Physician Assistants/Associates in Critical Care: A Descriptive Analysis Using the National Commission on Certification of Physician Assistants Dataset

Abstract

OBJECTIVES:

Little is known about the size, trajectory, and practice characteristics of the physician assistant/associate (PA) workforce specializing in critical care. The demand for critical care service delivery is growing, and the supply of physician critical care specialists is not fully meeting this demand. The purpose of this research is to describe the characteristics of PAs in critical care medicine.

DESIGN:

Descriptive cross-sectional analysis.

SETTING:

“PA Professional Profile” 2023 survey instrument from the National Commission on Certification for Physician Assistants.

SUBJECTS:

PAs who have identified their role in critical care medicine.

INTERVENTIONS:

Dataset regarding demographics, practice characteristics, income, and retention for the study population. Descriptive and bivariate statistics were used to compare findings of PAs practicing in critical care and PAs in all other disciplines.

MEASUREMENTS AND MAIN RESULTS:

By the end of 2023, 2561 PAs reported working in critical care (2.0% of PAs). Of these PAs, 1738 (67.9%) were under age 40 (mean, 37.5; sd, 9.3), and 1740 (67.9%) had 10 years or less as a board-certified PA (mean, 9.3; sd, 7.8). The average income was $137,793 (sd, $32,882). Geographically, there were more PAs in critical care in the Northeast (38.7%) and South (36.1%) compared with other regions in the United States, and 2493 PAs in critical care (97.7%) resided in urban settings. Additionally, 408 PAs (16.1%) in critical care reported completing a postgraduate training program, more prevalent than PAs in all other specialties (5.4%; p < 0.001). More PAs in critical care report symptoms of burnout (n = 944; 38.5%) than PAs in all other specialties.

CONCLUSIONS:

Team-based and multidisciplinary health care is becoming standard in the ICU setting, and the role of PAs is growing in critical care. This follows a trend over the last 10 years of PAs increasingly working in inpatient acute care settings and completing postgraduate clinical training.

KEY POINTS

Question: This study aimed to understand the evolving critical care physician assistant/associate (PA) workforce by exploring their demographic and practice characteristics.

Findings: This descriptive cross-sectional study found that, as of 2023, 2,561 PAs (2.0%) reported working in critical care with an average income of $137,793. Over two-thirds of PAs in critical care resided in the Northeast (38.7%) and South (36.1%), and nearly one-fifth of PAs who worked in critical care completed postgraduate fellowship/residency.

Meanings: There was a consistent trend for more PAs to complete postgraduate training and work in critical care over the previous decade.

Every year in the United States, more than 6 million patients require critical care treatment in ICUs for life-threatening conditions (1). The care for these patients is often high acuity and complex, with multiple concurrent comorbidities affecting management. The COVID-19 pandemic exponentially increased the demand for critical care, and persistent practitioner shortages are among the lasting impacts (2). The increases in ICU occupancy rates have not been accompanied by a growth in the number of critical care physicians (3, 2). As a result, the multiprofessional team with the use of physician assistants/associates (PAs) and nurse practitioners (NPs) has become recognized as essential to alleviate overburdening intensivist coverage in ICUs and deliver high-quality critical care medicine (2–4). Zhou and Pathak (5) predicted that critical care staff needs would continue to rise in the United States and that PAs and NPs would continue to be an important part of the workforce.

In 2024, there were 179,000 PAs and 385,000 NPs employed in the United States, with a projected 28% and 40% growth over the next decade, respectively (1, 6–9). At the same time, there were 1,010,892 licensed physicians in the United States in 2023, with 14,159 working in critical care (2, 10). With an expected 4% growth in the physician workforce and a projected physician shortage of 13,500–86,000 physicians by 2036, PAs and NPs, collectively known as advanced practice providers (APPs), are often considered to be part of the solution to the workforce shortage (11, 12). About 80% of critical care organizations reported staffing APPs in some or all of their ICUs (13). However, the Society of Critical Care Medicine notes that the lack of demographic data for the critical care APP workforce generally has made it challenging to identify the current state of the critical care workforce at large and predict future demands and trends (2).

Roles and responsibilities of APPs in this setting are multifaceted, including patient assessment, ordering and interpreting diagnostic tests, prescribing medications, managing mechanical ventilation, and performing procedures (14). The effectiveness of APPs in critical care is well delineated. Kleinpell et al (1) found that the addition of APPs to the ICU improved care coordination, including discharge planning and post-ICU discharge follow-up. The addition of a PA to a critical care outreach team led to a reduction in time-to-transfer to the ICU with no impact in hospital mortality or length of stay (2). Other findings include the positive impact of APPs on 24/7 and nocturnist coverage in the ICU; positive impact of APP-led rapid response teams with intensivist presence via telehealth; lower mean Acute Physiology Score and mechanical ventilation rates in ICUs with NPs and PAs; and enhanced training and ICU experience among residents working with APPs (2, 15, 16).

The growth of PAs into the critical care setting is part of a larger trend of more PAs working in hospitals as opposed to offices since 2015 (6, 17). Because graduate education for PAs focuses on general medicine, postgraduate training in critical care has become more prevalent in the last decade, with an estimated 60 postgraduate PA, NP, and APP critical care training programs nationwide (2, 6, 11, 17–21). Although most postgraduate training programs extend for 1 year, Zhou and Pathak (5) found that even a 4-month postgraduate training program for their existing APPs significantly improved both knowledge and skills assessments. As the demands of critical care increase, these postgraduate training programs are expected to remain important bridges for APPs into the critical care workforce (2).

Understanding this PA workforce will provide a foundation of knowledge to better equip health policy leaders to predict the future critical care workforce. The purpose of this study is to provide a foundational understanding of the critical care PA workforce, describing demographics, practice settings, and PA training in critical care.

MATERIALS AND METHODS

Instrument

Since 2012, the National Commission on Certification of Physician Assistants (NCCPA) has used a secure, online data-gathering instrument known as the “PA Professional Profile” to collect self-reported demographic and practice data from all nationally board-certified PAs (22). The “PA Professional Profile” consists of three modules (About Me, My Practice, and Recently Certified) with optional questions that are updated regularly (22). The “PA Profile” is a validated and reliable measure that was developed using the Health Resource and Services Administration minimum dataset guidelines, which offer parameters for health workforce data-gathering efforts (23). PAs can update their responses in the “PA Professional Profile” at any time or every 2 years when they log in to report their continuing medical education credits.

Study Design and Methodology

This cross-sectional, descriptive, observational analysis used the 2023 “PA Professional Profile” NCCPA dataset to compare PAs in critical care medicine. To PAs in all other specialties based on demographics (age, gender, race, ethnicity, U.S. region, and urban-rural setting), education (highest degree completed and completion of a PA postgraduate training program), practice factors (years certified, years working in specialty selected, hours worked per week, secondary position), and other essential characteristics (income, satisfaction of present job, burnout, and plans to leave principal clinical position in next 12 mo) (6). Prior studies have used similar methodology in PAs practicing in various medical specialties, such as geriatrics, obstetrics and gynecology, and psychiatry (24–26). Descriptive statistics and bivariate analyses (χ² test or Mann-Whitney U test) were conducted using IBM SPSS Statistics for Windows, version 29 (IBM Corp., Armonk, NY, USA) and a p value of 0.05 or less was considered statistically significant when a comparison was made.

Participants

In 2023, there were 178,708 board-certified PAs in the United States, and 149,909 PAs had responded to a portion of the “PA Professional Profile.” Of those PAs who responded to the PA Professional Profile, 127,915 PAs reported being clinically employed. Of the 127,915 clinically employed PAs, 126,941 PAs reported their principal clinical specialty (response rate of 83.9%), of which 2,561 PAs (2.0%) indicated practicing in critical care medicine and 124,380 (98.0%) indicated practicing in nearly 70 other specialties, such as family medicine, general surgery, pediatrics, and emergency medicine, among others.

Inclusion/Exclusion Criteria

For the purposes of our study, the inclusion criteria included PAs who had updated and confirmed their response to their principal clinical specialty in the “PA Professional Profile” in the past 3 years. PAs who did not indicate a primary clinical specialty or respond to the profile were excluded from the analysis. This research was deemed nonhuman subjects research by the Sterling Institutional Review Board (No. 10826).

RESULTS

Demographics Characteristics of PAs in Critical Care

In 2023, 2561 PAs reported practicing in critical care (Supplemental Tables 1–3, http://links.lww.com/CCX/B498). This is consistent with persistent growth over the last 10 years. In 2015, 1060 PAs reported working in critical care (17). By 2020, this number had increased to 1810 (Fig. 1) (27). Compared with PAs in all other disciplines, PAs in critical care were, on average, nearly 4 years younger than those practicing in the total of all other disciplines (mean age, 37.5 [sd, 9.3] vs. 41.3 [sd, 10.9]; p < 0.001), and more likely to identify as male gender (34.8% [n = 891] vs. 29.8% [n = 37,017]). Yet, the differences between PAs in critical care and PAs in all other disciplines were not statistically significant regarding their race (p = 0.084) and ethnicity (p = 0.749; Table 1).

Figure 1.

Growth of critical care medicine physician assistants/associates from 2014 to 2023.

TABLE 1.

Demographic Characteristics of Physician Assistants/Associates in Critical Care Medicine Versus Physician Assistants/Associates in All Other Specialties

Variable	Value	PAs in Critical Care Medicine (n = 2,561; 2.0%)	PAs in All Other Specialties (n = 124,380; 98.0%)	p
Age	Mean (sd)	37.5 (9.3)	41.3 (10.9)	< 0.001
	Median (interquartile range)	35 (31–42)	39 (33–48)
Gender	Male	891 (34.8%)	37,017 (29.8%)	< 0.001
	Female	1,670 (65.2%)	87,334 (70.2%)
Race	White	2,054 (83.5%)	100,084 (84.0%)	0.084
	Asian	177 (7.2%)	7,884 (6.6%)
	Black/African American	96 (3.9%)	4,122 (3.5%)
	Multirace	68 (2.8%)	2,899 (2.4%)
	Othera	65 (2.6%)	4,101 (3.4%)
Ethnicity	Hispanic/Latino(a/x)	178 (7.2%)	8,409 (7.0%)	0.749
	Non-Hispanic/Non-Latino(a/x)	2,298 (92.8%)	111,326 (93.0%)
Urban-rural setting	Urban	2,493 (97.7%)	114,482 (92.6%)	< 0.001
	Rural/isolated	58 (2.3%)	9,164 (7.4%)
Highest degree	Bachelor’s degree	235 (9.2%)	16,765 (13.5%)	< 0.001
	Master’s degree	2,238 (87.5%)	101,942 (82.0%)
	Doctorate degree	54 (2.1%)	2,896 (2.3%)
	Other	30 (1.2%)	2,700 (2.2%)
Completion of a PA postgraduate training program	No	2,131 (83.9%)	116,570 (94.6%)	< 0.001
	Yes	408 (16.1%)	6,710 (5.4%)
	Yes, I work in two or more clinical PA positions	515 (20.6%)	13,780 (11.2%)

PA = physician assistant/associate.

^aOther includes those who selected “other,” Native Hawaiian/Pacific Islander, and American Indian/Alaska Native.

Geographically, a higher proportion of PAs in critical care resided in the Northeast (38.7%) and South (36.1%) compared with the Midwest and West regions of the United States, and the majority (97.7%; n = 2493) resided in urban settings (Fig. 2).

Figure 2.

Map of critical care medicine physician assistants/associates in regions and median income.

Education Background of PAs in Critical Care Medicine

The most common highest degree completed by PAs in critical care was a master’s degree (87.5%, n = 2,238), followed by a bachelor’s degree (9.2%, n = 235), and a doctorate degree (2.1%, n = 54). Additionally, PAs in critical care, when compared with those in all other disciplines, were more likely to indicate completing a postgraduate training program (16.1% [n = 408] vs. 5.4% [n = 6710]; p < 0.001; Table 1).

Practice Characteristics of PAs in Critical Care Medicine

PAs in critical care medicine reported being certified for 3 years less (mean, 9.3 [sd, 7.8] vs. 12.3 [sd, 8.9]; p < 0.001) and working slightly fewer years in the current clinical principal position (mean, 7.1 [sd, 6.6] vs. 8.8 [sd, 7.6]; p < 0.001) compared with PAs in all other medical disciplines. However, PAs in critical care were more likely to report holding two or more clinical jobs (20.6% [n = 515] vs. 11.2% [n = 13,780]; p < 0.001) than their colleagues in all other disciplines (Table 2).

TABLE 2.

Practice Characteristics of Physician Assistants/Associates in Critical Care Medicine Versus Physician Assistants/Associates in All Other Specialties

Variable	Value	PAs in Critical Care Medicine (n = 2,561; 2.0%)	PAs in All Other Specialties (n = 124,380; 98.0%)	p
Years certified	Mean (sd)	9.3 (7.8)	12.3 (8.9)	< 0.001
	Median (IQR)	7 (4–13)	10 (5–18)
Years working in selected specialty	Mean (sd)	7.1 (6.6)	8.8 (7.6)	< 0.001
	Median (IQR)	5 (2–10)	7 (3–12)
Hours worked per week	Mean (sd)	41.8 (9.9)	39.7 (10.4)	< 0.001
	Median (IQR)	40 (40–44)	40 (36–45)
Secondary position	No, I work in only one clinical position	1,875 (74.9%)	104,497 (85.2%)	< 0.001
	Yes, I also work in a position where I do not provide direct patient care (i.e., education, research, administration)	115 (4.6%)	4,324 (3.5%)
	Yes, I work in two or more clinical PA positions	515 (20.6%)	13,780 (11.2%)

IQR = interquartile range, PA = physician assistant/associate.

Salary and Burnout of PAs in Critical Care Medicine

When comparing the income differences for the two cohorts, PAs in critical care indicated earning on average $14,101 more than PAs in all other disciplines (mean, $137,793 [sd, $32,882] vs. $123,692 [sd, $35,241]; p < 0.001; Fig. 3). The mean salary varies by region, with a difference of approximately $20,000 between PAs working in critical care in the Midwest vs. the West (Fig. 2).

Figure 3.

Income of physician assistants/associates (PAs) in critical care medicine versus PAs in all other specialties (p < 0.001).

Regarding job satisfaction and burnout, a slightly higher proportion of PAs in critical care (38.5% vs. 34.1%; p < 0.001) indicated one or more symptoms of burnout; however, they also reported being slightly more satisfied with their current employment (84.7% vs. 83.0%; p = 0.031). Furthermore, no statistical differences were found in terms of intention to depart from the current employment within the next year for PAs in critical care medicine compared with their colleagues in all other medical specialties (p = 0.124; Fig. 4).

Figure 4.

Burnout and job satisfaction of physician assistants/associates (PAs) in critical care medicine versus PAs in all other specialties.

DISCUSSION

As the demands of critical care needs rise in the United States, the APP workforce is growing in an attempt to meet this need. This growth in the number of PAs in critical care prompted the NCCPA to begin annual reporting of detailed information on this specialty in 2020 (27). Although the PA critical care workforce remained small in 2023 (2% of total PAs), it had an estimated growth of 141% since 2015 (28). By comparison, according to the American Association of Medical Colleges, the number of critical care physicians increased by 7% from 2020 to 2022, with 14,159 physicians (2). As for NPs, in 2016, when there were approximately 205,000 licensed NPs, the American Association of Nurse Practitioner Survey reported an estimated 18,655 NPs certified in adult acute care (including acute care and adult-gerontology acute care), with 20.5% working in a cardiovascular setting and 12.1% working in critical care (29). By 2022, 6.1% of the 385,000 NPs were certified in adult-gerontology acute care and 2.9% were certified in acute care, an estimated 34,650 NPs certified in adult acute care (85.7% growth since 2016) (8). Despite this growth of all three clinician types, many patients throughout the United States still lack local access to critical care resources (30). Further research is warranted to understand the factors that draw PAs and other critical care providers to this essential work.

PAs in critical care were higher paid than their noncritical care counterparts and more likely to complete postgraduate residency or fellowship training. In 2016, 32.1% of PAs in critical care had an income less than $100,000, and 34.3% had an income greater than $120,001 (27). In 2023, 7.4% of PAs in critical care had an income less than $100,000, and 68.8% had an income of greater than $120,001. With a mean income of $137,793, PAs working in critical care earn $14,101, or 11% higher annually than the average income for all other PAs. In comparison, within critical care, the average income is $418,200 for physicians and $129,330 for NPs (2). PAs in critical care are nearly 10 years younger than acute care NPs (mean age 37.5 for critical care PAs vs. 48.2 for acute care NPs) with less difference in years of experience (mean years of experience 9.3 for critical care PAs vs. 11.8 for acute care NPs) (29). Despite the relative youth and years of experience compared with PAs not working in critical care, PAs in critical care medicine are increasingly likely to be specialty trained. This study showed that 16.1% of PAs working in critical care had completed a PA postgraduate training program, and 69.9% of those PAs had completed their program in critical care medicine. In effect, nearly one in five of PAs who have completed a postgraduate training program are currently working in critical care. Further research is needed to understand the impact of APP specialty training on salaries, job satisfaction, and patient outcomes.

PAs in critical care work almost exclusively in urban areas. This workforce difference in PAs in critical care partially reflects the variations in ICU capacity (31, 32). Among the 79,876 adult ICU beds reported by hospitals in the U.S. rural areas had about half the ICU beds per capita compared with urban areas (30, 32). Kempker et al (30) additionally noted that the density of critical care beds was higher in highly populated urban centers compared with the large swath of rural midwestern United States. The mismatch between the supply of healthcare infrastructure (including personnel) and the need for it, known as the inverse care law, contributed to disparities in COVID-19 outcomes, and it still may persist (32). At the same time, the geographical heterogeneity is noteworthy, with the majority of PAs in critical care employed in the Northeast and South, whereas only around 15% work in the Midwest, and less than 10% in the West. The other factors contributing to this difference warrant further investigation.

More PAs in critical care report symptoms of burnout than PAs in all other specialties. This aligns with the notion that burnout among the critical care workforce is consistently higher than in other specialties (2). For PAs in critical care, the current reported burnout rate of 38.5% is increased from that of 2020 (31.8%) (27). As for other health professions in the ICU, burnout among ICU nurses has been reported as 28–42%, and burnout has been reported to be 25–71% for critical care physicians (14, 33, 34). Historically physicians have demonstrated a higher rate of burnout compared with other health professionals with less satisfaction with work-life balance (35). Risk factors for burnout in the ICU have previously been described as related to personal characteristics like younger age and female gender, organizational factors, such as lack of control of schedule and more night shifts, quality of working relationships, and interpersonal conflicts with colleagues and other health professionals, and the nature of working with dying patients (35). Despite the demands of working in an ICU, this study found that job satisfaction was high among PAs working in critical care and that only 10% were considering leaving their principal clinical position in the next 12 months. This aligns with previous research that demonstrates career satisfaction despite burnout among PAs (36). Further research is needed to understand the protective factors within the PA profession that allow for this sense of professional fulfillment.

LIMITATIONS

This is the first study to clearly outline the demographics and workplace characteristics of the PA critical care workforce. The utilization of NCCPA data allows for a large representative sample of practicing PAs in the United States. Despite the strengths of this study, the response rate to the PA Professional Profile was 83.9%. As a result, it is not possible to know exactly how many PAs are practicing in critical care. Additionally, this research is cross-sectional across varying time periods depending on when respondents entered their personal data. Particularly, the response to burnout question items may vary over time depending on external or internal circumstances. Respondents updated or completed the specialty question in their profile in the last 3 years, which could potentially introduce bias if PAs changed their specialty but did not update their profile during the study period. Additionally, the self-reported nature of the data lends itself to potential misinterpretation of questions as well as recall and acquiescence bias. Although the present work focuses on PAs, the role of the entire class of APPs in critical care needs to be explored further. Understanding the similarities and differences for PAs and NPs in the critical care setting can inform decisions for growing critical care teams, expanding opportunities for professional development, and developing strategies for burnout prevention.

CONCLUSIONS

The role of PAs is steadily growing in critical care medicine. As more PAs and NPs work in this field, team-based and multidisciplinary health care is becoming standard in the ICU setting. These findings demonstrate the relative youth but strong training of this PA population. Postgraduate PA training in critical care is a persistent source of output, with nearly one in five critical care PAs having completed a PA postgraduate training program. Despite the growth of PAs in critical care, there remain disparities in access to this service line throughout the Midwest. PAs in critical care seem to demonstrate similar levels of burnout to other critical care clinicians. However, most are satisfied with their current work. Further research regarding postgraduate critical care PA training and burnout pre- and post-pandemic might shed additional light on this member of the interprofessional healthcare team.