As the population of older people increases, the demand for eye care services will increase without a sufficient supply of ophthalmologists.1,2 The projected shortage of ophthalmologists is a looming predicament for ophthalmic patient care. Although ophthalmologists may have differing opinions on the matter, the authors note that a 2016 analysis by the US Department of Health and Human Services projected a potential deficit of more than 30% in ophthalmologists by 2025.3,4 In fact, ophthalmology was predicted to have the largest deficit of the 10 surgical specialties modeled, including orthopedic surgery and general surgery.4 If the deficit of ophthalmologists continues, eye disorders such as age-related macular degeneration, glaucoma, and diabetic retinopathy could go undertreated.1,2,5

Integrating physician associates/assistants (PAs) into ophthalmology is a sensible way to help meet the demand. PAs have practiced in ophthalmology for decades. In the United States, 79% of practicing PAs work in specialty care, and successful integration of PAs in specialty care is evident in areas such as emergency medicine, trauma, orthopedics, critical care, and psychiatry.6-11

Similarly, NPs frequently specialize early in their education. But unlike PAs, NPs have successfully been thoroughly integrated into ophthalmology and are managing eye conditions in primary eye care settings, triaging ophthalmic emergencies in emergency settings, and delivering intravitreal injections.12-14 Peer-reviewed research about outcomes for NPs and PAs in specialty care has established a model for the successful integration of PAs in ophthalmology.

Fifty-two PAs were practicing in ophthalmology in 1990; that number increased only to 94 by 2019.15,16 Of the 7,740 PAs who responded to the salary and specialty questions in the 2022 American Academy of Physician Associates (AAPA) Salary Report, only 13 (0.002%) said they worked in ophthalmology.17 Underrepresentation of PAs in ophthalmology is likely because PA students receive little ophthalmology training and exposure in PA school.1 Other reasons may exist, such as lack of interest or available employment. Unfortunately, many ophthalmologists believe training PAs on the job is expensive and time-consuming.16,18-20 Ophthalmologists might hire PAs more frequently if the PAs were adequately trained in a postgraduate training program, despite state variations in PA prescriptive authority for prescribing corrective lenses, prisms, and contact lenses, all of which have specific fitting regulations.

The literature has limited descriptions of the benefits and ease of integrating PAs into ophthalmology practices. PAs can offer ophthalmic care in all 50 states, primarily subject to limitations set by their supervising or collaborating physician's delegation of ophthalmic care. However, some states impose restrictions on PAs in terms of performing refractions and operating lasers, so these regulations are not set at the practice level.1,16,18 Ophthalmologists prefer the surgical training PAs receive over that of other healthcare professionals, such as NPs, optometrists, or ophthalmic technicians, and feel more comfortable adding PAs to a call schedule.1,18,20

Other options to fill the gap include using other ophthalmic professionals and making policy changes. Optometrists can assist ophthalmologists in providing ophthalmic care. Optometrists perform routine eye care evaluations in ophthalmology settings but are limited by strong procedural restrictions in many states.2,21 However, because scope-of-practice changes require legislative and regulatory action, the process often is slow and faces challenges.21 Also, optometrists do not receive the same level of surgical training as PAs, although postgraduate training does exist.20 Eye care needs could be addressed by optometrists and ophthalmologists, but for ophthalmologists to adequately manage their tasks, a model incorporating PAs should not be neglected. PAs could shape their own role on the ophthalmologist-led team without disrupting other ophthalmic professions.1,20

NPs also could be excellent additions to an ophthalmology team, but many lack the surgical training preferred by ophthalmologists.1,18 Opticians and ophthalmic technicians are good additions to the team and operate diagnostic equipment efficiently, but unlike PAs, cannot bill for physician services.20 Administrators have successfully expanded medical schools in response to increased demand for physicians and increased ophthalmology recruitment, but increasing ophthalmology residency positions is a slow, arduous process.1,2,22

Because PAs receive medical and surgical training, they are in an ideal position to provide the ophthalmic care expected in the future.20 This model does not threaten the role optometrists, NPs, ophthalmic technicians, and medical students seeking ophthalmology residencies play in the ophthalmic care team. Instead, with proper training in ophthalmic care, PAs could define the role of a primary support professional for ophthalmologists.

Examples of PAs in ophthalmology in the literature include PAs performing preoperative medical evaluations for eye surgery in large eye surgery centers, PAs triaging and managing emergency and nonemergency conditions in ophthalmology practices, PAs managing patients as part of a consult service, and PAs performing intravitreal injections.1,18,23-25 Unfortunately, little research exists about the role of PAs in ophthalmology. Recent publications about PAs in ophthalmology have included survey instruments and methodologies that may benefit from further refinement. Additionally, no comprehensive research has investigated the training programs available to PAs in ophthalmology or explored their perceptions on the most effective approaches to training.15,16 This qualitative investigation was deemed useful to assist in continued quantitative instrument development and add to the body of literature.

To examine current training of ophthalmic PAs and optimal education for PAs interested in ophthalmology, the following research questions were developed:

What role and tasks do PAs working in ophthalmology perform? What facilitators and barriers to education and training specific to ophthalmology do PAs working in eye care experience? What do PAs working in ophthalmology believe would be optimal education and training to prepare them for careers in this field?

Although PAs working in ophthalmology lack sufficient eye care training in PA school and may consider postgraduate programs in ophthalmology to be the best option for pursuing a career in eye care, they also may desire to expand their role on the ophthalmologist-led team from a supporting member to one with more autonomy. Expectancy theory was used as the theoretical framework for this explanatory qualitative case study to examine barriers and opportunities related to ophthalmology training for PAs and optimal training for PAs in ophthalmology.26 A qualitative case study can help reveal the role PAs play in ophthalmology. A case study also can help identify optimal training for PAs interested in a career in ophthalmology, leading to policy changes that increase the pool of qualified PAs in ophthalmology.

METHODS

The study was reviewed by the A.T. Still University institutional review board and approved as exempt.

As is standard in case study research, this study focused on a specific, small group of participants—in this case, 17 PAs with experience working in ophthalmology (Table 1). Because in-depth information was sought from information-rich individuals, purposeful sampling was used, and data saturation was reached after 17 interviews.

TABLE 1. - Characteristics of PAs in ophthalmology Participants n = 17 (%) Degree    Master's 16 (94.1)    Bachelor's 1 (5.9) Years practiced in ophthalmology    0-5 9 (52.9)    6-10 6 (35.3)    11-19 1 (5.9)    20+ 1 (5.9) Years in current practice    0-5 10 (58.8)    6-10 5 (29.4)    11-19 1 (5.9)    20+ 1 (5.9) Practice setting    Type of practice      Hospital 5 (29.4)      Private 12 (70.6)    Subspecialty      General 1 (5.9)      Oculoplastics 3 (17.6)      Retina 3 (17.6)      Multispecialty 8 (47.1)      Neuro-ophthalmology 1 (5.9)      Pediatric ophthalmology 1 (5.9)

Study participants were selected using convenience sampling from a provided database assembled by a PA working in ophthalmology, using Doximity, and through online searches. Because case study methodology focuses on a small group of participants in closed context (PAs in ophthalmology), the researchers conducted semistructured interviews using a prepared interview guide. The interview guide covered topics including participants' roles as PAs in ophthalmology, opinions of PA school curriculum on ophthalmology, perceptions of optimal training, facilitators and barriers in current training programs, and attitudes about changes in the role of PAs in ophthalmology. To apply the concept of content validity to the interview guide, the researchers consulted content experts in the field of ophthalmology to improve the trustworthiness of the qualitative research instrument. Two reviewers who have published research about PAs in ophthalmology provided feedback to the researchers. The first is an assistant professor of ophthalmology and chief of an eye institute at a prominent US university, and the other is a senior director of PA and industry research and analysis at the AAPA.

Information was collected from participants by semistructured interviews, except from one participant who preferred to type responses to the interview questions in a word processing document. The exact interview guide was given to this participant and the participant was instructed to respond to each question in as much detail as possible. Any follow-up questions or questions regarding ambiguous answers were discussed via secure email with the participant. Before each interview, participants gave informed consent. To assure overall study quality and trustworthiness, attention to credibility, dependability, confirmability, and transferability were emphasized.27 Credibility was established through prolonged and varied interviews, thorough investigation and presentation of current topic literature on the topic, and member-checking with participants. Dependability was established by describing any contextual and methodological changes in the data collection that might occur.27 Credibility and dependability of each participant were established through confirming PA certification by the National Commission on Certification of Physician Assistants, confirming state licensure, and confirming the existence of a practice website with participant biography, if available. Confirmability was established through reflexivity and triangulation. Weekly discussions were held with doctoral cohort candidates and the research project chair regarding methodology and coding strategies to implement reflexivity. Triangulation also was an important process that was applied using various techniques. Investigator triangulation and coder reliability were ensured by having authors code transcripts together and resolving discrepancies by debriefing with the doctoral cohort and considering the opinion of the more-experienced qualitative researcher.27 Theoretic triangulation was achieved by using the expectancy theory applied in the context of the proposed case study to generate propositions, construct codes, and validate findings. Finally, transferability was accomplished through extensive description of the research methods and by developing a comprehensive description of the study procedure.28 Transcripts were developed from audio recordings.

Interpretational analysis began by constructing deductive nodes based on existing literature and expectancy theory, followed by coding data in these deductive nodes. Next, open coding was implemented to inductively discover new themes, followed by grouping categories into broader themes. Codes were revised to review data for overlapping and uncoded material. Finally, major themes across inductive and deductive codes were formed to help answer the research questions. The coding and indexing of transcripts were carried out using NVivo software, version 12. Direct quotations from participants were used to support the identified themes.

RESULTS

The following themes emerged from the interpretational data analysis.

Primary ophthalmologist support

Themes extracted from deductive analysis when discussing the roles and tasks of PAs in ophthalmology included assisting in surgery, performing procedures, and seeing patients in the clinic. Most PAs in ophthalmology play an autonomous role in their practice of eye care under the delegation of an ophthalmologist. PAs reported they used this autonomy to “take some of the, not say burden, but the load [off] the ophthalmologist.” Illustrative quotes of PAs discussing their independent role included:

“I have total independence. He doesn't even check my charts.” “If I'm with the patient in the room for a follow-up there is total autonomy to let me see that patient, discuss with them what I wish, and get them for the follow-up.” “I work with [the ophthalmologist] and I independently run the lasers while she's operating” on the same patient. “I'm given as much autonomy as I feel comfortable with.”

PAs in ophthalmology reported reaching autonomy from as little as “right from day 1” when discussing treating eye conditions examined in PA school to up to 5 years for procedures and evaluations not described in PA school.

Range of procedures

When discussing the range of procedures performed by PAs in ophthalmology, subthemes included diagnostic procedures, therapeutic procedures, and cosmetic procedures (Table 2). As elucidated from the data, these subthemes highlighted the procedural nature of the PA profession. Most participants (n = 14) reported eventually performing procedures independently in as few as 2 weeks and as much as 1 year, which highlights the variety of procedures individual PAs perform.

TABLE 2. - Subthemes for procedures performed by PAs in ophthalmology and illustrative quotes from participants

Diagnostic procedures

“I also perform fluorescein angiographies in the clinic as well. We use a vegetable-based dye called fluorescein, and we inject that intravenously and basically take pictures thereafter.”

“I do the temporal artery biopsies.”

“I also perform RetCamera procedures. I am proficient in RetCam 4, RetCam 3, and Phoenix camera as well.”

Therapeutic procedures

“It's called aqueous release. If the patient has more than normal IOP [intraocular pressure], it's between 10 and 22. So let's say the patient has an IOP of 30 or more, we have to do an aqueous release, which just uses an instrument to tap the wound, the main incision, and let some fluid out. And then just make sure after you do that the wound is not leaking anymore.”

“I do all of the corneal cross-linking.”

“I administer monoclonal antibody intravitreal injections into premature babies in order to salvage the retina and prevent it from causing lifelong blindness. I think I'm the only one in the country that's probably performing that procedure. A lot of it has to do with the disparity in our location.”

“So, I actually run the lasers in my surgery center...it's a femtosecond laser...it does the capsulotomy, and it can help correct vision, so a significant correction, etc.”

“...intravitreal injection in a baby, which I perform as well, and do that at the bedside at the hospitals. I use a team of nurses.”

Cosmetic procedures

Barriers and facilitators in current training

Major deductive themes extracted from the data for barriers encountered in training included lack of training opportunities, the training/education gap, ophthalmologists' negative attitudes toward PAs, and the lack of role precedence. Facilitators to education and training of PAs in ophthalmology produced major themes that were largely associated with supportive supervising physicians and previous training. Table 3 highlights direct quotes about what barriers and facilitators to training and education look like for PAs in ophthalmology. Considering the facilitators and barriers identified and although all participants recommended a career in ophthalmology to their peers, PAs in ophthalmology found that training was a deterrent to a career in ophthalmology.

TABLE 3. - PAs in ophthalmology quotes related to barriers and facilitators in education and training

BARRIERS

Lack of training opportunities

“...it's hard because we also have residents and I think a lot of times some learning opportunities go to the residents rather than the PA.”

“That would probably be the biggest limitation that I find is just a lot of the opportunities like surgeries because the residents need so many surgeries to graduate.”

Training/education gap

“Difficulties in my training I encountered were probably trying to catch up with the pathology. Trying to catch up with the education necessary. A lot of that took independent study.”

“A lot of it had to be self-done research. So, it's been hard to find resources. Since I didn't have a residency program, I didn't have all the textbooks. And all the different specialty is in that hardcore book training that people had.”

“...my biggest, I guess, flaw as an ophthalmology PA is that I didn't get good training in all of ophthalmology.”

Ophthalmologists' negative attitudes toward PAs

“I don't know if I want this out there, but there have been some physicians that I work with closely that are not supportive.”

“I would say that they're not willing to train.”

“With the ophthalmologist, there's a lot of proving myself because they didn't think a PA should do this or that. And over time I was able to do it, but definitely a slow start.”

Lack of role precedence

“I think initially, there was a pretty solid training plan laid out, but they had never done it before, and they'd never had PAs before and so we just kind of floated along.”

“...expanding the position was a bit of a barrier because a lot of people hadn't necessarily worked with a PA.”

“I think the main thing was since I was the first PA for this group, and the doctors themselves never treated with a PA.”

FACILITATORS

Supportive supervising physician

“They only want me to succeed. It's been their focus here for the last 10 months.”

“...the amount of doctors that were willing to work with me in that clinic, because at any one point we might have had five physicians in the office that we were working with and I was the only PA.”

“It's been great. My supervising physician, I have two, and they're excellent. And, they really want to see me just go, and fly and they're open to new opportunities.”

Previous training

“I was a tech for 5 years and I had the technical skills that I needed. I just was missing the medical background and I guess that's why I guess it wasn't as difficult for me, that transition.”

“I've gone to academy where you're more geared towards technician, and surgical assist where I learned some skills in a more formal setting.”

Optimal training

Overall, ophthalmic PAs identified four major vehicles for optimal education to prepare PAs for a career in ophthalmology. When asked what optimal training looks like for PAs interested in ophthalmology, most participants described a formal postgraduate training program. Some said changes to PA school curriculum would suffice, others described on-the-job training, and one described establishing a PA professional organization in ophthalmology.

Participants who said that formal postgraduate training programs were the optimal education vehicles for PAs interested in ophthalmology varied in their recommendations for an optimal program length (ranging from 6 months to 2 years), with most participants suggesting 1 year. Importantly, some PAs pointed out that changes to PA school curriculum would not be beneficial because “to increase one little section in PA school is just not going to benefit everyone that is not planning to go into ophthalmology” and “until it gains a little traction by the ophthalmology community...this whole use of PAs, I don't see a real purpose to shape the curriculum.” Table 4 highlights direct quotes about PAs' perspective of optimal training for PAs interested in ophthalmology and rationales and helpful topics that could be used in each training program. Most of the statements reflected that respondents believed implementing a postgraduate ophthalmology training program would have a positive effect in bridging the education gap of PAs stepping into a career in ophthalmology and reducing the burden of ophthalmic practices to train PAs.

TABLE 4. - Participant quotes related to optimal education for PAs in ophthalmology

Formal postgraduate training program

“You can do a 6-month fellowship. I think that would be really interesting. And I think it would be something to think about if the PA is doing more of a comprehensive ophthalmology. And you could kind of pair that with them following and doing what residents do, make them go to the hospital and see patients there.”

“...there's definitely been this discussion about creating physician assistant fellowships at our PA school in ophthalmology. However, it's going to be very difficult to do such a thing because I believe that could only happen at an academic institution and a lot of ophthalmology practices that would be willing probably to take on PA students and PA fellows. A lot of it is in private practice.”

“I think that that would be probably the closest thing we have to a good training program for physician assistants in ophthalmology is creating some sort of fellowship programs at a few different institutions across the United States, just like cardiothoracic surgery does and emergency medicine does.”

“...doing a fellowship program would help educate physicians on what PAs can do for them and maybe shine some light onto that.”

On-the-job training programs

“I think it would be very similar to a residency program like the first year that residents go to. In terms of lectures and being on call and seeing things in clinic, I think I would do it as a very similar model to what residents do.”

“...a national protocol with checkoffs during on-the-job training, after PA school, while you're getting paid.”

Changes to PA school curriculum

“I think offering preceptors in ophthalmology would be a great start. Letting PAs get exposure to a field that they never imagined is a possibility.”

“...any kind of lectures that PAs could attend would be great. Ophthalmology courses, things like that would be great.”

Creation of an organization for PAs in ophthalmology

“I think it would even just be beneficial to establish our own mini-academy, or sub-academy of PAs of ophthalmology. And then from there... Now, obviously it's a little tricky, with everything going on now with the pandemic. But having specific meetings, or training, or where you could work on hands-on skills, and that sort of a thing. Because I think that's probably the biggest part of ophthalmology that I felt limited, because you can read all the books, and learn all of the anatomical knowledge, and watch surgical videos and learn that it's actually the hands-on, just practicing using a slit lamp on a frequent basis, practice evenings, doing a direct, or indirect ophthalmoscopy, those types of things. I feel you see it, but it's a lot different when you're actually doing it. Or even injections and things like that.”

Career effects

Another major theme revealed was career effects. Positive and negative career effects were subthemes during the data analysis. When PAs in ophthalmology discussed positive career effects, their comments were related to having a satisfying position, rewarding career, positive colleague relationships, honing skills and knowledge, and pioneering the role of PAs in ophthalmology. Comments about negative career effects focused on loss of generalist perspective and difficulty in finding employment (Table 5). Overall, practicing PAs were quite satisfied with their choice of profession, indicating a positive overall value valence.

TABLE 5. - Effects that practicing in ophthalmology has had on PAs' careers

POSITIVE EFFECTS

Rewarding career

“A rewarding career... Knowing that over my career I've found a few brain tumors. I got patients to neurosurgery. I've had patients, that actually saved a few lives there.”

“The free program that we have is absolutely amazing. It tells somebody that they can get free glasses or free surgery is pretty amazing. Like, I feel like I'm Oprah. I'm like, ‘Yeah, you get glasses, you get surgery.’ It's pretty amazing.”

“I think I've had really good experiences at my current job.”

Satisfying position

“Honestly, when I talk to the other people that I graduated with, most of them have already switched jobs once or twice in the past few years because they're unhappy. It's not what they thought it would be. They're not treated well. Something like that. And although I have changed jobs, but still doing the same thing, because somehow, I got lucky, and I found the thing that I really love doing right off the bat. And it makes me feel really just straight up lucky.”

Hones skills and knowledge

“Ophthalmology is linked to a lot of medicine, more than people think. It's not as narrow as you think. I feel like I've really homed in on a lot of my skills because you have to look at the whole patient when you see an eye disease.”

“I feel it's really pushing me to grow in my skills.”

“People who have seen eight other doctors who don't know what's wrong or don't want to touch it. They end up in our lab. And I love it. I love the high acuity, real medicine. I went to PA school for a reason, and I definitely don't want to end up being somebody who just does Botox and some cosmetics.”

Pioneering role

“The positive is that I get to bring awareness to what PAs can do in ophthalmology.”

“Sometimes the patients are unsure because it's not a normal field for a PA. However, with more and more PAs in other fields, it has at least given exposure to the PA in general and is usually a welcome from patients.”

NEGATIVE EFFECTS

Loss of generalist perspective

“Probably, the longer I stay in ophthalmology, the more knowledge I'm losing for just general practice.”

“It's such a narrow scope of practice as far as what the boards require. I had to study harder and harder.”

“I think that it does kind of pigeonhole you into a very specialized field. So, it's hard if you've been in this field for 10 years, it's hard to just up and change, and go into emergency medicine, or women's health.”

“I'm terrified to re-certify. I think I'm just going to need to go back to PA school before I take the PANRE.”

Difficulty finding employment

“I feel like it would be hard for me to just move because I love ophthalmology now, but I couldn't just easily move across the country because there's just not many ophthalmology jobs.”

“I think it'd be difficult to find another job in this setting, here where I'm at, in this state.”

DISCUSSION

An important finding in this study was identification of the role of the ophthalmic PA. The role involves assisting ophthalmologists in surgery, performing various procedures, and evaluating and managing ophthalmic conditions in the clinic setting self-sufficiently. However, a few PAs reported spending no time in the OR. This could suggest that some ophthalmologists and institutions might not fully implement the surgical role PAs can play, although other factors could contribute to this observation. Research conducted with PAs on multidisciplinary teams has supported that a mutual relationship between a PA and physician can lead to stability in practice, benefiting the ophthalmology team.29,30 An alternative explanation for a PA playing no role in surgery is that some procedures performed by the ophthalmologist, such as cataract surgery, do not require an assistant. Nonetheless, ophthalmologists have argued that with proper training, PAs could identify patients who are candidates for cataract surgery, leaving more time for the ophthalmologist to perform surgeries.23

Findings of this study also show that PAs in ophthalmology perform a variety of diagnostic, therapeutic, and cosmetic procedures. These findings highlight the procedural nature of the PA profession. The role of the ophthalmic PA parallels the role of PAs in obstetrics/gynecology and otorhinolaryngology, in which PAs independently perform procedures, manage patients' conditions in the clinic setting, and assist with surgery.30-32 Interestingly, PAs desiring to practice in these specialties can enroll in specialty-specific postgraduate training programs, unlike PAs seeking to practice in ophthalmology.

Because formal postgraduate training programs for PAs in ophthalmology do not exist and ophthalmology content in PA school curriculum is limited, determining the barriers and facilitators in existing training was essential. The participants in this study identified several barriers and facilitators in their training and in growing the PA profession within ophthalmology. The balance between barriers and facilitators expressed by participants in this study aligns with low expectations in expectancy theory.

Although all participants recommended a career in ophthalmology to their PA peers, they found the balance between barriers and facilitators to be unfavorable for a career in ophthalmology because training was a deterrent. This low expectancy may be due to having to find their own training opportunities and venues.

Most PAs in this study identified formal postgraduate training as a potential way to help bridge the education gap, allowing them to enter careers in ophthalmology with a more robust foundation and potentially reducing a practice's burden of training them. Graduates of PA postgraduate training programs have reported their improved attractiveness for the job market, higher compensation, quicker onboarding time, and overall enhancement of their careers as major reasons for choosing postgraduate residency training.33 Other methods of improving PA competence in ophthalmology, such as changes to PA school curriculum, on-the-job training programs, and constructing a professional organization for PAs in ophthalmology, could lead to an increased perception by PAs that they will perform well in the field of ophthalmology.

Changing PA school curriculum to accommodate more time for ophthalmology would be difficult. As one participant mentioned, “PA school... [is] 2 years and you [must] jam pack everything else in there. Talking to my medical school friends, they only get a week.” Findings from this study also support the idea that current on-the-job training programs are successful. However, the number of certified PAs practicing in ophthalmology has risen only slightly since 1990, making it obvious that ophthalmologists are not hiring PAs.15 The unwillingness of ophthalmologists to hire PAs likely is due to the cost of on-the-job training and PAs' lack of specialized eye care training. Under these conditions, some ophthalmologists may be more inclined to hire PAs who have obtained postgraduate training in ophthalmology, although other factors could influence their hiring decisions.20

An overarching theme important to the framework of this study is career effects. Extracting positive and negative career effects as subthemes from the data provided by ophthalmic PAs helped to determine if a career in ophthalmology satisfied individual goals for PAs. Most participants said they were satisfied in their careers and recommended ophthalmology as a career for PAs.

Expectancy theory involves analyzing the motivational force of possible behaviors based on an individual's perception of the chance of reaching a certain outcome.26 The findings of this study suggest formal postgraduate training programs for PAs interested in careers in ophthalmology could be a valuable approach to increase the likelihood of a successful career in ophthalmology, although further research and exploration of other options might be necessary. Research also is needed that compares the effectiveness and efficiency of PAs with other members of the ophthalmology team in a more quantitative manner, examining questions of productivity, patient satisfaction, job satisfaction, and team-based care.

LIMITATIONS

Because of self-reporting using an interview method, additional relevant themes may not have been identified due to potential bias affecting the data content. Given the small community of PAs practicing in ophthalmology in the United States, social desirability bias is possible because of anonymity concerns: respondents might have answered in a way they believe is acceptable or favorable rather than providing true opinions. The author addressed this possibility by ensuring each participant understood his or her personal data would be deidentified. Data were self-reported by PAs when asked about feedback given to them from their supervising physicians, and direct input from supervising physicians was not obtained to either support or refute the perceptions of study participants. One participant asked to provide written answers to the interview questions, and the inability of the researcher to interpose probing questions in that case may have limited data collection; nonetheless, written accounts in qualitative research should not be undervalued.34

CONCLUSIONS

The findings of this qualitative case study suggest PAs play a unique and autonomous role involving surgery, evaluating patients, and performing procedures in the clinic. An underrepresentation of PAs in ophthalmology over the past few decades has continued. The study findings indicate that the balance between training barriers and facilitators for PAs in ophthalmology is viewed as unfavorable. Unlike their PA colleagues in other specialties, PAs in ophthalmology do not have the option to develop foundational skills through postgraduate training programs. Study results demonstrate formal postgraduate training programs would likely have a positive influence on the underrepresentation of PAs in ophthalmology, reduce the burden of having to train PAs on the job, alleviate patient eye care demand, and provide PAs with the necessary skills to be successful in ophthalmology. Indeed, ophthalmologists, optometrists, and ophthalmic technicians all are vital parties in eye care. The findings of this study suggest the roles of PAs in ophthalmology do not hinder scopes of other clinicians of the ophthalmologist-led team. As the need for specialty eye care increases, PAs are a viable option to fill the projected healthcare gap with increased investments in training opportunities.

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