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Physician associates (PAs) are a foundational and rapidly expanding part of the US health system. Certified PA numbers have been up 28% since 2018, and an estimated 12,000 PA positions are expected to open each year for the next decade. The burgeoning class of providers has swiftly become indispensable to specialty care and a backbone of primary care. But how do PAs climb the career ladder?

Pathways for career advancement are less established for PAs vs their more traditional nurse and physician counterparts. PAs navigate complex regulatory landscapes, misconceptions about their expertise, and entrenched hierarchies within the health system on the road to fulfilling their career goals. Despite the obstacles, experts told Medscape Medical News that PAs of every experience level have opportunities for clinical, financial, administrative, and academic advancement.

Endless Options, Similar Beginnings

"The career pathways are endless," according to Jennifer Orozco, DMSc, PA-C, DFAAPA, chief medical officer of the American Academy of Physician Associates (AAPA). She said that because PAs are so versatile, advancement can take shape as any number of administrative, academic, clinical, entrepreneurial, and advocacy opportunities.

PAs may choose to manage people or specialize. They may choose to collaborate on research or pursue academic and teaching roles. And given that PAs have excellent horizontal mobility and can change specialty with relative ease, a PA may pursue more than one of these pathways over the course of their career. According to a 2022 practice survey, 40% of practicing PAs are already in some form of leadership role.

However, PAs diverge professionally; the majority share a similar beginning. For early career PAs, building clinical skills is the primary road to advancement. Some PAs will do a fellowship to advance clinically; others will specialize. But for all PAs, the initial years on the job come with a steep learning curve, said April Stouder, associate program director of the PA program at Duke University, Durham, North Carolina.

Jessica Wallace, a primary care PA at Denver Health, Denver, said, "When a lot of us are thinking about advancement, it's about building the practical skills that could give you a different role in your organization, not leaving the clinical side, but how do you build in the clinical side?"

Experts agree that it's usually after a PA has 2-5 years of clinical experience, depending on the specialty, that they're ready to consider more responsibility.

For some PAs, this means increasing their scope of practice, seeing more patients, and performing more procedures. They may choose to get more voluntary certifications like a CAQ, which demonstrates advanced expertise within a specialty. Other PAs may prefer to add more management responsibilities by becoming a team lead or onboarding new hires.

However, if PAs choose to move up the career ladder, opportunities to step into leadership will only increase. "PA grads now have a tremendous opportunity for advancement just because of the changing landscape of the workforce and patient population," Stouder told Medscape Medical News. The aging population has increasing healthcare needs, just as a significant number of providers near retirement age. PAs will be essential to fill the widening gap.

Pay Bumps for PAs

There's no separating career advancement and pay increases. Fortunately, PA pay — while it varies by specialty and organization — tends to be pretty good, with an average annual compensation of $134,000, according to the Medscape Physician Assistant Compensation Report 2023. Specialties like dermatology, emergency medicine, and surgery command higher salaries.

"Pay continues to go up because we make practices money," Stouder said. "We see a lot of patients and do a lot of procedures."

However, it's worth noting that the Medscape report found that PAs were increasingly dissatisfied with their pay. Average PA compensation rose 4% from 2021 to 2022, and 59% of respondents said their income had increased. Still, 50% said they did not feel that PAs were fairly compensated, up from 26% in 2020.

Experts Medscape Medical News spoke with for the story said that any number of factors could drive that dissatisfaction. Inflation has made the same salaries less livable. Many PAs work in primary care, which is notorious for lower pay and longer hours than other specialties. And while base pay is good, PAs don't always see the same pay increases and promotions as their physician counterparts.

"I do think that compensation becomes the lowest common denominator if people don't feel respected and heard," said Wallace. She is part of an in-house body at Denver Health that supports and represents advanced practice providers. They advocate for good base pay and pay and promotion trajectories that are on par with their physician colleagues.

Lennea Coombs, MHS, PA-C, an oncology PA in Louisville, Kentucky, and clinical director of PA practice within Norton Healthcare's Office of Advanced Practice, said base pay is only part of the compensation conversation. PAs are also looking for other benefits that affect their opportunities for advancement and quality of life such as "licensure fees, membership dues, a continuing education budget, and vacation accrual and time off," Coombs said.

Your Supervising Physician

The supervising physician has become somewhat of a controversial figure in PA practice. Critics argue that making a single physician responsible for a PA puts unnecessary pressure on the doctor, implies the PA isn't equipped to treat patients independently, and creates cumbersome approval processes. Still, supervising physicians and physician colleagues play an undeniable role in PAs advancement opportunities.

"I was very fortunate to be a part of a team that wanted me to be as knowledgeable and independent of a provider as I could be," Coombs told Medscape Medical News. For 19 years of her 22 in practice, she worked for the same supervising physician. "He pushed me out of my comfort zone," she said. Coombs' supervising physician invited her to be a part of research, selection committees, and leadership opportunities in a notoriously restrictive state for PAs.

"I'm not sure where my career would be without him," she said.

Similarly, Orozco said her supervising physician and team in vascular surgery played a significant role in her career path. "I worked in a positive PA environment. My leadership and pathway to leadership was encouraged," she said.

But Coombs said there's still room for education when it comes to PAs. She regularly interacts with physicians who tell her they didn't get much exposure to PAs in medical school and don't know how to best work with or utilize them. And patients don't always understand a PA's role or authority in the clinic.

Even the language of "supervising physician" has been caught in the crossfire. "It makes people think we can't practice independently. We do need supervising physicians, but they don't have to physically supervise us 24 hours a day," Coombs said.

As the physician shortage swells, health systems need PAs to practice to the fullest extent of their education and training, Orozco said. Observational data suggest restricting PA's scope of practice doesn't improve patient safety. And Orozco argued it weakens efficiency, "When they don't have the ability to practice to the full extent they were trained to practice, we have challenges." It's in the best interest of patients and the entire workforce to allow PAs to do the work they are trained to do, Orozco said.

Back to School?

There is some concern that because a PA's terminal degree is a master's degree, they are at a disadvantage for some promotions — namely academic or clinical administration — compared with their physician counterparts.

"The big debate now is whether we go to a doctorate as the terminal degree instead of a master's degree," Stouder said. Now in a teaching role at Duke, Stouder has a PhD in education. Orozco at the AAPA has a doctorate of medical science (DMSc), and Wallace just finished her doctorate in public health.

Some PA programs are expanding to offer a doctorate, which Coombs has looked into. But at this point, the degree would not increase her pay, teaching opportunities, or clinical scope of practice, she said. AAPA's 2022 practice survey reported that 33% of PAs were considering a doctorate. However, according to Medscape's compensation survey, only 4% of PAs have reportedly gone on to get their doctorate.

For most PAs, advancement won't require a doctorate or leaving the clinic for full-time leadership, but it might mean diversifying their roles. Both Wallace in Denver and Coombs in Louisville are part-time in the clinic and spend the rest of the week in other roles. Wallace is the director of Healthy World, a public health initiative, and the lead advanced practice provider for family medicine at Denver Health. Coombs is in the oncology clinic 3 days a week and spends the other 2 days in her role at the office of advanced practice or advocating for PAs in state government.

While it's not without roadblocks, PA advancement is customizable to each PA and unique to your specific role and relationships, experts agree.

"You have to find what your strengths are, or if you have a vested interest in something," then pursue that, Coombs said.

Donavyn Coffey is a Kentucky-based journalist reporting on healthcare, the environment, and anything that affects the way we eat. She has a master's degree from NYU's Arthur L. Carter Journalism Institute and a master's in molecular nutrition from Aarhus University in Denmark. You can see more of her work in Wired, Teen Vogue, Scientific American, and elsewhere.