Physician assistants in rural America
By Maria Frisch

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There is a shortage of doctors in rural America, and this is not a new problem.1,2 In 1977, the U.S. Congress enacted the Rural Health Clinics Act (Public Law [PL] 95-210) to address this issue. This act supported the work of physician assistants (PAs) in rural areas by entitling PAs to receive reimbursement from Medicare and Medicaid on a cost basis, thereby improving care access and reducing care costs in underserved areas. Since 2009, federally qualified rural clinics have received significant federal support, designed to improve access to cost-efficient care.3 Physician assistant programs also receive government funding to boost the primary care work force, in hopes of bolstering the numbers of providers who branch out to rural care.

Henry, Hooker and Yate looked at physician assistants in rural healthcare within a comprehensive, systematic review.4 They found 51 papers on this topic from 1974-2008. They reported that the literature generally supports PAs as a cost-effective necessity in rural communities. Additionally, rural PAs have a larger scope of practice than urban PAs, because of the broad range of capabilities that are essential to meet the diverse needs of entire communities. However, rural populations can be challenging to work within; people are often older, less wealthy and have greater rates of being uninsured or underinsured. Reimbursement can also be lower in these areas. The most common concern reported by PAs was the lack of access to continuing education and isolation from peers.


What is the most appealing aspect of working in a rural practice?
  • 1. The desire to serve the needs of the community
  • 2. Greater sense of independence, freedom and flexibility
  • 3. Financial incentives

What factors influence PAs to choose rural practice? Typically those with a rural background or those that complete rural clerkships have a greater propensity towards rural practice after graduation.5,6 Additional drivers include a desire to serve the needs of the community, a desire for a broad scope in practice and collaborating physician characteristics.5 One study also emphasized the importance of support of, and for, one’s significant other when choosing a practice location.7 Major factors contributing to retention among rural PAs include: confidence in the ability to provide adequate healthcare, desire for small-town life, residing in the community, and being involved with the community.4 PAs who work in rural practices also report a greater amount of independence, freedom, flexibility and control than they would have in a larger and/or urban settings.8

What are some additional reasons some consider a rural practice? That is, besides the fresh air, lower crime rates and tight-knit communities? Consider these financial incentives: federal, state, and private scholarships and loan repayment programs; tax credits; malpractice insurance reduction; and shortage area bonus programs.

Rural settings offer a variety of incentives, including financial, to try and attract new PA graduates. While this setting is highly rewarding, it also brings a unique set of challenges. Ultimate success or failure in attracting new PA staff to rural facilities, or retaining them in rural posts, depends on PA preferences and professional goals. If you are interested in learning more about rural health or are currently working within rural health and could benefit from some resources, check out these helpful links: Maria Frisch is a healthcare consultant and clinical research scientist. She received her medical training from St. George's Medical School and graduate training in public health from the University of Minnesota.

1. MacDowell M, Glasser M, Fitts M, Nielsen K, Hunsaker M. A national view of rural health workforce issues in the USA. Rural Remote Health. 2010;10(3):1531.
2. He X. Physician demography and policy implications. J Health Care Poor Underserved. 2012;23(4):1566-1576.
3. Grants. US Department of Health and Human Services Rural Health Resources and Services Administration Web site. Published 2013. Updated 2013.
Accessed June 23, 2013.
4. Henry LR, Hooker RS, Yates KL. The role of physician assistants in rural health care: A systematic review of the literature. J Rural Health. 2011;27(2):220-229.
5. Diemer D, Leafman J, Nehrenz GM S, Larsen HS. Factors that influence physician assistant program graduates to choose rural medicine practice. J Physician Assist Educ. 2012;23(1):28-32.
6. Coombs JM, Morgan P, Pedersen DM, Koduri S, Alder SC. Factors associated with physician assistant practice in rural and primary care in utah. Int J Family Med. 2011;2011:879036.
7. Smith B, Muma RD, Burks L, Lavoie MM. Factors that influence physician assistant choice of practice location. JAAPA. 2012;25(3):46-51.
8. Hart G. Why NP’s and PA’s choose to work in rural settings. Updated 1/18/2013. Accessed June 23, 2013.