Summarize key findings
The goal of this research study was to investigate admission criteria used by PA postgraduate programs in selecting licensed PA applicants for postgraduate training in the United States. Importantly, this study revealed the influence and weight of particular selection criteria as well as the stakeholders evaluating that criteria. Criteria driving the selection process include personal interview, board certification/eligibility, letters of recommendation, achievement of a graduate degree, and personal essay. Least important to key stakeholders, namely program directors, but also medical directors, associate program directors, and staff PAs/NPs was participation in research/publication, membership in local PA/NP associations, and undergraduate transcripts. To date, there is no published data detailing factors used by postgraduate programs to drive admission decisions, making this a landmark study.
Aside from board certification/eligibility and achievement of a graduate degree, the factors deemed most important of the selection criteria for admission to a postgraduate PA program are subjective in nature. The weight placed on the personal interview, personal essay, and letters of recommendation supersedes that of graduate GPA, class rank, and clinical rotation grades, suggesting that applicant characteristics of personability, interpersonal skills, communication skills, emotional intelligence, and adaptability are as important to demonstrate as clinical acumen via board certification. This is not too dissimilar from how physician residency programs evaluate certain characteristics in the selection of candidates for postgraduate training (3). Moreover, these non-cognitive characteristics may serve as more reliable predictors of success in PA postgraduate training as it does in physician graduate medical education (4).
Some thoughts on research and advocacy: According to published research, 36% of physician residency programs cited “demonstrated involvement and interest in research” as a factor when granting applicants an interview (5); however, our study demonstrated a lower importance on research/publications of PA postgraduate education applicants, which serves to highlight the scant contribution of PAs to the field of medical research that has been previously observed. In fact, one study reported a precipitous drop in PA scholarship activity over the last decade, which may be related in part to recruitment practices (6). Moreover, many postgraduate applicants are new graduates, with little or no research experience, which may reflect a knowledge gap and lack of research mentorship.
Barriers to research contribution have previously been considered and include lack of experience with research, lack of time, lack of interest, lack of mentors and lack of funding (7); data from this study suggests that these barriers need to be addressed at both the graduate and postgraduate levels especially if the goal is to bring greater attention and awareness to increasing the number and caliber of PA research contributors (7-9). Also, of little importance was membership in a PA/NP association. Encouraging participation in local and national organizations should be a priority at both the graduate and postgraduate level to increase advocacy of the PA profession from career inception.
Additionally, this study identified the key players in the admission process, from screening applications to conducting interviews and making applicant selections, indicating that the program director primarily, along with associate program directors and medical directors had the greatest influence on the interview process and selection of candidates for admission. It should be noted that the graduate medical education (GME) office was not found to be involved in the screening, interviewing, or selection of candidates for postgraduate PA training. This distinction suggests that, while housed in the same institution, PA postgraduate education processes and GME education processes are two separate entities with different funding, goals, and resources.
Despite some furloughing of trainees, the vast majority of postgraduate PA programs remained operational, while many saw an increase in application volume. The uptick in applications may have been attributed to a perceived skills gap among recent PA and NP entry level graduates who experienced limited face-to-face clinical education (clinical clerkship/practicums) during their training or encountered difficulty in securing employment subsequent to graduation as a consequence of the COVID-19 pandemic. Additionally, a quarter of postgraduate programs experienced a decrease in program funding. This may be largely due to financial losses exacerbated by COVID-19 in which US hospitals now face a liquidity crisis; some institutions may have elected to cut back on funding for training programs that they deem a drain on already limited resources (10).
Our study is not without limitations. First, we did not examine how selection criteria correlated with resident or fellow success in postgraduate training program. Second, we did not evaluate the impact of racial, geographical, or gender differences among applicants during program selection. Thirdly, this study includes a low response rate of (31.5%), which may have contributed to response bias. Overrepresentation of emergency medicine programs may also have led to some bias. Lastly, when programs were asked to report on the total cost (salary/benefits) of training a PA resident or fellow, five programs reported only salary costs. Therefore, we multiplied the salary cost by the 32% benefit rate (Bureau of Labor Statistics) as a percentage of salary (2018) to determine total postgraduate cost of training an APP in those 5 programs (11). Despite some limitations, our study highlights differences in selection criteria by postgraduate PA programs in the initial screening of applicants and subsequent selection of candidates for specialty training.