Physician associates/assistants (PAs) can change specialties during their careers with no additional training; this flexibility contrasts with the rigidity experienced by physicians, who must complete specialty-specific residencies, and advanced practice RNs (APRNs), who are trained in a single domain, in their practice. The ability to switch specialties is an important characteristic of the PA role, with more than 90% of PAs rating this flexibility as at least a little important in combating burnout or attrition.1

Switching specialties is common over the course of a PA career. A study of PAs who graduated between 1978 and 1998 found that 75% changed specialties at least once during their career.2 This same study noted that PAs worked in an average of 1.95 specialty practices per decade.2 Another study found that over 4 decades, 49% of active PAs had practiced in at least two specialties, and 10% reported at least three specialties.3

Despite the importance and prevalence of PAs practicing in multiple specialties, research is lacking on how switching specialties is experienced by PAs and advanced practice hiring managers. Two related studies focused on APRNs: One examined transitions to a pediatric acute cardiac care environment and found that clinicians felt unprepared and would have benefited from advanced cardiac education and training.4 The other recommended the development of specialized residency programs.5 Additional research focused on the stressful transition from RN to APRN, finding that formal orientation was the only factor that correlated with APRNs' positive perceptions of the transition experience.6 Although these results may apply to PAs, they do not consider the more generalized training of PAs compared with APRNs. Furthermore, these studies were limited to experiences after starting a new role and did not include the hiring process.

To address this gap, we conducted open-ended interviews with PAs who had experience with switching specialties and managers responsible for PA hiring to explore their experiences of switching specialties and the hiring landscape.

METHODS

This study was found exempt by the Stanford University institutional review board. We recruited study participants for semistructured interviews from a single academic medical institution. We recruited from two overlapping populations:

PA and APRN leaders who hire PAs and had responsibility for onboarding PAs who switched specialties at least once.

We recruited participants from March to July 2022. Recruitment emails initially were sent to 225 PAs and 60 PA and APRN team leaders using electronic mailing lists. Follow-up emails were sent to both groups in July 2022. The emails described the study and the eligibility criteria, and it asked recipients to self-identify as fitting the study criteria and to volunteer for an interview.

Data collection

Each participant completed a 30-minute semistructured interview through video conferencing. We used an iterative approach to develop the interview guide based on a review of the related existing literature. PAs were asked about their training, past professional roles, job search, and onboarding experiences, including during switching specialties. Advanced practice hiring managers were asked to describe their team composition as well as their hiring and onboarding practices and preferences. Both groups were asked about specific onboarding strategies identified by Morgan and colleagues in their study of the onboarding of new PAs and NPs: clinical mentorship, professional mentoring, tailored productivity expectations, didactic content, meeting with or shadowing other professionals, and assessments with feedback.7 PAs who were both hiring managers and who had personal experience with switching specialties were asked questions relevant to both. All interviews were conducted by the primary investigator (EW).

Data analysis

Interviews were recorded and transcribed from March to August 2022 using Otter.ai and Grain software. Transcriptions were spot-checked for accuracy. We used NVivo 1.6.2 to conduct a thematic content analysis involving inductive and deductive codes.8 One investigator (EW) reviewed all transcripts to iteratively generate a codebook and identified all excerpts directly relevant to the questions addressed here in collaboration with the senior author (MH). Two coders (EW and JN) independently applied the codebook to all excerpts relevant to the final analysis. Interrater reliability was assessed based on percentage agreement, and discrepancies were resolved by consensus and used to refine the code definitions.

Themes were developed based on codes that appeared across multiple interviews and are presented in narrative format with direct quotes illustrating each theme.

RESULTS Participant characteristics

Eleven PAs and seven advanced practice hiring managers agreed to participate. Three PAs were excluded because they had not switched specialties, for a final sample of 15 (Table 1). All PAs who participated had switched specialties at least once—participants self-identified as having switched, which included some similar specialties. Four managers also described their experiences as PAs switching specialties.

TABLE 1. - Participant characteristics PA characteristics (N = 10; 8 PAs and 2 hiring managers/PAs) Years since last switch Total years of experience Range 1-6 4-27 Median 3 9 Mean 3.1 11.3 Hiring manager characteristics (N = 7; 4 PAs and 3 APRNs) Years as hiring manager Total years as a PA or APRN Range 1-6 8-27 Median 2 10 Mean 2.2 13
Thematic analysis

Our results describe factors shaping the landscape for PAs switching specialties (Table 2) and the experiences of those who have switched. Factors shaping hiring included:

contextual elements of job openings, including the candidate pool and role-specific characteristics characteristics of the candidates themselves, including likelihood of retention and network connections advanced practice hiring manager preferences, including preferred experience level of new employees and bandwidth for training. Factors shaping hiring decisions Illustrative quotes Contextual considerations Specific characteristics of candidates other than previous specialty experience (for example, personality match with surgeon, acuity experience, previous level of autonomy) “The other thing I look at [is] autonomy. ...if someone's applying and they have been running the show, [I worry they will struggle with having] a lot more oversight.” HM2 Candidate pool (for example, did people with specialty experience apply for the role?) “I think it has mostly to do with the job market.” HM7 Candidate considerations Preexisting relationships between hiring managers and candidates “I knew someone who knew this older PA [who] worked in a primary care office and she was going more part time, so she spoke to the guy who owned the practice ...and she ended up bringing me in.” PA7 Hiring managers' predictions about retention of potential new hires “I want people to come and stay.” HM5 Hiring manager preferences Manager or team bandwidth for training “We just don't have the resources that we need to really mentor somebody.” HM4 Individual hiring managers' preference for “clean slate” candidates who did not have established practices that they may need to change “PAs that have a little bit more experience coming in have a little harder time being told how to do things or ...to take that feedback.” HM2 Experiences of starting a new role Illustrative quotes Learning the hard way PAs transition from being experienced and competent to being expected to treat conditions they have never seen before, in new settings with new processes “I've been doing this one thing, one specialty [for so long]. And then when [I decided] to jump into a whole different field, I just, I just kind of froze.” PA8 Hiring managers do not often consider the unique needs or strengths of this population “We [don't] treat them any differently from the get-go.” HM1 Training frequently is insufficient “Everyone's like, hey, you've been a PA for 5 years, not like a newbie. They literally just threw me in it and threw me into it. And I got no training.” PA7 “In the end, it was good” Eventually, PAs and advanced practice leaders were satisfied with the outcomes “Eventually, I got better ... and I feel like it's because of what I had learned at [my previous job] as far as like, presenting and just maturity.” PA4
Candidate pool

Hiring managers discussed the limitations of candidates who applied for roles. On one end of the spectrum, with a plethora of candidates, hiring managers generally reported selecting those with significant experience in the specialty over someone who was trying to switch specialties. As participant HM7 described: “As much as I liked a lot of these candidates [who have different specialty experience], when I have somebody who's in front of me with 12, 15 years of experience in “ the given specialty, it would be difficult for HM7 to choose not to pick them.

On the other end of the spectrum, hiring managers in niche subspecialties reported rarely having the option of selecting someone with subspecialty experience. This increased the likelihood that someone with experience in a different specialty would be chosen for the role. One hiring manager described finding someone with experience in her specialty as finding a unicorn.

Role-specific characteristics

Hiring managers commonly mentioned circumstances in which specific characteristics needed for a role were orthogonal to specialty experience. For example, leaders in surgical specialties described looking for personalities compatible with a particular surgeon. Other hiring managers mentioned looking for similar levels of autonomy in past roles: Some were looking for clinicians comfortable practicing independently; others wanted to ensure that new hires appreciated significant oversight. Experience with similar patient populations and in settings with similar clinical acuity also were considered.

Candidate characteristics: Retention is top of mind

Within a candidate pool, likelihood of retention was key in hiring managers' preference for certain applicants. Managers recognized the significant time required to learn a new role and were more likely to hire “somebody who wants to be here, is willing to put the time in, [and] wants long-term growth” (HM2). The investment of “about 2 years of training before they feel comfortable in the job” (HM2) is only worthwhile if the new hire is still in the role well beyond 2 years.

Participants discussed signals that they perceived as correlating with retention, including candidates demonstrating strong interest in the specialty, the clinical setting, and specific role expectations. For example, one manager wanted candidates who were excited about the role's nonoperative components, because some PAs she had hired left due to disappointment with the lack of operative time. Other managers mentioned disinterest in candidates who “just want to be inpatient or don't have a passion for “the specialty (HM2) or candidates who “just wanted to get out of their old” jobs (HM4). Internal applicants also were perceived as more likely to stay.

Networking is key

Many participants said that “networking's key” (HM4). All 10 participants who described experiences switching specialties had previous connections to their hiring managers. Often, they knew the hiring manager or supervising physician personally or professionally. Others applied internally, allowing them to interact with the team before submitting an application. Sometimes a person leaving their job recommended someone to replace them. Hiring managers said that having a candidate who “knew multiple people who already worked with us” assured them that the candidate was “going to fit in well” (HM4). Some hiring managers reflected that the networking of more experienced clinicians was an advantage in the application process.

Hiring manager preferences: Experience level of candidates

On one end of the spectrum, managers reported feeling positive about new graduates because of their likely “ability to, and ... interest in learning,” “willingness to be flexible” (HM8), and expectation of constructive feedback. In the middle, some managers preferred candidates with more experience interacting with patients and families but were willing to teach specialty skills. As HM7 described: “Teaching people the medicine part is not the difficult part as much as teaching people how to be a clinician...how to talk to patients, how to do the exam, how to work through the whole process” (HM7). On the far end of the spectrum, some managers had a strong preference for candidates who had experience practicing similar medicine: “If they had just been doing cardiology or ENT or ortho or something, there's some skills there, but it would be pretty hard. ...I also need them to be able to treat an ear infection and work up an abdominal pain or do a pelvic exam or some of these other things that maybe they haven't done for a while” (HM4).

Bandwidth for training

Hiring managers greatly differed in how much time they allocated for onboarding. Some expressed an expectation to hire PAs who could practice independently immediately, citing a lack of “the resources that we need to really mentor somebody” (HM4). Others were willing to devote significant resources for onboarding. For example, HM2 talked about pushing back on pressure to onboard quickly because she recognized the importance of training: “We need to invest this time and I know it's going to hurt a little bit more, but it's worth it to get them to come out stronger.”

Experiences of starting a new role: Learning the hard way

PAs reported initially struggling in a new specialty. Several participants reported that they received no training. Most described inadequate training, resulting in feeling overwhelmed in their new job. One surgical PA talked about “learning the hard way” in the OR and having objects thrown at her. She also expressed concern about the safety of being placed in a role without training. Another PA (PA8), who switched from a surgical to a medical specialty, said she needed more support than she or her new manager expected: “I think it's hard because they thought, or they assumed, because... I've been a PA for a while that I'll probably just be able to pick it up so quickly and have no trouble with the transition. And I probably wanted to believe that as well...[but] the onboarding, the training should have been 2 months instead of 2 weeks.”

In general, hiring managers reported that when designing onboarding programs, they did not specifically consider the needs of experienced PAs who are moving into a new specialty. They discussed either treating them like clinicians with experience in the given specialty or like new graduates.

Some managers recognized the importance of onboarding, but “because of short staffing,” new hires were “pressured to take more patients before they were ready” (HM2). This had negative consequences: PAs felt they were “missing a lot of education” and “people were quitting very quickly” (HM2).

In the end, it was good

Despite the challenges, participants reflecting on less-recent experiences expressed satisfaction with the outcomes of switching specialties and of hiring those who switched. One PA who had been in her role for 5 years said of her experience: “I think in the end, it was good” (PA7). Another PA shared that after she became more comfortable, she realized the value of her skills from another setting. She explained that as an inpatient PA, she would teach concepts to patients by “drawing pictures with colored markers all over windows,” and after transitioning to a different outpatient specialty, she still drew “but on pieces of paper.” Her patients “loved it. They thought it was a great way to learn” (PA9). Another PA who transitioned from the OR to an outpatient postsurgical setting talked about how when there were complications, it was invaluable knowing exactly what “happened in the OR. I knew it was from the positioning; I knew it was from the sutures” (PA4).

Hiring managers also talked positively about past experiences hiring PAs who were switching specialties, saying that after an onboarding period, the PAs were not only proficient, but also brought unique expertise from past positions. HM1 explained how she “utilizes the skills” that experienced PAs bring from their past roles. She gave the examples of someone with experience in the ED being a “champion of diagnostics” or someone with experience in neurocritical care being a resource when the team has patients who have complex neurologic challenges.

DISCUSSION

To our knowledge, this study is the first to examine the experiences of PAs switching specialties and their managers. Our findings suggest that although switching may be common, the specific opportunities for switching specialties may depend on individual and contextual factors related to the available candidate pool for the desired specialty, other desired characteristics of new employees (such as likelihood of retention), and a hiring manager's bandwidth and desire to train employees. Our findings also highlight the important role of networking in successfully switching specialties. Furthermore, those who switch may experience a long period of adjustment during which training may feel insufficient.

To summarize, our findings suggest that when there are no candidates with significant previous experience in a specialty in a candidate pool, those hoping to switch may have a greater likelihood of being hired. Previous experience in a specialty may not be the only relevant background for hiring managers; candidates who have had similar autonomy, worked in the same setting (for example, inpatient versus outpatient), or managed medical problems with the same level of clinical acuity, as well as those with a personality match, also may be attractive to hiring managers. In addition, managers may be more likely to select candidates who can convincingly explain why they are likely to stay in a new role and candidates with whom they have a previous connection. Finally, hiring managers who have more bandwidth for training may be more willing to hire PAs who want to switch specialties.

IMPLICATIONS

First, our findings highlight the potential importance of building and leveraging professional networks. This expands on previous research that suggests that among current NPs, most found positions through networking.9 Second, in selecting roles, applicants may wish to explore areas where they can demonstrate relevant experience in at least a subset of the new role, such as matching practice setting, patient acuity, or level of autonomy required. Third, PAs could consider emphasizing their likelihood of staying in a new role, for example by highlighting longevity in previous roles, a detailed understanding of the realities of the job, and/or concrete examples of why the new role is a good fit.

Practicing PAs seeking a particularly competitive role could consider applying multiple times to increase the odds that they will be the most competitive applicant in one of the candidate pools. This strategy also can demonstrate sustained interest and create opportunities for networking. It also may be helpful for PAs who want to switch roles to stay in an institution where they may be more likely to have existing relationships and relevant experience.

Finally, PAs may want to think more about realistic expectations, the limitations of their previous experience and training, and the support they will need to be successful. In addition, it could be helpful to discuss realistic expectations with new managers and colleagues. Previous research has shown that it can take an extended time for a new PA to feel proficient.7 Based on our study, this also appears to be true for PAs lacking specialty experience. People transition from being experienced and competent to being expected to treat conditions they have never seen before in new settings with new processes and limited training and support. Self-compassion, patience, and self-advocacy could all contribute to thriving during this challenging transition.

IMPLICATIONS FOR ORGANIZATIONS

The central role that networking plays in hiring decisions carries potential risks and benefits. Employment systems that depend on personal connections for hiring may perpetuate existing biases and disparities.10 On the other hand, some of the most critical skills for clinicians, such as effective communication and teamwork, may be hard to differentiate in a typical hiring process; these soft skills may be more evident through longer-term connections with potential employees. Therefore, a networking-based system of hiring may result in choosing clinicians with better soft skills. Hiring managers may want to be aware of these risks and benefits when choosing to hire an applicant they know over those who do not have any connections.

PAs frequently reported that they did not get the support that they needed in transitioning to a new specialty. At the same time, hiring managers did not have a clear approach for how to support the unique needs of this population. In many cases, there was a discrepancy in the expectations of experienced PAs and their managers about the PAs' level of preparedness compared with reality. Lack of support may increase the risk that a new hire will leave. In addition to the negative effect on retention, this also can create challenges for risk management and patient safety. Hiring managers could be more realistic about expectations for experienced new hires and prioritize providing sufficient training and support for PAs to be successful and satisfied in their new role.

LIMITATIONS

Although our sample size represented multiple perspectives from PAs and hiring managers, and themes were consistent across most interviews, the sample was not sufficiently large or diverse to fully represent the experiences of PAs switching specialties, even at a single institution. We also are unable to account for the effects of confounding factors such as time spent in a specialty before switching, degree of difference between specialties, and number of years in a manager role. Other potential sources of bias include recall bias (because participants discussed events that may have happened many years ago) and bias from only having a single author identify quotes from the interview transcripts. We also only interviewed PAs who switched specialties, missing the perspective of those who may have wanted to switch but were unsuccessful. Furthermore, the findings may not apply to other institutions, settings, or geographies. This research generated themes from a small sample size, warranting further investigation with larger samples and in other settings.

CONCLUSIONS

This study identified several critical factors contributing to experienced PAs being able to successfully transition to a new specialty. These factors relate both to the application and selection processes and the initial period of employment. PAs who were successful in their job search reported establishing connections, demonstrating likelihood of staying in a role, and describing significant similarities between their past experiences and unique characteristics of the desired role. Both PAs and hiring managers had unrealistic expectations of PAs' ability to quickly achieve competence, and hiring managers did not consider the unique needs or strengths of this population.

Given the frequency and importance of flexibility to the career path of PAs, further research is needed to make this common practice successful for patients, clinicians, and organizations. Specifically, we recommend a larger quantitative study to examine the generalizability of these results as well as more investigation into best practices for onboarding and training programs for this unique clinician population.