The physician assistant (PA) profession in the
United States began in October 1967 when three
former Navy corpsmen graduated from the Duke
University PA program. The profession, which came
about during a nationwide physician shortage, was
developed based on a medical model similar to the way physicians were fast-tracked through training during
World War II.
Since the Army was losing physicians to civilian practices in the 1960s, it quickly saw the benefit of PAs. With
congressional approval, the Army trained 400 PAs, and the first class graduated in July 1973. The other services quickly followed the Army’s lead and started their own
PAs initially were warrant officers. In February 1992,
the Army began commissioning PAs into the Army Medical Specialist (SP) Corps. Other commissioned officers already in the SP corps included occupational
therapists, physical therapists, and dietitians. This was
a major force-management transition for the Army, and
it took many years to work out the issues resulting from
Much progress has been made over the years, but major
concerns for the future still need to be addressed. The
most critical issue that needs immediate attention is the
significant lack of PA field-grade officer authorizations
in both the operating and generating forces.
Field-Grade Officer Deficit
The field-grade officer deficit began when PAs were
first commissioned in 1992. Commissioned rank was
awarded based on a warrant officer’s time in service and
educational background. Since few PAs had sufficient
educational backgrounds during the constructive credit
calculation for commissioning, only a few were appointed
as field-grade officers.
Many PAs decided not to go the commissioned-officer route and, instead, resolved to finish their careers as warrant officers and retire. Others who did not finish their degree requirements for commissioning by the deadline were forced out or involuntarily retired. This created a severe manpower shortage, especially at the higher ranks.
Moreover, half of the remaining PA force was eligible for
retirement during the post-Desert Storm timeframe when
stop loss and the retiree recall expired.
Many of the field-grade PA authorizations were transferred elsewhere in the Army Medical Department (AMEDD) because the newly transitioned PA inventory did not have the field-grade officers to fill the positions. Even when the PA inventory developed and transformed, these authorizations were never returned, which resulted
in the present-day force structure inequality.
Current PA authorizations and inventory are unbalanced and do not provide for reasonable growth past the O–4 (major) level. The total number of PA authorizations for fiscal year 2011 was 803, and of those, only 29 were for O–5 (lieutenant colonel) and 3 for O–6 (colonel), making the total for O–5 and O–6 less than 4 percent of the PA authorizations. This affects the life-cycle model for growth and development for all PAs because once a PA attains the rank of major he has little promotion
potential. With this realization, the PA community must anticipate abnormally high nonselection rates for lieutenant
colonels and colonels.
The Army is currently well over strength in PAs at the O–3 and O–4 levels. The fiscal year 2011 staffing document had O–3 and O–4 authorizations at 536 and 149 respectively; however, the 2011 inventory had 623 O–3s and 234 O–4s. This force structure does not provide for sufficient career progression and appears to become a throw-away force at the grade of O–3.
The best Army PAs view their profession in the Army as having little progression potential, unchallenging positions, and a bleak promotion rate. Meanwhile, their skills are valuable and the civilian job market is attractive. The best PAs will start to look at the civilian sector just as the physicians did in the past. In 2010, CNN Money magazine ranked the PA profession as the second best job in the United States for the past 3 years. The inability to retain quality PAs at all levels will soon be a reality the
Army will have to manage.
Increasing the number of field-grade officers in the PA profession would help provide leader development for
junior PA officers. In any area of concentration (AOC),
it is important to have a sufficient number of field-grade officers to mentor, teach, and coach the junior-grade officers. Moreover, guiding future leaders by providing assessment and feedback maximizes their development
and improves their career success. Experienced fieldgrade officers can influence the future of the Army and how junior officers perform by showing them “what right looks like.”
Mentoring is the essential component that is missing here. Any leader or supervisor can provide the personal development, but an experienced PA can best guide professional development in technical and tactical competence and career path knowledge. To gain experience in the operating and generating forces, field-grade PAs need to hold key developmental positions, which currently do
not exist, as junior officers.
General Officer Representation
In order to provide field-grade officer PAs with the developmental opportunities and representation needed within AMEDD, the SP Corps needs a general officer (GO). This representation is important for bringing to light the issues in the PA force structure. The GO could sit at the decision table with AMEDD for table of distribution and allowances (TDA) decisions and with the Army G–1/3/5/7 for modified table of organization and
The Army Personnel Proponent Directorate (APPD) and the Office of the Surgeon General Program Analysis and Evaluation host the Command Grade Allocation Conference each year in October. With the proper representation, the PA field-grade deficit issue could be addressed at this conference. AMEDD has six branches: the Medical Corps, the Dental Corps, the Veterinary Corps, the Medical Service Corps, the Army Nurse Corps, and
the Army SP Corps. Of these six corps, the SP Corps is the only one that does not have
|A physician assistant
examines a patient’s finger
as part of a typical workday
for a deployed medical team. (Photo by Private Emily V. Knitter)
Some PA authorizations need
to be upgraded to the fieldgrade
level in order to achieve
the rank structure required to
conduct the warfighting mission
properly. With the development
of the brigade combat
teams, the PA position in the
brigade support battalion was
established appropriately as an O–4 senior PA. The PA
positions in all of the combat aviation brigades need to
be upgraded to O–4 as well.
In the special operations community, the 75th Ranger
Regiment headquarters has properly documented its
PA as an O–4. The same needs to be done in the 528th
Special Operations Sustainment Brigade and the 160th
Special Operations Aviation Regiment. The Army
Special Operations Command headquarters PA billet is
currently an O–4 and needs to be upgraded to an O–5.
This is necessary because the command PA is the assignments
officer for all special operations PA assignments
and needs to have a rank equal to that of the staff officers
he negotiates with to perform his duties.
On the AMEDD TDA, upgrades to O–5 also need
to be made for all PA directors of specialty programs
(emergency medicine, orthopedics, and general surgery)
and for all of the phase II clinical coordinator positions
at phase II hospital sites. A tiered career-progression
rank structure up to O–6 for specialty PAs is needed; it
currently cuts off at O–4. These upgrades are needed to
represent the PA training programs since all of the other
program directors and clinical coordinators for other
medical programs are either O–5s or O–6s. All of these
changes are needed to give the PA officer the proper rank
and authority to perform his duties within the staff command
and rank structure.
Lack of PA Senior Grade Authorizations
Not enough authorizations currently exist in the
generating force (AMEDD) to provide for assignment
diversity and to develop PAs who are competitive for
promotion and leadership positions. When this article
was written, no PAs at the O–5 or O–6 level had been
selected to command a TDA hospital or an AMEDD
training command because no advocacy or mentorship
existed to establish that career path for PAs.
All of the other AMEDD corps have adequate representation
because most of their authorizations are in
AMEDD. However, 80 percent of the PA authorizations
are in the Army Forces Command and only 20 percent
are in AMEDD. PAs excel in the operating force because
they are respected at all levels of command as the trainers
and leaders of the combat medics and the battlefield “docs” who save lives. Commanders rely on this multifunctional
officer not only to provide healthcare as a
clinician to the Soldiers but also to serve as a staff officer
advising on the medical readiness of the unit and to provide
operational health service support.
In AMEDD, however, the PAs do not have the opportunity
to lead at all levels of clinic command. The
experience and diversity gained from operating a clinic,
supervising civilians, writing policy, managing a budget,
and developing medical education opportunities are key
skills that must be mastered to be a successful clinic or
hospital commander. As PA officers increase in rank,
their opportunities to serve in the operational force as
clinicians decrease because of the rank structure of maneuver
commanders and staff. Thus, ample PA positions
need to be available in the generating force to provide
increased responsibility and opportunity.
Solving the Authorization Problem
The Army has always been short in its physician inventory.
PAs are trained as family practice generalists and
can be employed in all medical and surgical services.
In the civilian sector, PAs are currently employed in all
the same specialty areas as physicians. Using more PAs
in medical treatment facilities will assist PAs with their
professional and clinical development and decrease the
Army’s strain caused by the physician shortage.
New PA positions can be funded by authorizations that
are not being used by hospitals or AMEDD. This will
ultimately increase both Soldier and dependent access to
care. Other key positions that could benefit the Army and
the career progression of PAs include—
- Commander of a forward surgical team.
- Staff officer on the Joint and Army Staffs.
- Staff officer in the Office of the Surgeon General.
- Staff officers at combatant commands and theater
special operations commands.
- Faculty at the Uniformed Services University of the
Health Sciences, the Army Command and General
Staff College, and the United States Military Academy.
PAs should have the opportunity for assignment to
important developmental positions in order to prepare
for future command and key leadership positions at the
field-grade level. Not all PAs will choose this career
route, but those who do need the opportunity to compete
for these positions in order to demonstrate the mastery of
skills, knowledge, and abilities needed to command and fill key leadership positions. Currently, most PA assignments
are clinical in nature, and developmental jobs and
leadership positions are scarce.
Some opportunities exist in AMEDD branch-immaterial
positions. However, those jobs are scarce as well and
depend on the luck of timing and the competition pool.
Several fortunate PAs have had the opportunity to command
at the company-grade level in years past. Two PAs
have commanded forward surgical teams as field-grade
officers, and two O–6 PAs have commanded an Army
health clinic and a combat support hospital. Although
all of these PAs were successful as commanders, none
of them received any key developmental positions to
prepare them for assuming command, which would have
made them more successful.
Some of the key developmental positions PAs should
be allowed to fill include executive officer or S–3 with
a combat support hospital or medical battalion, primary
staff officer with a medical brigade, deputy division surgeon,
and Army health clinic or medical treatment facility
chief of staff, executive officer, or deputy commander
for clinical services. PA clinicians must seek diversity in
order to develop their skills and become more competitive
for positions of increased responsibility.
The PA profession will continue to grow in the Army,
and so will its officers despite their many challenges.
Change takes time because of the dynamic nature of the
Army. Great progress has been made over the years in
integrating the PA AOC into the operating and generating
forces, but the PA AOC still lacks sufficient field-grade
authorizations to provide for officer growth, professional
advocacy, and career progression.
Providing these valuable officers with more positions
and opportunities will help retain quality PAs, allow for
leader development and mentorship, increase leadership
opportunities, increase access to care, provide assignment
diversity, increase competitiveness for promotion,
and promote, sustain, and enhance warrior and military
family healthcare. With the appropriate increase in PA
field-grade authorizations, experienced PA field-grade
officers will continue to pioneer in leadership roles, leading
by example and mentoring the next generation of PA