Background and Purpose of Survey
In August 2022, a survey was conducted via the Puerto Rico Médico Asistente Facebook page to better understand the composition of PA title holders on the Island. This effort was necessary due to the lack of government-provided statistics and transparency regarding these numbers. It is important to note that this survey provided a general idea rather than a comprehensive one, given the small pool of participants.
Survey Findings & Policy Implications
Understanding the Composition of PAs in Puerto Rico: Insight from a 2022 Survey
Who Holds the PA Title in Puerto Rico?
PAs in Puerto Rico fall under the umbrella term Médicos Asistentes, where 10% are Certified Physician Associates (PA-Cs) and 90% are Medical Doctors (MDs) who have not passed all their boards. Of these medical doctors, about 60% had held the PA title in PR for 2-3 years, while the remaining 40% had either held the title for 1 year or dropped it upon passing their medical boards. Among the 27 MDs who held the PA title and participated on this survey, 20 expressed willingness to renew their PA license until they passed their medical boards, because they needed a job, or because they wanted to remain in a medically related field until they passed their boards and worked as residents.
MDs holding the PA title graduated from their medical programs as early as 2007, with approximately 65% of them having graduated from medical programs outside the United States, including the Dominican Republic, Mexico, and Montserrat. If these MDs did not hold a physician license from the time they graduated medical school until they became eligible to hold a PA license in PR in 2019, and had not passed all their boards, what standards were they being held to? What standards are they being held to? Did they stay current with continuing medical education? How can we ensure that patient safety isn't compromised?
There's a prominent saying in Puerto Rico that goes: 'La educación es la única riqueza que nadie nos puede quitar,' or something along those lines. Personally though, I was out of practice for a couple of years and know that time is the biggest factor in losing one's education. So, I argue that this prominent saying is actually skewed. It is time itself that can take away our education... along with certain other health conditions, of course. However, that’s beside the point. The main concern is: How do we regulate this issue to maintain high quality of care while introducing a new profession to the Island?
Licensure, Oversight, and Regulatory Gaps
To make matters more questionable, the survey revealed that 10% of MDs holding the PA title in PR responded affirmatively to prescribing medications, despite Law 71 stating that PAs in PR are not allowed to prescribe. So who is overseeing, who is auditing? That is yet to be concretely addressed. Oh, and one PA indicated that their supervising physician would not require them to renew their PA license.
Clinical Roles & Scope of Practice Variability
PAs in PR can be found in various fields of medicine, including gastroenterology, gynecology, general medicine, urology, surgery (general, vascular, trauma), internal medicine, cardiology, hospitalist roles, and radiation oncology. However, their responsibilities were noted to be inconsistent, ranging from data entry and administrative tasks to clinical duties such as progress notes, dealing with health insurance, physical exams, and interpreting and ordering labs.
Compensation, Benefits, and Working Conditions
The benefits for PAs in PR were also inconsistent. About 50% had no benefits, while the other half had perks such as sick days and vacation days, with only one reporting partial health insurance coverage.
Work hours for PAs varied, with most working 8 hours a day, 5 days a week, while some working more than 40 hours a week, and one respondent working 16 hours a day. The pay grade for PAs in
PR also varied, with some working as independent contractors and others receiving predetermined salaries. Hourly wages ranging from $8.50 to over $40, with the majority earning between $16 and $35 per hour.
Perceptions of the PA Title Among MDs
Near the end of the 10-question survey, we wanted to understand the perceptions of MDs holding the PA title regarding the umbrella term 'profession,' and it revealed mixed feelings. Some notable quotes included:
“Basically, I am a secretary with superpowers.”
“As medical graduates who have passed some of our boards, we are above any PA program in the nation. Just because of that, we should be allowed to be eligible for the NCCPA exam.”
“We should be allowed to perform more duties like administering tuberculin tests.”
“I won’t renew my PA license due to mistreatment and belittlement.”
Professional Aspirations & Tensions
The goals of MD’s holding the PA title included holding the same qualifications as PAs in the US, being given more responsibilities, being allowed to prescribe and have more autonomy, receiving more education, higher pay, and more benefits. They also commented on aspiring to be equals to PA-Cs and be allowed to sit for the NCCPA exam to work in other states.
Implications for Patient Safety & the PA Profession
One thing remains unclear. Did they all eventually want to drop the PA title to work as physicians? What challenges can that pose for the PA profession?
Demographic Snapshot of Survey Participants
Of note: The demographic breakdown of survey participants included MDs from the Dominican Republic, Mexico, Montserrat, and Puerto Rico, as well as two PA-Cs. One MD from El Salvador, who graduated in 1997, expressed interest in moving to PR to work as a PA.
Summary of the Issue
Law 71 merges two distinct professionals under one title through unequal licensing processes, leading to stigma and misunderstanding about the PA profession, which impedes its development and growth. The general misunderstanding of the PA profession limits the professionalization process of PAs in PR. The medical and general community often stigmatizes the PA profession as a fallback for those who have not passed their boards, overshadowing the preparation of PA-Cs.
Proposed Resolution
Amendment of Law 71 to create clear roles and delineations for PAs.
Creation of a new law for physician associates that dissociates PA-Cs from Médicos Asistentes, making PA-Cs the sole proprietors of the PA title abbreviation.
Establishment of regulatory standards that include full scope of practice, billing, and prescribing authority.
