 case studies in which new MA roles and opportunities for advancement were implemented alongside primary care model redesigns found associated improvements in patient and employee satisfaction, cost reduction, and quality. 5 Despite these bene ts, health organizations face challenges expanding the MA role and structuring meaningful advancement opportunities. 7,17 Lags in implementation of a career ladder following MA role expansion can lead to MA frustration, particularly as these workers may see their responsibilities, but not pay, increase. 7 Career ladders often require institutional-level support, given that adjustments to compensation often occur at a system-wide level. 7,18 Variation in state certi cation and licensure requirements present further obstacles. 7 As healthcare organizations continue to establish and re ne career ladders, MA perspectives of how career ladders impact their professional intentions are lacking. This assessment aims to ll this gap with qualitative analysis of MA focus groups discussing career ladders implemented at three institutions.

Methods
MA perspectives of existing career ladders within their institutions were assessed through a series of semi-structured focus groups. Implementation outcomes were drawn from the Implementation Outcomes Framework, including acceptability, appropriateness, and perceived effectiveness at improving recruitment and retention. 2

Settings
Sites included primary care clinics in three health systems across urban, suburban and partially rural U.S. geographies (University Healthcare Alliance, Newark, CA; Stanford Health Care, Stanford, CA; Intermountain Healthcare, Salt Lake City, UT). Within each institution, a subset of sites were chosen to represent urban (including suburban) and partial rural settings where available.
MA career ladders were in place for at least one year across organizations, though two organizations were in the process of revising career ladder details. The study was reviewed by the Stanford School of Medicine and Intermountain Healthcare Institutional Review Boards and, as quality improvement, did not meet the de nition of human subjects research (Protocols #51945, #1051215, respectively). All participants gave verbal informed consent.

Data Collection
From August to December 2019, all MAs within each selected clinic were emailed an invitation to participate in an hour-long focus group by managers who were not present during the conversation. Participants did not receive nancial compensation, though lunch was provided. No author practiced within these clinics. Focus groups consisted of a qualitative semi-structured discussion around MA perceptions of career ladders and nancial incentives, the latter of which is the focus of other work. 19 (See protocol in Appendix A.)

Data Analysis
Conversations were recorded with permission from all participants and transcribed (Rev, Austin, TX). Data collection continued until thematic saturation was achieved. Authors created an initial codebook based on emergent themes from early transcripts and used a constant comparative method 20 to categorize remaining data using software (NVivo 12, Burlington, MA). Authors collectively reviewed a subset of transcripts to reach consensus on a coding structure before recoding all remaining transcripts in sequence to ensure consistency. Codes were further analyzed to identify any potential differences in MA perceptions across clinic organizations and geographies. Early ndings were reported back to operational leaders at each institution to inform ongoing improvement. 21

Results
Across the three institutions, ten focus groups were conducted with 4 to 9 participants each for a total of 59 participants. Most MA participants (78.0%) worked in urban/suburban settings, 44% were 30-39 years of age, 92% were female, 37% were white, and 54% were non-Hispanic. Nearly half had worked as an MA for 10 + years (Appendix B). Findings were consistent across institutions as well as urban versus partial rural areas and are therefore described uniformly.
Qualitative analysis led to the following ve ndings: 1) MAs' decisions to join and remain in a given role are in uenced by a number of factors, with opportunities for economic and professional growth predominating.
2)Career ladders are acceptable in theory but current implementations are felt to be sub-optimal.
3) MA career aspirations vary with some using their role as a stepping stone to advance into other health professions and others hoping to grow within their MA career.

4) "
Stepping stone" MAs face several obstacles in obtaining additional education to transition into other health and non-health professions. 5) "Contented career" MAs desire additional economic and professional opportunities within their existing role, which are often felt to be lacking.

Factors in uencing recruitment and retention
Medical assistants described a range of factors considered in their decisions to join and remain within their organization, including economic growth opportunity, professional growth opportunity, compensation re ecting job responsibilities, job security, fair compensation relative to internal and external peers, lasting interest in healthcare, appropriate workload, and social attachments to peers (Table 1). Several MAs focused on the frustration that MAs have recently been asked to take on more administrative responsibilities without commensurate increases in pay: "Two [years ago the work increased]…My workload's way different …a lot more computer stuff, reports, calling patients" (MA4, FG7). MAs expressed that this felt unfair: "It's just discouraging if we're doing all this work, and we're not being recognized on our title and on our paycheck" (MA8, FG6). Some expressed a desire for a return to their prior responsibilities, or reported the variety of responsibilities and sheer workload created time pressures that reduced job satisfaction. At the same time, MAs shared frustration at the limitations of what their licenses or job responsibilities allowed them to do. This sentiment clustered around the lack of upward growth opportunities available (see Finding 5 below) as well as limitations in day-to-day activities. One MA expressed dissatisfaction at the loss of her ability to place intravenous lines (IVs) due to changes in institutional protocols. Activities that were valued included patient-facing interaction, minor procedures (e.g. IV placement); less valued were computer work and scheduling. Overall, MAs' desire for increased patient-facing and procedural responsibilities was uniform and appeared conditional on having enough time during the day to complete such tasks and the recognition of this added value in their paychecks.
Finally, job security was another factor that some MAs described as driving their desire to leave a given organization. Even while MAs were reportedly in short supply, they reported hearing the message from administration that they were dispensable. Some MAs described their human resource contact as being largely unhelpful, particularly related to questions of work performance, promotion, or career ladders.
Career ladders acceptable but current implementations are sub-optimal MAs overall welcomed the existence of a career ladder that would help them understand steps to gaining skills and increasing professional and economic growth. One MA shared, "I think it's [career ladder] a positive thing. Also, if they're going to pay you more, then it's a really, really good positive thing" (MA 1, FG 2). However, most MAs described a lack of clarity regarding career ladder details: This challenge was attributed to a lack of communication from administration, both about the overall system and where individuals t within that system: "We don't know what level we're in." (MA1, FG 5). Other challenges included inconsistent recognition of responsibilities, inability to advance without re-applying for an open position or specializing, lack of individual career counseling, education funds that were challenging to use in practice, and desire for greater appreciation from local physicians and the health system overall. These sub-themes have been converted to direct and implied recommendations for career ladder improvement ( Table 2). Further, MAs felt the career ladder did not acknowledge responsibility differences across clinic sites within the same institution, or differences in individual years of experience and training. Several MAs reported that job responsibilities varied between clinics. For example, some standard MAs are asked to do front desk, back o ce, phlebotomy work, and patient phone calls while others simply obtain vitals and room patients; MAs reported these differences were not re ected in the career ladder.
Underscoring these concerns was a sense that MAs were not appreciated for their work. MAs highlighted the need to build this recognition into career ladder and compensation structure: "I think being more appreciated is a huge thing… knowing that I'm making a difference." (MA5, FG9) These collective challenges made it di cult for MAs to advance within their existing role and clinic.
MA career aspirations vary MA career aspirations varied considerably and fell in two clusters: "stepping stone" MAs who are pursuing their current role as one step along a path to obtain a higher level license in healthcare, and "contented career" MAs who are not interested in obtaining a higher license in healthcare but rather are largely interested in growing within their careers as MAs (Table 3). Whether a given MA fell into one category or another was reported to depend on their backgrounds: "…personality-wise, we're not all the same person. We have huge diversity groups in how you were raised or what your projection is on what you want out of life.." (MA 2, FG 7) "Stepping stone" MAs reported a desire to gain experience and save money in order to return to school primarily to become a nurse, though individuals also shared plans to become a physician or health administrator. Understanding their personal interest in healthcare before committing to additional training was felt to be a key reason for choosing the MA role: "Nursing... it's expensive, and then it's hard to get into. So, you don't want to be that committed [before knowing you are ready]... I have friends that went into the medical eld, and then after [they] were done or close to being done, they found out that they hate blood" (MA6, FG 6). The cost of making a mistake in investing in one's career was thought to be high.
Alternately, "contented career" MAs did not nurture plans to return to school or switch professions. Instead, they expressed general contentment in their eld and even described the bene ts of being an MA over other healthcare careers: "MA3:…I wouldn't even want to go to school as an RN... You just don't get that interaction with the patient…they [nurses] have time to go in, start the IV, run the machine, change bags, and then they're gone….I don't want to be that, I want to do patient interactions.
MA4: Our patients know our names." (MA3, MA4, FG9) A majority hope to grow within their existing career and share a desire to move into administration, teaching, or other leadership opportunities. Rare individuals expressed no desire to move up the career ladder. One attributed this to being late in her career: "Maybe at age 60, I might want to retire…So, why stress myself out even further along…my mental health is something to consider too. So then, I said, 'I'd rather leave it for somebody that's younger.'" (MA 3, FG 2) "Stepping stone" MAs face several obstacles to achieving their goals MAs who hope to return to school face challenges obtaining nancial resources to pursue this education, often while balancing family responsibilities: "[Returning to school requires] debt, time. Hard especially if you have family." (MA8, FG6) While MAs in several settings described receiving funds for continuing education for their employer, these were a small portion of what was required for additional training.
One MA described a loan-forgiveness program where the health system paid a fraction of her loans in exchange for an agreement to work at the institution following training. This program did not seem to entice the MA to shift her plans.
"Contented career" MAs desire additional growth opportunities within their profession Some of the MAs who expressed a desire to stay within their given roles and clinics still hoped for increased growth opportunity within this role. Many felt this was lacking: "I'm in that mode where I'm struggling…I want to be more but I have to do X, Y, and Z, and leave where I'm currently happy at in order to do that." (MA1, FG1) Other MAs gave clues as to what might constitute these growth opportunities within their given roles. In particular, an MA at an outside clinic was reportedly hired into an administrative role; the MAs in the focus group found this to be motivating. Another participant identi ed that taking on a new specialized responsibility might increase her job satisfaction.

Discussion
Well-designed career ladders have the potential to improve job satisfaction, thereby improving recruitment and retention of health workers with downstream bene ts on patient care and operational e ciency. We found positive MA perceptions of career ladders in principle, though elements of their practical implementation were reported to need improvement across three institutions. Reported and implied recommendations for career ladder improvement included the need for clear and transparent expectations for advancement; consistent recognition of training, experience, and work responsibilities across the organization; the ability to advance in place or with increased specialization; career counseling; and streamlined opportunities to use educational funds. The need for transparency and consistency in career ladder implementation is consistent with prior work 7 , though this evaluation further contributes to discussions around structuring opportunities for advancement including continuing education and recognition that MAs may cluster into distinct segments based on their needs and career aspirations.

Employee segmentation based on wants and needs may be warranted
MAs varied in terms of their professional ambitions, including the degree to which they hoped to grow within their existing role and whether they planned to pursue additional training to move into another profession. Designing career experiences around employee career aspirations, including "grouping employees into clusters based on their wants and needs" has been brie y explored in business literature, 22 yet such programs have yet to be formally explored in healthcare. Diverse MA needs discovered here suggest opportunities to optimize career ladders from the perspective of two distinct groups: "stepping stone" MAs and "contented career" MAs.
Build the bridge to other health professions For "stepping stone MAs", these results suggest health systems may bene t from anticipating-and moreover supporting-transitions from MA to other health professions, particularly for individuals who hope to remain within a given medical system. MAs frequently reported considering nursing as the next step in their career, a profession with well-documented worker shortages and high turnover cost. [23][24][25][26] Supporting these "stepping stone" MAs in their desire to become fully-trained nurses or other types of healthcare professionals may be a savvy way for health systems to create talent pipelines. We heard a single example in which one health system paid a small amount of tuition for additional education in exchange for an agreement to work after training for a minimum number of years. Such agreements exist in other industries and are increasingly used with physician trainees 27 ; extending an adapted program to other health professions, including MAs, deserves further exploration.
MAs' varied levels of ambition suggest that at least some turnover should be anticipated. Further study is needed to quantify the impact MA career intentions have on turnover, including the portion of MAs who may be retained or positively directed towards other roles within a given health system. We also note that supporting such MA advancement opportunities may bene t institutional goals towards diversifying workforce and leadership, as MAs typically come from diverse backgrounds that often closely align with the patient population they serve. 5,28 Create advancement-in-place opportunities For the "contented career" MAs, we heard that opportunities that allow for advancement within their current MA profession may increase job satisfaction and thereby retention with its downstream nancial and organizational bene ts. 10,11 Literature outside healthcare also suggests that organizations can bene t when promoting from within, given that employees retain institution-speci c knowledge that increases productivity. 29,30 We note major barriers to facilitating MA advancement within their current roles include licensing restrictions and common sta ng structures in primary care-MA role expansion may mean MAs have taken over the historical positions they might have once stepped up into. Some primary care settings, including those in this analysis, are actively exploring further specializing MA roles based on additional training in mental health, population health management, or value-based care. 5,31 These opportunities may facilitate higher level advancement-in-place opportunities for MAs without requiring years of additional training.
We recognize another tension in that local clinic needs can vary signi cantly, and each may require different competencies from their MAs (e.g. phlebotomy, population health measures). This goes against MAs' voiced desire that a career ladder consistently re ect competencies across an organization. Based on our overall ndings, is seems that allowing for some local clinic-level exibility to facilitate advancement-inplace opportunities may outweigh MA desire for career ladder consistency across the organization. Administrators must recognize and balance this tension in their efforts to optimize career ladder design.

MA role expansion often not re ected in career ladders
Underlying these conversations was the dominant theme of MA role expansion in the last several years. While prior work has largely emphasized the bene ts of this transition 5,32,33 , we were struck by the unfavorable perspectives many MAs held when role expansion was discussed in the context of their career progression and, indirectly, compensation. In particular, MAs seemed to recognize they were providing more value to the health system than before, generally without increased compensation. Fortunately, despite these sentiments, early literature based on a subset of the population represented here suggests MAs do not experience signi cantly elevated rates of burnout 13 , though additional study is needed. Future efforts to optimize career ladders may bene t from participation from both administrative and MA representation to address aspects of compensation.

Limitations
Focus groups within three institutions across two geographies cannot encompass the full range of MA perspectives across the U.S., particularly as licensing laws vary from state to state. This evaluation re ects learnings to inform institutional practices, and extrapolation to outside settings is therefore limited. Furthermore, we acknowledge two institutions at the time of interviews were working on career ladder improvements; this period of ongoing change may have reduced overall MA knowledge and satisfaction with the pre-existing programs. Our use of focus groups may also have limited certain individuals disclosures, though we felt the bene ts from a synergistic discussion with multiple voices outweighed that risk.

Conclusions
MA roles have undergone signi cant expansion in recent years, and identifying the right balance between organizational and employee needs is ongoing. Career ladders are perceived favorably by MAs in principle but their practical implementation merits further attention. Segmenting MAs into distinct clusters based on their career aspirations may serve as a useful model to further tailor career ladders to employee needs, though additional evaluation is still needed. Such efforts have the potential to strengthen the healthcare workforce and talent pipeline, with downstream bene ts to patient care and operational e ciency. Abbreviations