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Examining the underrepresentation of Black students, practitioners, and faculty in the physician assistant/associate profession

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Examining the Underrepresentation of Black Students, Practitioners, and Faculty in the
Physician Assistant/Associate Profession
by
Sonya Earley

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

May 2023

© Copyright by Sonya Earley 2023
All Rights Reserved

The Committee for Sonya Earley certifies the approval of this Dissertation

Anthony Maddox
Helena Seli
Tracy Tambascia, Committee Chair

Rossier School of Education
University of Southern California
2023

iv
Abstract
The fast-growing number of physician assistant/associate programs in the United States has more
than quintupled in the last 30 years. Yet Black PA graduates have continually declined. This
mixed-method study aims to understand and examine the barriers that lead to the
underrepresentation of Black students, practitioners, and faculty studying, working, and teaching
in the PA field in the United States. Using critical race theory as a theoretical frame, interview
and survey data investigate and explore the Black PA experience in medicine and build on the
growing public health momentum toward achieving health equity. The study revealed that
despite the PA profession existing for nearly 60 years, it is yet to be widely known, and most
learned of at the end of their undergraduate education or later. Limited access to science and
math curricula, inadequate academic counseling, lack of representation and mentorship via
protégé development, and economic barriers significantly decreased the threshold for study
participants meeting PA program entrance requirements. The study offers recommendations for
practice to alleviate the underrepresentation of Blacks in the PA field in the United States.
Keywords: Physician assistant/associate programs, underrepresentation, counseling,
mentorship, protégé development

v
Dedication
My family is everything, and this dissertation is dedicated to them. First, to my dad, who
was not here to witness this event but was a big proponent of my education, and always exhorted
me to, “never get so educated that you lose your common sense.” To my mom, who started me
on this educational journey and always knew what I would become. To my older brothers, who
challenged me to excel and be better and more than just a little sister. To the Earley Crew- Darin,
Micah (Ibifuro), Moriah (Jadon), Melody, Melea, and Mishael, you all encouraged me to stay on
course. Finally, to my newest family members, my grandkids, Mr. Hezekiah and Ms. Sekai.
Your arrival came at a critical time, giving me the motivation when I needed it most. Your births
gave me a renewed desire to continue our family legacy of always finishing well.

vi
Acknowledgements
First, I want to thank my husband, Darin, my biggest cheerleader. You are amazing and
incredibly thoughtful! Your love, care, and support throughout this process helped me to finish
well. To Micah & Ibifuro and Moriah & Jadon, your unions have encouraged me throughout this
educational journey. To Melody, I look forward to becoming a Trojan Alumni with you (I am
now officially a Brojan) and sharing our graduation year. Melea, thank you for your
understanding and for giving me a big pass on my normal household and traditional mommy
duties. I’m back! Mishael, thank you for being the last of the MCE Crew at the “ponderosa” and
for studying with me and staying up late nights together as you finished high school. I’m looking
forward to sharing your graduation year, also. Thank you to my mom for always encouraging me
and being in my corner for everything, no matter what the endeavor or cause. I love you and
cherish our nightly talks. To my big brothers and the Barber families, thank you for your moral
support and encouragement throughout life and this doctoral process. To Nana Bernice, thank
you for your kind words and unwavering support for me in all that I do.
To all my sisters and sisters in Christ, I love and appreciate each of you for your prayers,
phone calls, warm wishes, and unwavering support. To the GUBC Crew- the Kidds, Kellys,
Potters, Hayes, Armstrongs, Moores, and Guardados. Thank you to the Hadnot, Jones, Butler,
Davis, Cunningham, and Williams families, and to Ms. Ingrid and the CAAP family for your
continued encouragement.
Thank you to my doctoral, Ed.D., and Ph.D. colleagues and friends who encouraged me
to take the right steps to complete my dissertation and Doctoral program: Drs. Donna Elliott,
Latanya Thomas, Rosslynn Byous, and Erica Gomez. To my new travel family- the amazing

vii
Global Executive Doctoral Cohort 9, I am so thankful that our cohort is the best and happy to
have had this experience with all of you.
Thank you to my wonderful Dissertation Chair, Dr. Tambascia. You made the writing
process manageable, and your encouragement meant the world to me. You have helped renew
my desire to research, discover and write. To my dissertation Committee members; Dr. Maddox,
thank you for reminding me how creative I am and can continue to be, and Dr. Seli for reminding
me to always speak to the issue without wavering. Finally I want to thank all of my USC Global
Executive Professors, the program was amazing and I am thankful that I am a part of the USC
Rossier School of Education family.

viii
Table of Contents
Abstract ........................................................................................................................................... iv
Dedication ........................................................................................................................................ v
Acknowledgements ........................................................................................................................ vi
Chapter One: Introduction to the Study ........................................................................................... 1
Background of the Study ..................................................................................................... 1
Purpose of the Study ............................................................................................................ 2
Significance of the Study ..................................................................................................... 3
Overview of the Theoretical Framework and Methodology ............................................... 4
Limitations, Delimitations, and Assumptions ..................................................................... 6
Definitions ........................................................................................................................... 6
Organization of the Dissertation .......................................................................................... 7
Chapter Two: Literature Review ..................................................................................................... 9
Historical Background of the Physician Assistant Profession .......................................... 10
Black Student Enrollment and Graduation From Physician Assistant Programs .............. 15
Current Physician Assistant School Educational Model ................................................... 19
Barriers Preventing Increases in Black PAs ...................................................................... 22
Critical Race Theory .......................................................................................................... 29
Conclusion ......................................................................................................................... 31
Chapter Three: Methodology ........................................................................................................ 33
Research Questions ........................................................................................................... 33
Methods ............................................................................................................................. 34
Population and Sample for the Study ................................................................................ 34
Instrumentation .................................................................................................................. 35
Data Collection and Methods ............................................................................................ 36

ix
Data Analysis ..................................................................................................................... 37
Credibility and Trustworthiness ........................................................................................ 39
Ethics ................................................................................................................................. 39
Positionality of the Researcher .......................................................................................... 40
Chapter Four: Findings .................................................................................................................. 42
Participating Stakeholders ................................................................................................. 42
Emergent Themes .............................................................................................................. 45
Conclusion ......................................................................................................................... 65
Chapter Five: Discussion and Recommendations for Practice ...................................................... 67
Discussion of Findings ...................................................................................................... 67
Theoretical Framework ..................................................................................................... 70
Recommendations for Practice .......................................................................................... 71
Future Research ................................................................................................................. 74
Limitations and Delimitations ........................................................................................... 75
Concluding Thoughts ........................................................................................................ 75
References ..................................................................................................................................... 77
Appendix A: Survey Protocol ....................................................................................................... 92
Appendix B: Semi-Structured Interview Protocol ...................................................................... 102
Appendix C: Information Sheet for Exempt Research ................................................................ 105
Appendix D: Recruitment Letter ................................................................................................. 107
Appendix E: Evaluating Recommendations 1–4 ......................................................................... 108

x
List of Tables
Table 1: Black Demographics in the United States Physician Assistant Schools and in Practice 23
Table 2: Interview Participants by Gender and Enrollment Class 45

xi
List of Figures
Figure 1: Council of MEDEX Programs (1973) 14
Figure 2: Participants’ Ages 44
Figure 3: Lack of Awareness About the PA Profession Reduces the Chances of Entering the
Field 46
Figure 4: Having More Black Providers Would Attract More Blacks to the PA Profession 51
Figure 5: Black PA Practitioners Are Needed to Ensure That the Black Patient Population Is
Treated Equitably 52
Figure 6: Increasing the Number of Black Practitioners Will Positively Impact Black
Patients 53
Figure 7: Mentorship of Qualified Black Students Should Begin Before Entering College 59
Figure 8: Black Mentors Are Available at my Current Workplace 60
Figure 9: My Financial Aid Package/Financial Resources Are Adequate to Complete My PA
Schooling 62
Figure 10: Black PA Students Received the Same Level of Educational Support As Non-
black PA Students 63

1

Chapter One: Introduction to the Study
The number of physician assistant/associate (PA) programs in the United States has more
than quintupled in the last 30 years, growing from 52 programs in 1991 to 300 in 2022 (PAEA,
2022). However, Black graduates have continually declined and reached an all-time low of 4.7%
in 2015 and 3.0% in 2020 (Hamann, 2015; PAEA, 2020). This study addresses the low
representation of Black students, practitioners, and faculty, studying, working, and teaching in
the United States PA field.
The relatively low Black student admissions to PA schools have reduced the pathway for
increasing Black practitioners and faculty in PA programs. In 1999, while Black Americans
made up 12.1% of the U.S. population, 10.6% of PAs were Black (Miller et al., 2000). In 2004,
Black Americans made up 12.8% of the U.S. population, and 4.8% of PAs were Black (U.S.
Census, 2004; PAEA, 2004). In 2020, Black Americans made up 13.4% of the U.S. population,
and only 3.3% of certified PAs are Black (U.S. Census Bureau, 2020; NCCPA, 2020). Although
these proportions fell short of an equitable national representation, the PA profession fared better
than most healthcare professions (H. Reed, 2021). Like many other medical programs, the PA
profession has struggled to recruit a workforce racially and ethnically representative of the
population it serves (Camacho et al., 2015).
Background of the Study
The PA field was created out of the need to increase access to medical care in the 1960s
and reduce the burden placed primarily on physicians. It is critical to understand that the
expansion of PA programs took place during the Civil Rights Movement when political
movements aimed to secure and ensure civil rights and other social rights for all people
(specifically Black people) so they would be equally protected by the law. Although Black
2

soldiers were not new to the American military, Vietnam was the first major conflict in which
they were fully integrated (Goodwin, 2017). Despite the passage of the Civil Rights Act of 1964
and the Voting Rights Act of 1965, integration did not translate into full acceptance. Blacks were
often treated as second-class citizens, yet they comprised nearly 100,000 military men in 1965.
Although the first PA program began in 1965, the PA concept began two decades earlier
when Dr. Amos Johnson, a general practitioner, trained his Black assistant, Henry Lee "Buddy"
Treadwell, in 1940 (Physician Assistant History Society, 2016). Treadwell helped pioneer the
profession and paved the way for the nation's first Black PA graduates, Prentiss Harris and Joyce
Nichols (Howard, 1997). Howard and Charles R. Drew Universities were the only Historically
Black Colleges and Universities (HBCUs) with graduate schools that matriculated and trained
Black PAs (Muchuu, 2016; Smith et al., 1971) for the first three decades of the profession. Dr.
Richard Smith was responsible for initiating and generating federal funds for PA educational
programs (Howard, 1997), which helped fund the MEDEX PA programs across the country. Dr.
Smith's efforts helped increase Black representation in the PA field in the United States.
Further decreases in matriculating Black PAs occurred when many community college
PA programs were phased out, decreasing diversity in the profession (Coplan et al., 2018).
Currently, all PA programs award master's degrees, and no community college PA programs
exist. Limited access to affordable PA programs may have contributed to the rapid decline of
Blacks in the PA field. In 1999, 5.3% of PA graduates were Black, and over 20 years later, in
2020, only 3.0% of graduates were Black (PAEA, 1999, 2020). Community college closures may
have played a significant role in the sharp decline in Black graduates in the PA profession.

Purpose of the Study
3

The purpose of this study was to understand the barriers that lead to the
underrepresentation of Black PA students, practitioners, and faculty members. This study sought
to provide a lens to understanding the influence of the historical racial exclusion of Blacks from
education on currently low numbers of Black PA students, healthcare providers, and faculty. It is
essential to find the causes of the declines and identify solutions so that Black students,
practitioners, and faculty will begin to flourish in this field to assist and improve the lack of
medical access in the Black community. Better access to health care may help improve the
morbidity and mortality rates of the Black Community.
The research questions that guided this study are:
1. What are the barriers hindering the number of Black students, practitioners, and
faculty in the physician assistant field?
2. What are the racialized, lived experiences of Black PA students?
Significance of the Study
With fewer Black students admitted to PA schools and fewer Black practitioners able to
provide care in underserved areas, there is a misalignment between the Black PA workforce and
the communities they serve. Reductions in Black practitioners and faculty losses such as
retirements, illness, and general attrition will necessitate an overwhelming need to increase Black
students, practitioners, and faculty to address the lack of PA representation in the profession and
impact health access for Black patients. Increasing Black PAs may change the increasingly dire
healthcare needs that affect the Black community. Fewer Black students, providers, and faculty
have ultimately reduced adequate medical providers who usually are willing to work in
underserved communities (Muma et al., 2010). During the COVID-19 pandemic, the African
American community had the highest death rates compared to other races (Reyes, 2020). The
4

Black community could have benefitted from a higher representation of Black providers
delivering additional care to the patients in greatest need. The lack of Black representation
exacerbated increased morbidity and mortality in the Black community.
Overview of the Theoretical Framework and Methodology
This study includes critical race theory (CRT) as the theoretical framework. CRT calls
attention to racism and its connection to the larger social context and ideological forces of
domination. Ladson-Billings (1998) noted six ways in which CRT has a role in education: (a)
CRT argues that racial inequality in education is the logical outcome of a system of achievement
presided on competition; (b) CRT examines the role of education policy and practices in the
construction of racial inequality and the perpetuation of normative whiteness; (c) CRT rejects the
dominant narrative about the inherent inferiority of people of color and the normative superiority
of White people; (d) CRT rejects historicism and examines the historical linkages between
contemporary educational inequity and historical patterns of racial oppression; (e) CRT engages
intersectional analysis that recognizes the ways that race is mediated by and interacts with other
identity markers (i.e., gender, class, sexuality, linguistic background, and citizenship status); and
(f) CRT agitates and advocates for meaningful outcomes that redress racial inequity.
Critical race theory (CRT) posits that racism is a norm so fully enmeshed within
American society that it cannot be seen as aberrant within our cultural context (Ladson-Billings,
1998; Taylor, 2009). The resultant invisibility of racism is intrinsic; therefore, many feel it does
not exist or is associated only with isolated overt incidents. This invisibility also allows the
influence of racism on our institution to go unnoticed (López, 2003) and become a permanent
aspect of the lives and experiences of people of color (Urrieta et al., 2015). Critical race theory
views race and White supremacy as an intersectional social construction (Gillborn, 2015) that
5

serves to uphold the interests of White people (Curry, 2009) at the expense of marginalized
communities (Crenshaw, 1989, 1991).
The CRT framework has been used in medicine and medical education to explore African
American men's experiences in medical school, promote cultural competence in medical
education training, and further public efforts and understanding (Betancourt, 2006; Ford &
Airhihenbuwa, 2010; Morgan, 2013). This framework is used to understand the role of
underrepresented Black practitioners in the field, students, and faculty in PA schools across the
US. To facilitate the appropriate and systematic use of CRT within the public health field, Ford
& Airhihenbuwa developed the public health critical race framework. That framework and the
CRT concepts build on the growing public health momentum toward achieving health equity.
This study used a mixed-methods approach to collect data, including interviewing via
audio/video recording and emailed electronic surveys. The survey collected demographic
information and asked questions about the underlying factors of the experiences of Black PA
practitioners, faculty members, and students. The interview was conducted via a web-based
video platform. For a more insightful interview, one-on-one interactions, and conversational
information regarding the participants’ perspectives, including how they view, feel, and think
about specific subjects, occurrences, or situations, were gathered (Patton, 1990). The semi-
structured interview format offered more flexibility and allowed the researcher to rearrange or
rephrase questions and adjust probing questions. Personal interviewing also provided
information about the subject, feelings toward a particular situation, and insight into participants’
viewpoints (Patton, 1990). All interviews were recorded to capture the participants’ true essence
of all responses. Detailed notes were taken as the interview was conducted and transcribed
shortly afterward.
6

Limitations, Delimitations, and Assumptions
The study is limited to Black PA practitioners, faculty members, and students in the field.
The study did not seek other people or races outside of this demographic. Other limitations could
include unintentionally minimizing or not being 100% authentic in answering the questions.
Definitions
Key definitions and terms will help describe the meanings of specific words used
throughout this dissertation.
American Academy of Physician Assistants/Associates (AAPA): The national professional
society for PAs in the United States. It represents approximately 148,500 certified PAs across all
medical and surgical specialties in 50 states, the District of Columbia, US territories, and military
services. The AAPA advocates and educates on behalf of the profession and the patients that PAs
serve.
African American: An ethnic group consisting of Americans with partial or total ancestry
from any of the Black racial groups of Africa.
Accreditation Review Commission on Education for the Physician Assistant, Inc. (ARC-
PA): An organization that encourages excellence in PA education by establishing and
maintaining standards for the quality of educational programs.
Black: A member of various peoples whose ancestors were born in Africa, Oceania, and
Australia.
Community college: A 2-year institution offers reasonably priced higher education that
provides academic programming and skills training to prepare students for jobs or transfer to a 4-
year college and university, also called junior colleges.
7

Historically Black Colleges and Universities (HBCUs): Higher education institutions in
the United States were established before the Civil Rights Act of 1964 to primarily serve the
African American community.
National Commission on Certifying Physician Assistants (NCCPA): The only certifying
organization for PAs in the United States. It provides certification programs that reflect standards
for clinical knowledge, reasoning, and other medical skills and professional behaviors required
upon entry into practice and throughout the careers of PAs.
Physician Assistant Education Association (PAEA): The only national organization
representing PA educational programs. PAEA works to ensure quality PA education by
developing and distributing educational services geared toward the needs of PA programs, the
profession, and the healthcare industry.
Physician assistants (PAs): Medical professionals who diagnose illness and develop and
manage treatment plans.
Physician associates (PAs): The official title of the physician assistant (PA) profession.
The AAPA House of Delegates (HOD) passed the resolution affirming the name change on May
24, 2021.
Organization of the Dissertation
This dissertation consists of five chapters. Chapter One provides a general introduction of
the study, the background of the problem, the purpose, and the importance of the study. It also
includes a brief organization context, an overview of the theoretical framework, methodology,
limitations, assumptions, and key terms and definitions. Chapter Two presents a literature review
that examines the underrepresentation of Black students, practitioners, and faculty in the PA
profession. It will include the historical background of the PA profession, early PA programs,
8

Black student enrollment, PA programs, HBCUs, current PA school education models, reform of
PA education and Black student enrollment, barriers preventing the increase of Black PAs,
diversity, equity and inclusion in admission practices, biases in admissions, recruitment,
retention, and best practices for hiring. Chapter Three provides information about the
methodology, population of the study, research design, data analysis and collection process,
credibility and trustworthiness, ethics and positionality of the researcher, and limitations. After
receiving, reviewing, and interpreting the data, Chapter Four discusses the study's key findings.
Lastly, Chapter Five will summarize and discuss the results and provide implications,
conclusions, and recommendations for ongoing research.

9

Chapter Two: Literature Review
The PA profession was developed in the 1960s in response to a shortage of primary care
physicians in the United States. PAs are trained to meet medical demands and increase public
access by improving and expanding healthcare. Accredited PA schools in the United States have
more than quintupled in the past 30 years, spanning from 52 programs in 1991 to 300 in 2022
(PAEA, 2022).
In 2010, there were 148 accredited PA schools, and less than 5% of graduates were Black
(AAPA 2017a; PAEA 2010). Since then, there has been a significant decline in Black PA
graduates. In 2020, despite significant PA program growth in the overall number of accredited
programs, only 3.0% of graduates were Black (PAEA, 2020). Several PA schools have closed,
including the premier HBCUs and community college PA programs that were the primary
sources for training underrepresented minorities (Coplan et al., 2018; Howard, 1997). This may
have contributed to a decline in Black PA students, practitioners, and faculty.
Black PA graduates, practitioners, and faculty are underrepresented, which is a problem
that impedes the goal of achieving ethnic diversity in the PA profession. The few Black PA
faculty members often experience a lack of institutional support, gaps in mentorship, and an
absence of a solid support network (LeLacheur et al., 2019). Recruiting and retaining minority
PA faculty may be one way to attract and retain a more diverse student body and faculty
workforce (LeLacheur et al., 2019). Solving the problem of low Black PA representation may
enhance overall student educational experiences in all backgrounds, as racially integrated
classrooms can reduce racial bias, improve satisfaction, and increase intellectual self-confidence
and leadership skills (Maxwell & Garcia, 2019). Additionally, solving underrepresentation may
reduce morbidity and mortality in the Black community (Huerto, 2020; Moy & Bartman, 1995).
10

The literature review will discuss the historical background and factors contributing to
changes in the PA profession that influenced the decline in the number of Black students,
practitioners, and faculty members in the field. The literature review will conclude with a
discussion of the CRT framework used as a lens to examine low Black representation in the PA
profession in the United States.
Historical Background of the Physician Assistant Profession
The PA profession was born out of a desire to solve a labor shortage of primary care
physicians and improve healthcare access. Dr. Charles Hudson was one of the first physicians to
formally suggest that non-physician support personnel be trained and utilized to help alleviate a
growing disparity between supply and demand for healthcare services (Hudson, 1961; Carter,
2007, Carter, 2009). However, the PA concept was modeled after the relationship with Dr. Amos
Johnson, who trained his Black apprentice assistant, Henry Lee "Buddy" Treadwell, in 1940
(Physician Assistant History Society, 1964). In 1961, at an American Medical Association
(AMA) meeting, Dr. Hudson proposed that individuals with no previous medical education be
trained to perform routine clinical tasks utilizing Army and Navy corpsmen in similar roles
(Carter, 2001). However, it was not until 1970 that the AMA House of Delegates passed a
resolution to develop PA educational guidelines and certification procedures (AMACME, 1971).
Dr. Hudson initially turned to corpsmen in the Army and Navy as assistants. He was
keenly aware that these programs to train nonprofessional personnel would not survive without
the AMA's endorsement. Dr. Hudson asked his colleagues within the AMA to take his proposal
seriously, even though many were skeptical that physicians or patients would accept the services
of these assistants once they were trained (Hudson, 1961). The American Medical Association
11

achieved the endorsement, which assured those implementing the plan of the propriety of their
actions.
Four physicians who took Dr. Hudson's suggestions seriously were Dr. Eugene Stead, Jr.
at Duke University, Dr. Richard Smith at the University of Washington, Dr. Hu Myers at
Alderson-Broaddus College (Carter, 2001), and Dr. Henry Silver at the University of Colorado.
These four men created the first successful PA programs in the United States, which continue to
be top-tier PA schools. Drs. Stead and Smith launched their programs in 1965 and 1969,
respectively, and relied on ex-military corpsmen, primarily males. Drs. Stead and Smith designed
2-year programs rooted in competency-based curricula. They thought this would quickly build
on prior experience and training and felt valuable time would be lost if candidates completed two
or more years of college before entering their programs (Carter, 2001). However, Dr. Myers
believed that the PA curriculum should award a legitimate academic bachelor's degree, and this
academic-based program was established in 1968. Most PA programs soon followed Dr. Myers's
lead when it became clear that the federal government would not financially support non-degree-
granting educational programs. Dr. Silver established the Child Health Associate (CHA)
Program at the University of Colorado, emphasizing the specialty program in pediatrics, in 1968
(Physician Assistant History Society, 1968) and went on to establish the first master's degree
program in 1973.
The Duke University Model
The development of this new skilled clinician would improve healthcare access (Hudson,
1961), and the premier PA program was launched in 1965. Duke University's PA program design
called the new healthcare team member a physician's assistant (Stead, 1966). The physician's
assistant was seen as a new category within the structure of the health field, designed as a trained
12

professional working under the direction of doctors and with more capabilities and growth
potential than informally trained technicians. The apostrophe in the PA name was eventually
dropped as the profession grew, leaving the organization with its current title. Many programs
used physician assistant and physician associate titles, and Yale University, established in 1971,
has maintained the physician associate title. In May of 2021, the American Academy of
Physician Assistants (AAPA) House of Delegates voted to return the PA name to physician
associate and is currently in the legislative process to implement the new title.
MEDEX Physician's Assistant Program
Dr. Richard Smith, a Howard University Alumnus, designed the University of
Washington's MEDEX Physician's Assistant Program (Smith et al., 1971). Graduates were called
Medex, and these individuals would relieve practitioners of routine work and utilize the training
and experience of former military medical corpsmen. Military medical training totaled 2,000
hours and 2 to 20 years of patient experience at an advanced or independent-duty level (Ford,
1975). With nearly 30,000 medics being discharged yearly from the armed services, about one-
third found their way into civilian health employment positions, costing the taxpayer up to
$25,000 to train each medic. Educating former medics to become PAs appeared to be a sound
economic decision (Ford, 1975) and indirectly became a prerequisite for PA program entrance.
Physician preceptors of the Medex thought the highly skilled professionals demonstrated the
ability to significantly increase physician productivity and medical care accessibility while
maintaining or improving the quality of medical care provided to patients (Smith et al., 1971).
There was wide patient acceptance of the MEDEX model, and programs of this type were
viewed as promising in meeting healthcare demands.
13

The essential elements of the MEDEX program included six elements to improve the
delivery of medical services: (a) a collaborative model, (b) a receptive framework, (c) a
competency-based training, (d) practitioner involvement, (e) a deployment system, and (f)
continuing education.
This training method also gave rise to the deployment system, which allowed the
program to send assistance where it was most needed and selected physicians in areas of need to
be preceptors. The MEDEX approach addressed the maldistribution of health manpower and
worked to correct it (Muchuu, 2016). The final element of MEDEX was continuing medical
education to help bolster education following the end of the 15-month training program under the
guidance of the Washington State Medical Education and Research Foundation (Washington
State Medical Education). The original MEDEX schools were located in nine locations
representing each time zone in the United States (Figure 1): the University of Washington,
Seattle, University of North Dakota School of Medicine, Grand Forks, Dartmouth Medical
School, Hanover, Charles Drew Medical School, Los Angeles, University of Utah, Salt Lake
City, Howard University, Washington, DC, Medical University of South Carolina, Charleston,
Pennsylvania State University, Hershey, and, the University of Hawaii, Honolulu (Muchuu,
2016; Smith et al., 1971).

14

Figure 1
Council of MEDEX Programs (1973)

Note. From “MEDEX Northwest: Workforce Innovations” by R. Ballweg and K. Wick, 2007,
The Journal of Physician Assistant Education, 18(3), p. 33 (https://doi.org/10.1097/01367895-
200718030-00004)

This nearly 2-year experience with the MEDEX Program in the State of Washington
influenced dialogues with numerous professionals interested in health manpower development in
the United States and created an appropriate solution to address the health manpower shortage
(Muchuu, 2016). Later, MEDEX included South Dakota, Northern Minnesota, Georgia,
Alabama, Spokane, Tacoma, Yamika, Washington, Sitka and Anchorage, Alaska, and British
Columbia. Dr. Smith’s goal was national expansion and having a MEDEX program in every time
zone (Muchuu, 2016).
15

Baccalaureate Program
Dr. Myers introduced the baccalaureate degree program in 1968. Alderson-Broaddus
College was the first PA educational program to award an academic degree in 1970, using a 4-
year model. The curriculum consisted of 2 years of general college work and a 2-year
professional phase, known as the 2 + 2 model (Cawley, 2007). Some of the early graduates of the
Duke University PA program, which did not offer an academic degree, obtained their bachelor's
degrees from Alderson Broaddus College (Perry & Breitner, 1982). With successful foundational
support and publicity given to the PA programs, national interest was stimulated.
CHA/PA Pediatric Design
Dr. Henry Silver and Loretta Ford were the Child Health Associate Physician Assistant
Program (CHA/PA) founders at the University of Colorado. Established in 1968, CHA/PA was
the first PA program in the United States centered primarily on pediatric care and the first PA
program to award a master's degree for entry-level training in 1973 (Anschutz School of
Medicine, 2022). This program was among the first specialty-focused PA programs, and it
demonstrated the generalist PA education model and the ability of PAs to play a vital role in
primary care delivery (Anschutz School of Medicine, 2022).
Black Student Enrollment and Graduation From Physician Assistant Programs
The Association of American Medical Colleges (AAMC) defines underrepresented
minorities (URMs) as Blacks, Mexican-Americans, Native Americans (American Indians,
Alaska Natives, and Native Hawaiians), Pacific Islanders, and Hispanic and mainland Puerto
Ricans (DiBaise et al., 2015). URMs were incorporated into PA education as student trainees to
facilitate the education of diverse providers, yet, early efforts to promote diverse enrollment
16

demonstrated a commitment to healthcare delivery in underserved and rural communities and the
access of URMs to the PA profession (Mulitalo & Straker, 2007).
This historical development of the PA profession is critical to understanding the context
of PA programs during the Civil Rights Movement and the enrollment and graduation of Black
PAs during this time. In 1966, hospitals in the United States were racially desegregated, which
meant that minority patients could no longer be denied access to any service provided by the
hospital or part of the hospital (Muchuu, 2016). Desegregation was a required component of
implementing the newly created Medicare program. Medicare is the federal government program
that provides patients with healthcare insurance coverage (insurance). Hospitals wishing to
become Medicare providers had to comply with Title VI of the Civil Rights Act. Although
desegregating the hospitals came with tremendous opposition, it facilitated the development and
success of the first nine MEDEX programs, which included Charles R. Drew and Howard
University PA programs.
Implementing the MEDEX programs and other PA programs that facilitated African
Americans' access to the profession was instrumental in the Black PA pathway. The
development of these programs, particularly during the early 1970s, ensured more significant
access to minoritized communities promoting Black scholars and practitioners. Renowned
leadership and innovative physician leaders quickly adopted the PA concept. Dr. M. Alfred
Haynes established the first urban MEDEX Program at Charles R. Drew University in Los
Angeles, California. The first class in 1972 graduated 21 former military corpsmen; seven were
African American (Howard, 1997). Dr. William Matory started the Howard University PA
Program. The program began in 1973 and graduated their first class in 1974 with 16 graduates,
and 14 were African American (Howard, 1997). Dr. Charles Felton was responsible for starting
17

the Harlem Hospital PA Program in 1970. Although not an HBCU, the Harlem Hospital Program
was the only federally funded PA Program with an emphasis on minority student enrollment and
graduated many Black PAs (Fonville, 1976). The first graduating class of the Harlem program
was in 1973, and graduated five African Americans (Howard, 1997).
Although there are no specific numbers of Black PA graduates over time, until the
passage of the Civil Rights Act of 1964, many medical and health science educational
institutions routinely rejected Black applicants based on color alone. For this reason, HBCUs
offered the best and sometimes the only opportunities for Black students who wanted to study
medicine to become doctors or PAs (Terry, 2020). HBCUs were established to serve the
educational needs of Black Americans. Before their establishment, and for many years afterward,
Blacks were generally denied admission to traditionally White institutions. As a result, HBCUs
became the principal means for providing postsecondary education to Black Americans (U.S.
Department of Education, 1991).
From the inception of the PA profession, Charles R. Drew University and Howard
University PA programs were instrumental in graduating large numbers of Black PAs. Charles
R. Drew University is the only HBCU graduate PA program west of the Mississippi River in
Watts, California. It trained more than 1,200 PAs before completing its bachelor program's
teach-out phase when current students finished the program, and no students were accepted to
phase out of the program of study in 2011 (Wise, 2016).
Despite the few HBCU PA programs, one commonality is that they all have strong
community ties, reaching urban and rural underserved populations, promoting equal healthcare
access, and including minority concerns and perspectives in coursework (Terry, 2020).
Historically, HBCUs have enhanced equal educational opportunities for all students. They are
18

leading institutions awarding baccalaureate degrees to Black students in the life sciences,
physical sciences, mathematics, and engineering. HBCUs continue to rank high in the proportion
of graduates pursuing and completing graduate and professional training. Fifty percent of Black
faculty in traditionally White research universities received their bachelor's degrees at an HBCU
(U.S. Department of Education, 1991). One of the invaluable training experiences at an HBCU
PA program is that it allows students to learn from, train, and work with same-race role models
and mentors (Terry, 2020). This is especially important because Black students still face
numerous hurdles in pursuing medical careers stemming from inequities in race, class, chronic
unemployment, and a lack of role models and advocates, particularly for men of color (Gavins,
2009).
Early governmental funding helped support HBCU PA programs to train medical
personnel working in designated workforce shortage areas established by The Comprehensive
Health Manpower Training Act (CHMTA) of 1971 (Mulitalo & Straker, 2007). This act helped
establish PA programs in colleges and institutions to reduce healthcare disparities by increasing
minority PAs. Non-White enrollment in PA programs increased in 1983–1984 from 13.8% to
22.1% in 1999–2000, suggesting that most early URM PAs and leaders were trained at CHMTA-
recipient institutions (Miller, 2000). Federal amendments like the CHMTA of 1971 paved the
way for PA infrastructure but are no longer in existence, which may be why few programs
promote URM education. Today, there are only a few HBCU PA programs: Charles R. Drew
University of Medicine and Science, Meharry Medical College, Morehouse School of Medicine,
University of Maryland Eastern Shore, and Xavier University of Louisiana (Terry, 2020).

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Current Physician Assistant School Educational Model
The AAPA (2017b) states that PA education is a preparation for excellence, where
“comprehensive educational programs prepare PAs for a career in medicine with a team-based
approach by providing high-quality, patient-centered medical care” (p.1). The broad nature of the
primary care medical education PAs receive makes the profession uniquely flexible and
adaptable to the United States healthcare delivery system (AAPA, 2017b). The traditional PA
program is commonly 27 continuous months (PAEA, 2019), but a few programs are three years
long. The didactic or classroom phase, the first phase of PA school, covers basic medical
sciences and includes anatomy and physiology, behavioral sciences, medical ethics, and physical
diagnosis. The second phase is the clinical phase, which consists of clinical rotations in the
following: medical and surgical disciplines, such as family medicine, internal medicine, general
surgery, pediatrics, obstetrics and gynecology, emergency medicine, and psychiatry. Before
graduation, PA students complete a minimum of 2000 hours of supervised clinical practice in
various settings and locations (AAPA, 2017b). Accreditation standards require PA programs to
provide students with a solid grounding in the non-clinical aspects of healthcare, including the
healthcare delivery system, billing and coding, quality improvement, and licensing and
credentialing. As of 2020, to maintain accreditation, all PA programs award master's degrees
(AAPA, 2017b).
Created after the medical school model, current prerequisites for PA schools require an
additional 500– 3,000+ clinical work/direct patient care hours. Prospective students bring a
wealth of patient career experience, which is mandatory for entrance into most programs, and PA
students often take classes or have clinical rotations alongside medical students and residents
(AAPA, 2017b). With 300 PA educational programs in the United States, most are housed within
20

medical or health science schools, universities, teaching hospitals, and the military (AAPA,
2017b; PAEA, 2022). PA graduates peak at over 9,200 annually, with several developing
programs in the pipeline for accreditation (PAEA, 2020; PAEA, 2022).
Reform of Physician Assistant Education and Black PA Student Enrollments
For more than 30 years, the Accreditation Review Committee on Education for the
Physician Assistants Standards had not changed its stance on degree requirements for the
profession. However, in 2001, Accreditation Review Commission on Education for the Physician
Assistant, Inc (ARC-PA) released the third edition of standards (ARC-PA, 2022b), and two
resolutions affecting PA education were adopted. The first established a master's as the terminal
degree, and the second included the terminal degree as a condition of accreditation in the ARC-
PA standards (Miller et al., 2000). In 2009, the master's degree became the terminal degree for
PA clinical education.
Two significant ARC-PA rulings occurred after the AAPA and PAEA endorsement. All
programs developed after 2012 had to be established within a 4-year university, college, medical
school, or school of allopathic or osteopathic medicine to create a uniform higher education
paradigm (ARC-PA, 2018). Additionally, all sponsoring institutions had to award a graduate
degree by 2020, and programs that did not comply with the degree requirement by January 1,
2021, would have their accreditation withdrawn (ARC-PA, 2019). The ARC-PA standards also
outlined procedures for forming and maintaining PA programs and accreditation terms. During
accreditation terms of up to 10 years, PA programs must continuously meet criteria by
submitting periodic reports regarding program administration, curriculum, instruction, and
information on supervised clinical practice experiences annually (ARC-PA, 2018). Failure to
21

comply may result in probation or loss of accreditation. As a result, many PA programs were
closed.
The significance of these rulings seems equitable when looking at the long-term goal of
the terminal degree change. However, the long-term effects of these rulings resulted in
devastating low Black and URM student graduate percentages in PA programs which may have
led to significant declines in Black practitioner and faculty numbers. After ARC-PA’s 2009
rulings that all programs must move to a graduate degree, programs must be established within a
university, 4-year college, medical school, or allopathic school, and all community college
programs were phased out. According to the new guidelines, community college PA programs
could no longer exist if they could not relocate to an institution of higher learning. These
programs produced a large number of URM PAs. During this same time, the longstanding
HBCU programs at Charles R. Drew and Howard University closed their doors for reasons
unknown.
HBCU PA Program Closures
Charles R. Drew (Drew), Howard University (Howard), and the Harlem Physician
Assistant Programs had a long history of training Black PAs. Drew, one of the very first
MEDEX programs in California, trained more than 1,200 PAs until 2011, when it completed its
bachelor program's teach-out phase--a period when current students finished the program, and no
new students were accepted (Wise, 2016). Shortly thereafter, Howard University closed its
doors. Although community college PA programs were not HBCUs, they matriculated
significant URMs before their phase-out. This may have played an essential role in the
underrepresented Blacks in the PA field. In 1999, reports showed that 5.3% of PA graduates
22

were Black, yet 20 years later, in 2019, reports showed only 3.0% of graduates were Black
(PAEA, 1999, 2020).
After several years, the Drew PA program reopened in 2016, conferring a Master of
Health Science degree, and is accredited until 2031; however, Howard University has not
restarted its program. With the closure of the HBCU and community college programs, the
number of Black PAs declined sharply and has not rebounded. The percentage of Black PAs has
decreased significantly across the United States since the initial ARC-PA rulings in 2009 (Table
1).
Barriers Preventing Increases in Black PAs
Low Black student admissions to PA programs have compounded and prevented a
pathway for increasing Black PAs in US programs. Common barriers for URMs entering health
professions include the cost of education, lack of academic preparation to meet entrance
requirements, lack of concordant mentors, stereotype threat, limited exposure to health careers,
and poor advising (Toretsky et al., 2018). Black health providers play significant roles in relating
culturally and socio-economically to their patients, and prior research has shown increased levels
of trust and patient satisfaction (Street et al., 2008). Admission requirements are a significant
challenge for URMs interested in health professions. Some states prohibit consideration of
race/ethnicity in admissions and emphasize high GPAs and scores on admission tests, which
were associated with substantial reductions in the numbers of URMs admitted to health
professions schools (Toretsky et al., 2018). In 2000, 6.2% of PA students who were enrolled
were Black. Yet in 2020, Black Americans made up around 14% of the US population (U.S.
Census Bureau, 2020), and 3.9% of students enrolled in PA programs were Black. In 1999, while
Black Americans made up 12.1% of the US population, they represented only 10.6% of PAs
23

(Miller et al., 2000). In 2000, Black PAs made up over 9% of the profession (LeLacheur et al.,
2015). In 2004, 6.8% of PAs were Black. In 2015, approximately 13.3% of the US population
was Black (U.S. Census Bureau, 2017); however, 3.7% of practicing PAs were Black.

Table 1
Black Demographics in the United States Physician Assistant Schools and in Practice
Year % U.S. population % 1
st
Yr. enrolled
students
% PAs in practice
1999 12.1 6.5 10.6
2000 12.3 6.2 9.4
2004 12.2 6.1 6.8
2015 13.3 3.4 3.7
2019 12.8 3.9 3.1

Note. Data from Coplan et al. (2018), LaLacheur et al. (2015), H. Reed (2021), Salsberg et al.
(2021), Miller et al. (2000b), Minority Health (2019), PAEA (1999, 2000, 2004, 2015, 2019).

24

Like many other medical programs, the PA profession has struggled to recruit a
workforce that is racially and ethnically representative of the population it serves (Camacho et
al., 2015). Black PA representation plummeted after the 2009 ARC-PA rulings, and the
percentage of Black PAs now stands at slightly over 3% (AAPA, 2021). The PA programs
experienced significant growth in the last 30 years, from 52 in 1991 to 300 accredited programs
in 2022. Despite this growth, during this same time, the proportion of Black students admitted to
PA programs, graduating from PA programs, and practicing in the field has declined.
Whether by omission or commission, racial injustice against marginalized people can
occur nationally and professionally, even if unintentional. The deep historical roots of systemic
racism in the United States may have overlapped with a flawed PA school admissions process
creating a smothering cloud of discrimination (H. Reed, 2021). Some people are kept in a
vulnerable position and may be disadvantaged routinely. Therefore, marginalization begets
further marginalization: economic, educational, medical, and social (H. Reed, 2021). The cost of
entering health professions poses a significant barrier as well. In 2016, Black households had the
lowest median income of $39,490 (U.S. Census Bureau, 2016). In 2015 and 2018, Blacks in US
medical schools had nearly double the premedical school debt as White matriculants (AAMC,
2016, 2018).
Regarding the number of applications submitted, Black PA applicants sent between 2 and
7 PA applications and had the most substantial incremental benefit, 2.5 times higher. Yet, the
median number of programs applied for by Blacks was 33% lower than non-Latin X Whites
(Honda et al., 2021). A lack of resources may prevent prospective students from applying
through the Centralized Application Service for Physician Assistants (CASPA, 2020). All
applicants must pay nearly $180 for the first program to receive an application and $56 for each
25

subsequent program since the PA profession has been ranked among the Number 1–2 best
professions for the past decade (CNN, 2011; US News & World Report, 2021). There are no fee
waivers for low-income students.
Application-bolstering activities also require significant social capital, where potential
applicants often leverage time and social connections to secure shadowing opportunities and
letters of recommendation (H. Reed, 2021). Most students hire professional PA coaches and
enroll in pre-PA programs, which cost upward of $10,000 to $30,000. The advising services
offer mock interviews, application advice, course critique, and essay editing (H. Reed, 2021).
Volunteer hours ranging from 500–3,000 hours are a prerequisite for applying. Volunteerism
becomes unattainable for people who must provide for themselves or their families, and
minimum entrance requirements may not be easily met. Lack of racial or ethnic mentors may be
challenging to leverage the connections for minority applicants, thereby placing another barrier
in the application process (H. Reed, 2021; Toretsky et al., 2018). Educationally, Black students
are also sometimes behind the curve, often matriculating from less academically enriched high
schools. Competing is often difficult if the student had limited or no access to AP classes
(Quinton, 2014). URM applicants often received lower grades in gateway courses, which are
entry-level undergraduate classes in math and science, and may not be as well prepared as their
peers (Alexander et al., 2009).
With the hope of establishing a diverse and equitable PA profession inclusive of Black
applicants, the PA admissions process must move to a more holistic evaluation process taking a
deeper look at the expectations of the most marginalized and considering the deep roots of
systemic racism (Coplan et al., 2018; H. Reed, 2021). Improving racial and ethnic diversity may
26

increase representation and correct some imbalances in the professional outlook of Blacks in the
PA profession.
Diversity, Equity, and Inclusion in Admission Practices
The United States Census data show that underrepresented groups in medicine (URiM)
are growing much higher than the US White Population (Frey, 2018, U.S. Census Bureau, 2019).
If this holds, a healthcare workforce that mirrors the diversity of the population can help reduce
health disparities (Moy & Bartman, 1995; Senf et al., 2003). Yet, while underrepresented
minority populations in the US are increasing, their representation in the PA workforce is
decreasing, and the profession remains predominantly White.
Changing the narrative of diversity messaging is key (Ryujin et al., 2021). Programs need
more intentionality in their admission processes, with greater access to financial and educational
support. Diversity messaging can be changed simultaneously by addressing new mission goals
that better reflect the mission of ARC-PA guidelines that state it is essential that the programs be
an environment that fosters and promotes diversity to prepare PAs to provide service to others
that are not exclusionary for any group, race, or culture (ARC-PA, 2019).
Universal PA program mirroring is when the local or state population is mirrored in the
demographic makeup of the local PA student population, and this is the first step to intentional
diversity (Ryujin et al., 2021). The diverse faculty, staff, and student body offer various
perspectives and resources to increase the Black PA professional's overall impact on patients and
the global community (ARC-PA, 2019). Black faculty representation in PA schools may help
improve the pathway of Black PAs and possibly deter further decreases in numbers by readily
addressing the low representation across the profession, beginning with the PA applicants and
graduates. Thus, the lack of Black PA faculty representation affects Black students applying to
27

and being accepted into PA programs (Coplan et al., 2018). Racial and ethnic concordance
between healthcare professionals and patients is associated with increased access, improved
compliance, better interpersonal care, and greater patient satisfaction (Camacho et al., 2015;
Smedley et al., 2004; U.S. Department of Health & Human Services, 2018). As one of the
essential members of the medical team, increasing diversity in healthcare professionals has been
attributed to better health outcomes (Honda et al., 2021).
Implicit biases are involuntary and unconscious attitudes that influence behavior and
cognitive processes (Greenwald & Krieger, 2006; Greenwald et al., 2009). Researchers found
that a midwestern medical school used the Implicit Association Test. It is a widely used and
validated tool measuring implicit biases to demonstrate the majority of admissions committee
participants, particularly faculty, and showing implicit preferences for White versus Black
applicants (Capers et al., 2017). The likelihood of matriculation was lower among URM, older,
and male applicants, but controlling for academic achievement and GRE status indicates the
importance of these components in the admissions process (Yuen & Honda, 2019). URM and
age findings were contingent on GRE status. The odds of matriculation decreased among URM
and older applicants without GRE scores, suggesting that standardized test requirements may be
a barrier to PA workforce diversity. Reliance on traditional academic metrics or standardized
tests, such as GRE or MCAT, may hinder the recruitment of a diverse student body, suggesting
that health professions training programs should explore alternate or supplemental admissions
methods and criteria (Yuen & Honda, 2019). Thus, evidence of effective strategies to increase
diversity involves multiple interventions such as restructuring admissions policies, developing
innovative training approaches, providing social and financial support, and recruiting
28

underrepresented minority PAs to serve as educators. This may positively affect the diversity of
the PA profession (Coplan et al., 2018).
Recruitment, Retention, and Best Practices for Hiring
Recruitment, retention, and best practices for hiring Black faculty must be strategically
implemented when recruiting and retaining diverse faculty members. Improving racial and ethnic
diversity in the PA profession is vital to providing better care for underserved communities
(LeLacheur et al., 2019). Recruitment and retention of minority PA faculty is one way of helping
to attract and retain a more diverse student body. Additionally, a better understanding of the
experience of minority PA faculty may lead to improved efforts at recruiting and supporting a
more diverse faculty workforce (Reed, 2006).
Minority faculty can be an integral part of increasing diversity in the PA profession, yet
they should not be expected to be the sole faculty members focused on diversity and inclusion
(Torres et al., 2010). All faculty members addressing these values might better serve a globally
diverse population. Strategies for recruiting and maintaining an inclusive faculty should include
formal mentoring, which takes in the needs of minority junior faculty members, faculty and
student training, and would provide opportunities to collaborate on scholarly activities and create
positive professional relationships; leadership role opportunities; ability to take an active role in
decision-making; advancement opportunities, perceived or concrete opportunities for
advancement, including faculty rank opportunities; salary improvement, income and job security
opportunities, and clear job responsibilities: written and consistent job responsibilities (L. E.
Reed, 2006; Torres et al., 2010).

29

Critical Race Theory
Critical race theory (CRT) calls attention to racism and its connection to the larger social
context. Ladson-Billings (1998) identified six areas of CRT in education: (a) racial inequality in
education is the logical outcome of a system of achievement presided on competition, (b)
educators must examine the role of education policy and practices in the construction of racial
inequality and the perpetuation of normative whiteness, (c) CRT rejects the dominant narrative
about the inherent inferiority of people of color and the normative superiority of White people,
(d) educators must reject historicism and examine the historical linkages between contemporary
educational inequity and historical patterns of racial oppression, (e) intersectional analysis
recognizes the ways that race is mediated by and interacts with other identity markers (i.e.,
gender, class, sexuality, linguistic background and citizenship status, and (f) CRT agitates and
advocates for meaningful outcomes that redress racial inequity.
Critical race theory is a race equity methodology that was not derived from the medical
or scientific world. It was developed by a group of legal scholars of color, used to illuminate,
study, and fight embedded systems of racism in the post-Civil Rights Era and new to the public
health community. Critical race theory posits that racism is a norm so fully enmeshed within
American society that it cannot be seen as aberrant within our cultural context (Ladson-Billings,
1998; Taylor, 2009). The invisibility of racism is pervasive, and many feel it does not exist or is
associated only with isolated overt incidents (LeLacheur et al., 2019). This invisibility also
allows the influence of racism on our institution to go unnoticed (López, 2003) and become a
permanent aspect of the lives and experiences of people of color (Urrieta et al., 2015). CRT
views race and White supremacy as an intersectional social construction (Gillborn, 2015) that
30

serves to uphold the interests of White people (Curry, 2009) at the expense of marginalized
communities (Crenshaw, 1989, 1990).
Another essential concept in CRT is the counter-narrative, a way for those with
marginalized identities to challenge dominant and often negative narratives through their lived
experiences (LeLacheur et al., 2019, McCoy & Rodricks, 2015). CRT acknowledges that racism
is every day and permanent. Racialized individuals (those perceived to have a non-White racial
identity) experience microaggressions, the generally unintended but ongoing slights by majority
members acting according to culturally accepted norms and counterstories expose this subtle and
cumulative nature (McCoy& Rodricks, 2015; Orelus, 2013; Urrieta et al., 2015).
The CRT framework has been used in medicine and medical education to explore African
American men's experiences in medical school, promote cultural competence in medical
education training, and further public efforts and understanding (Betancourt, 2006; Ford &
Airhihenbuwa, 2010; Morgan, 2013). This framework was used to discover the factors at play
and better understand the role of the low Black faculty in PA schools across the US. To facilitate
the appropriate and systematic use of CRT within public health, Ford and Airhihenbuwa
developed the public health critical race framework (Ford & Airhihenbuwa, 2010). That
framework and the CRT concepts build on the growing public health momentum toward
achieving health equity.
Critical race theory can empower communities of color and shows that racism should not
be viewed as acts of individual prejudice that can be eradicated. Instead, it is an endemic part of
everyday life, deeply ingrained through race's historical conscience and ideological choices
(Parker, 2003). This theory embraces the injustice experienced when combating negative issues
during the fight for African Americans' health equality during the COVID-19 pandemic. Perhaps
31

if more Black medical providers were present, they could have helped deliver better medical
care.
The COVID-19 pandemic is a human tragedy of unprecedented scale in our lifetimes,
especially for Blacks globally (Reyes, 2020). The pandemic presents an opportunity for White
healthcare providers to fight for health equity (Bureau of Health Workforce-HRSA, 2020;
Sindhu, 2019). Health providers should understand CRT because it affirms that racism remains
pervasive and ordinary in the United States, impacts all aspects of society, and is seamlessly
embedded in policies, social life, and health. For progression and change, the critical tenet of
CRT, developed by one of the originators of CRT, Derrick Bell, is the concept of interest
convergence, or the notion that progress toward racial equity is only accommodated when it is
also in the interests of Whites (Morse et al., 2020). The CRT framework was used to discover the
factors that influence the persistence of low Black PA faculty and practitioners, focusing on a
decrease in Black student access to the PA pathway that can overall affect morbidity and
mortality rates in the Black community.
Conclusion
The literature review presented an overview of the historical background of how the PA
profession came into existence. The advancements of ARC-PA’s 2009 rulings decreased the
number of HBCUs and community college PA programs that matriculated large numbers of
Black PAs. This decline in Black PA students directly results in low Black practitioner
representation with potential increases in morbidity and mortality in the Black community as
minority PAs often return to the Black community to work after matriculation. Although the
number of PA programs in the United States has increased five-fold, the last report shows
declining numbers of African American PA school graduates (PAEA, 2020). The subsequent
32

chapter details the population and methodology used in this study. Chapter Three explains the
rationale for selecting the mixed-methods approach to examine the factors contributing to low
Black PA student, practitioner, and faculty representation.

33

Chapter Three: Methodology
The purpose of this study was to understand the barriers that lead to the
underrepresentation of Black PA students, practitioners, and faculty members and identify
solutions for increasing Black enrollment in PA schools in the United States. This study
discussed the influence of the historical racial exclusion of Blacks from education on the current
deficits of Black students, healthcare providers, and faculty in the PA field. In response to the
decline in the underrepresentation of Blacks in PA education leadership (PAEA, 2018), I
explored solutions for bolstering the number of Black PA students, Black practitioners, and
Black faculty working and teaching in the PA field. This chapter discusses the study's
methodology and rationale for utilizing a mixed-method research design. It included an overview
of the study methodology, research questions, the population and sample, instrumentation, data
collection, and analysis, trustworthiness, conclusion, and appendices.
Research Questions
The overarching research questions that guided this study were
1. What are the barriers hindering the number of Black students, practitioners, and faculty in
the physician assistant field?
2. What are the racialized, lived experiences of PA students?
A mixed-methods approach was chosen to integrate both qualitative and quantitative
research. I utilized the philosophical assumptions of qualitative and quantitative methods and
integrated both approaches in this study. I used purposeful (purposive) sampling. I surveyed all
groups and interviewed 14 PA student participants. Berg and Lune (2012) stated that “when
developing a purposive sample, researchers use their special knowledge or expertise about a
group to select subjects who represent the target population” (p. 52).
34

Methods
I utilized a mixed-methods approach to develop findings and solutions (Merriam, 2016). I
integrated both qualitative and quantitative methods, then drew interpretations based on the
combined strengths of both sets of data to answer the research questions (Creswell & Creswell,
2018). The method implemented for this study was best captured by interviewing via web-based
video conferencing and emailed electronic surveys. The survey collected demographic
information and asked pertinent questions about the experiences of Black PA practitioners,
faculty members, and students.
Population and Sample for the Study
The population for this study was Black students, faculty, and practitioners in the PA
field. Although the PA profession began in the mid-1960s, programs’ growth has significantly
increased the number of PAs over the last decade from approximately 83,466 in 2011 to over
148,560 in 2020. In California alone, there were over 12,000 PAs in 2021. There is no accurate
data on the total number of Black PAs since the profession’s inception. However, the overall
number of Black PAs has steadily declined over the last decade (H. Reed, 2021)
Sampling Criteria and Rationale
When developing a purposeful sample, researchers use their unique knowledge or
expertise about a specific group to select subjects representing the target population (Berg &
Lune, 2012). I utilized purposeful sampling to recruit Black PA practitioners, faculty members,
and students. Participants were eligible for the survey and interview if they identified as Black or
African American (African descent) and met the following criteria: working practitioners,
students in a U.S. PA program, or PA faculty members teaching for at least 3 years in public or
private U.S. universities. The criterion regarding faculty experience was to ensure they had
35

ample time to become immersed in medical academia, organizational and professional expertise
as program leadership, and engagement with the institution's faculty, staff, and student culture.
For practitioners, I asked permission to post and recruit members of the National Society
of Black PAs. For faculty, I asked for permission to post a recruitment email to the PAEA PA
minority faculty listserv. For students, I utilized PA student social media to access and recruit PA
students. Participants were surveyed at the beginning of data collection, stratified into the
appropriate demographic, and given specific questions about their level of practice.
Additional participants were recruited through snowball sampling. Snowball sampling is
when each research participant who volunteers to be in the study is asked to identify another
person who meets the study characteristics to participate in the study (Johnson & Christensen,
2014).
Instrumentation
The survey used in this study contained fewer than 20 questions and was created using
Qualtrics, a web-based survey system. A combination of open-ended, Likert-scale, and forced-
choice response questions was used. The survey collected demographic information and asked
questions about the underlying factors of the experience of Black PA practitioners, faculty
members, and students (Appendix A).
The interview allowed for insightful one-on-one conversational information regarding the
student participants’ perspectives, including how they view, feel, and think about a specific
subject, occurrence, or situation (Patton, 1990). Interviews took place online using a web-based
video platform, Zoom. The interview protocol consisted of less than 20 questions, and the semi-
structured interview format offered more flexibility and allowed the researcher to rearrange or
rephrase questions and adjust probing questions (Appendix B). Personal interviewing provided
36

information about the subject, feelings toward a particular situation, and insight into participants’
viewpoints (Patton, 1990). All interviews were audio or video recorded to capture the
participants’ true essence of all responses. Detailed notes were taken as the interview was
conducted and transcribed shortly afterward using Otter AI.
Data Collection and Methods
I followed all institutional review board (IRB) guidelines for the protection, rights, and
welfare of the participants of this study. Strict ethical guidelines were followed for the survey
and interview. An information sheet was provided to each participant providing necessary
detailed information regarding the study (Appendix C). Participants were informed that
participation is voluntary, all discussions are kept confidential, and participants can withdraw at
any time during the study without penalty (Glesne, 2011).
I posted (with permission) a recruitment email (Appendix D) on the PAEA PA minority
faculty leadership listserv. An email including a brief introduction of the researcher, an overview
of the study, and a survey link was sent with the information sheet to members of the PAEA’s
minority faculty leadership listserv to recruit participants. Black practitioners were recruited
through the National Society of Black PAs via email. Black PA students were recruited via PA
student social media sites and local PA schools. The survey included demographic questions
regarding each participant’s race, title, number of years in the PA school, and education. I sent a
reminder to each listserv or social media platform two weeks after posting.
Participants were surveyed at the beginning of the data collection process. A total of 87
participants completed the survey yielding information on 38 PA students, 34 PA practitioners,
and 15 faculty members.
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Once responses to the surveys were completed, I reviewed the survey responses to
identify those who met the inclusion criteria. Selected participants were notified for an interview,
and 14 PA students were interviewed. I conducted individual interviews via an online, web-
based video platform called Zoom and transcribed them using Otter AI. Participants did not have
to answer all questions. Interviews took place in a quiet and private setting that was best for both
researcher and participant. The interviews were voluntary, recorded, and participants could
withdraw at any time. Before each interview, I sought permission to record the interview.
Neither name nor other identifying information was associated with the audio or video
recording of the interviews or the transcript. Only the researcher/ transcriber was able to listen to
the recordings. The recordings were erased once the transcriptions were checked for accuracy.
Transcripts of the interview can be reproduced in whole or in part for use in presentations or
written products that result from this study. Names and identifying information will not be used
in presentations or written products resulting from the study.
All data were secured and password-protected. No incentives for participation were
given. However, a small gift card was given to the 14 interview participants to thank them for
participating in the study.
Data Analysis
The data analysis used a contemporary design that consisted of three phases of analysis.
Creswell notes that "the data analysis will begin with the quantitative, followed by the
qualitative, and lastly, mixed-methods data analysis" (Creswell & Creswell, 2018, p. 219). The
data analysis began with the initial survey responses to analyze the quantitative data and gather
statistical results.
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Next, the qualitative interview data were analyzed by coding the data. Coding the data
revealed themes that aligned with the research questions. A priori codes from CRT were pre-
selected and used to generate themes addressed in the research questions, but most codes
occurred organically through the research process (Miles & Huberman, 1994). The data was
aligned with the CRT and protocols and was organized into broad themes (Creswell & Creswell,
2018). Lastly, the quantitative and qualitative document analysis was integrated, and a mixed-
method analysis was utilized.
After the survey was conducted, the initial step in analyzing the documents was to
manage the data. After the interview, I compiled the data to organize the documentation
effectively to minimize volume overload. After each interview, the participant interview and
field notes were transcribed manually, and a transcription service Otter AI was utilized.
Transcripts were read, field notes with written documentation were reviewed, and participant
feedback clarification was provided as needed to understand the participants’ perspectives. The
transcribed information revealed essential phrases and ideas that helped identify thematic
relationships in the coding phase.
With the revealed thematic frequency codes, the data generated themes that conveyed the
overarching research questions. Some codes were preselected, but most were derived from the
research process (Miles & Huberman, 1994). Data interpretation provided healthy descriptions
from the participants. To broaden the findings, quotes, and expressions were utilized.
Multiple data collection methods and sources were used to interpret the study, known as
triangulation. Triangulating the data provided an understanding of the findings and addressed the
global research questions. Interviews, field notes/ documents, transcription via Zoom, and Otter
39

AI were used to triangulate the data in this study. Comparative work and salient factors were
captured across the three groups and their responses.
Credibility and Trustworthiness
In qualitative research, credibility and trustworthiness are essential. Trustworthiness is
thought of as the degree to which your data collection, analysis, and presentation of findings are
presented in a thorough and verifiable manner (Lochmiller & Lester, 2017). Strategies for
establishing trustworthiness include but are not limited to audit trails, engaged time in the field,
member checking, peer debriefing, and triangulation. I kept a detailed record of all observations,
field notes, documents, and interview transcripts that were gathered, collected, and analyzed. The
included/captured emails, invitation letters, demographic surveys, consent forms, and
audio/video transcriptions on a secured computer. Participant names were removed from
documents to adhere to USC IRB requirements, and a unique identifier was assigned to each
participant to protect confidentiality (Creswell, 2007). Data triangulation of the surveys,
interviews, and mixed-methods document analysis were used. I reviewed all data, made sense of
it, organized it into codes and themes, and reorganized the data sources. Lastly, verbatim data
and direct quotes in the findings were utilized.
Ethics
Strict ethical guidelines were followed to ensure the data collection in all modalities used,
such as personal conversation, video, audio, Zoom, and survey. I submitted my study design to
the University of Southern California IRB and was approved. I followed all IRB rules and
guidelines for the protection, rights, and welfare of the participants of this study. An information
sheet (Appendix C) was provided to each participant, providing detailed information regarding
the study. Participants were informed that participation was voluntary, all discussions were kept
40

confidential, and participants could withdraw at any time during the study without penalty
(Glesne, 2011).
Critical features of the ethical principles informed participants that their participation was
voluntary, confidential, the estimated time, and they could withdraw at any time. Because of the
information captured, confidentiality was of paramount importance due to the nature of the topic
and potential first-hand accounts of sensitive information. The researcher respected the desire of
anyone who wished to withdraw from the study. The researcher did not provide incentives for
participation. However, the researcher sent all interview participants a thank you card and a
small monetary gift card to acknowledge their appreciation for taking time out of their busy
schedules to share their experiences and knowledge.
Positionality of the Researcher
The researcher maintained an unbiased position. As the researcher, I hold a worldview
that has shaped my life through various experiences that have led to unconscious bias. Life-
shaping experiences have directly influenced my thoughts, views, and responses. From the
nurturing family, special bonding friendships, the community and cultural impact that has shaped
me, and the educational experiences from undergraduate to doctoral work to my places of
employment, all have shaped my worldview. With only a few Black professors at the graduate
and postgraduate level, and now a Black Professor myself, I would like the answers to the
questions that have shaped my existence. This life-long continuum affects my thought process
and perspective even as it relates to my research.
Having very few Black PA students, practitioners, and faculty members in the PA
profession has also shaped my perspective. It has provided the impetus for my research questions
and my quest to sustain approaches toward finding answers that can shed light on the issue of
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low representation in the PA profession without bias. My worldview holds most of the values
that help shape my identity. Graduating from the number one public undergraduate institution in
California with fewer than 1% Black students and even fewer Black faculty members has shaped
me. Graduating from the only historically Black graduate school west of the Mississippi River,
located in the heart of South Central Los Angeles, now as a professor myself, I seek answers to
the questions that have shaped my existence: Where are the Black members of the PA
profession, and why are the numbers declining?

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Chapter Four: Findings
This study aims to understand the barriers that lead to the underrepresentation of Black
students, practitioners, and faculty members in the PA profession and to learn the racialized,
lived experiences of PA students. It is essential to find the causes of the declines and identify
expeditious solutions so that Black students, practitioners, and faculty will begin to flourish in
this field to assist and improve the lack of medical access in the Black community. Better access
to health care may help improve wellness and reduce mortality rates experienced in the Black
community. Two research questions guided this study:
1. What barriers hinder the number of Black students, practitioners, and faculty in the
physician assistant field?
2. What are the racialized, lived experiences of PA students?
This chapter presents survey and interview results that report key themes that emerged from the
data as they relate to the research questions.
Participating Stakeholders
Both quantitative surveys and qualitative interviews were integrated into this research. I
interviewed all three participant groups and interviewed 14 PA students.
Survey Participants
This study consisted of three participant groups: Black PA students, practitioners, and
faculty members in the United States. Participants were eligible for the survey if they identified
as Black or African (African descent) and met the following criteria: working practitioners,
students in a U.S. program, or faculty members teaching for at least 3 years in public or private
U.S. universities.

43

Collecting Survey Data
The quantitative data was collected via Qualtrics for approximately 4 weeks. There were
no discrepancies in the data collection and no deviations from the plan in Chapter Three. There
were 131 surveys logged. One hundred six (106) participants' demographic information was
captured. A total of 87 participants completed the survey, yielding information on 38 students,
34 practitioners, and 15 faculty members. Fifteen student survey respondents agreed to be
interviewed. However, 14 met the criteria and were individually interviewed. Interviews were
conducted and recorded on the web-based platform via Zoom conferencing at mutually
convenient times to accommodate participants' schedules, and the transcription service, Otter.AI,
was used.
The following information was obtained from the survey questionnaire on demographic
data. All participants identified as Black or of African descent, 85% were female, and 15% were
male. Almost 51% had a bachelor’s degree, 44% had a master’s degree, less than 4% had a
doctorate, and 1% had an associate degree. The predominant age category was between the range
of 21 and 30 (Figure 2), capturing 59% of participants; 23% were between the ages of 31 and 45,
16% were between the ages of 46 and 65, and less than 2% were older than 66. Student
participants constituted 44% of completed surveys, while 39% came from practitioners and 17%
from faculty members.

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Figure 2
Participants’ Ages

Interview Participants
After a review of the survey responses, 14 student participants met the inclusion criteria
and were interviewed. All participants were Black and enrolled in a PA program in the United
States. Table 2 presents their gender and enrollment.

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Table 2
Interview Participants by Gender and Enrollment Class
Pseudonym Gender Class Year
Harrison Hansen Male Second
Christian Crispenson Female Second
Daniella Doyle Female First
Lorain Lawson Female Second
Kezzia Kramer Female First
Carrie Callahan Female Second
Cierra Cohen Female Second
Ulysses Ulrich Male Second
Harriett Hart Female Second
Bibiana Bancroft Female First
Moriah Meyer Female First
Larissa Lee Female Second
Laura Lane Female Second
Barbara Boone Female First

Emergent Themes
Five themes emerged during the data analysis: racial inequity in exposure and branding
of the profession; limited access to science and math curriculum decreased eligibility and
academic threshold for Black Students; career counseling fueled the soft bigotry of low
expectation; lack of representation, mentorship, and a pathway for protégé development; and
systemic economic barriers and limited financial literacy. This section will describe each theme,
and references will be provided from the data.
Theme 1: Racial Inequity in Exposure and Branding of the PA Profession
One of the more prominent and frequently occurring themes was that many of the student
survey respondents were unaware of the PA profession, even when attending a distinguished
university with a notable PA school and one of the top-rated professions for over a decade.
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Surveyed students learned about the profession during college and switched majors after learning
about the PA field. Students did not realize being a PA was a career option until late in their
undergraduate careers. Surveyed students had to take additional coursework after graduation,
often taking classes in the summer, and sometimes had to dually enroll in community colleges to
complete the coursework. Survey results revealed that over 95% of participants agreed that a
lack of awareness about the PA profession reduces the chances of entering the field (Figure 3).

Figure 3
Lack of Awareness About the PA Profession Reduces the Chances of Entering the Field

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For example, Lorain discussed that she was unaware of the PA field even when she was a
premed major at a university with a prominent PA program. Lorain said,
Technically, my undergrad had a PA program that I was unaware of, which is really odd
because they weren’t really advocating, advertising, or recruiting, or I missed it. I wasn’t
fully aware of PAs until I started scribing (when a medical paraprofessional specializes in
charting physician-patient encounters in real-time, such as during a medical examination)
after undergrad while figuring out my next steps.
Similarly, Larissa agreed with the notion of racial inequity in exposure to the profession for
reasons unknown. Inequity in exposure to the profession may perpetuate low representation of
Black PAs in the field:
For whatever reason, there is a lack of knowledge or maybe recruitment of African
American students into the PA profession. I don’t think many people of color,
specifically Black people, know about the profession. And it definitely impacts the
profession because as we become providers, we know that our patients really affect the
patient-provider relationship. It improves when a patient can feel as though they have this
connection.
Nearly 80% of interviewees reported not finding out about the PA profession until
college or thereafter. This data supports the report that participants said many people still do not
know what a PA is. Harrison concurred by stating,
Medicine has always been my focus, and when it came to being a PA, it was something I
didn’t even realize was a career. I didn’t have PA school in my mind until college, and I
played a lot of catch-up. It was a lot of catch-up. I ended up switching majors twice.
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When I went to undergrad originally, I was going into physical therapy. So, I had to
change my major because once I figured out what a PA was, there was no turning back.
Carrie also agreed with the belief that there is limited exposure to the PA field for Blacks. This
may delay establishing an early patient-provider relationship: “I was almost 20-something, the
mid to late 20s when I found out what a PA was for the first time because I had never seen one in
my life.”
Although the PA profession has existed for almost 60 years and has been one of the top-
rated professions for over a decade, it is still not widely known. With over 125,000 PAs in
clinical practice, PAs work in over 65 areas of medicine, with the most visible being in primary
care (Hooker, 2021), and PAs are still not widely known in the community. Interview data
revealed that the participants did not widely know about the profession, and delays in finding out
about it as late as college or after slowed their ability to meet entry requirements for nearly 4-10
years and proved difficult for many.
Theme 2: Limited Access to Science and Math Curriculum Decreased Eligibility and
Academic Threshold for Black Students to Meet Requirements
Over 71% of the participants reported having difficulty meeting entry requirements
because of a lack of early exposure and familiarity with science and math concepts. Science was
difficult to grasp, staying on top of concepts learned was a daily struggle, and the cost of tutors
and additional units was expensive. Christian stated,
I grew up in Detroit, but then we moved to the suburbs, and I definitely feel that if I
hadn’t moved to the suburbs, I don’t think I would have been exposed to this so early.
They had a medical class I took for two years in high school, preparing me for different
health professions.
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The difference in early exposure seemed to start Christian on a positive trajectory in learning
difficult science- and math-related concepts and increased exposure to the medical field. In
contrast, Bibiana attended poorly funded schools with limited access to high-level academics,
particularly in science. She stated,
I went to school in the Detroit Public School District, which unfortunately has a very rare
reputation for preparing students for college successfully, so my high school wasn’t very
beneficial. When I decided to take the prerequisites for the PA Program, because of how
poorly I performed at my university as an undergraduate, I had to retake classes at the
university and community college; I was also failing those courses.
Harrison described himself as having always been intelligent and stated that he was never given
the big picture of achieving good grades and overall logical importance. He felt he was smart
enough to handle science concepts but did not know much about how these classes applied to his
life or why he should take certain science classes. Harrison said,
I didn’t realize how important having those grades, having that education, and that
science background until I got to undergrad and college. They wouldn’t tell us why. You
know, you didn’t go that deep into the future, like future careers and things you would
have to do to get in. So, the big picture was missing.
Daniella reported how hard science was for her when taking science courses late in her college
career due to deterrence in junior high school. Daniella felt that she was not well-prepared for
college-level sciences because of her middle school and high school education:
Yeah, I remember it well; it was middle school. I remember telling my counselor I
wanted to be in advanced classes because I was interested in science but was not allowed
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to. However, my high school counselor responded by getting me into advanced AP
classes, which really catapulted me, and I could see things coming together.
Entry requirements were often hard to meet while working full-time, decreasing study time and
contributing to sub-par test-taking skills. Carrie felt that it was tiresome trying to achieve her
goals after working several menial jobs, which took away valuable study time and did not
contribute to better test-taking skills, and she said,
I grew up below the poverty line in a town where the average median income was like
$30,000. I was working a job and had to finish college. I did 2 years, and then I dropped
out again because poverty in my family couldn’t afford to help me continue going to
school. So, I started working, and this was exhausting, like the hours, and I’m still poor. I
saw an order signed by a PA, and I googled it and said, yep, I want to do that. At about
that time, I worked my way back into undergrad and started working on my prerequisites
for PA school.
The CRT tenet of interest convergence is actualized here, where student participants
depicted the difference in educational demographic patterns in the two schools in Detroit. One
student participant expressed better educational options when she moved to the suburbs of
Detroit. One student participant who remained in the inner-city school in Detroit depicted a
worse educational experience where the ravages of white flight were prominent, exemplifying
the inequities in education for those left behind and unable to move. Inequities in school funding
yielded persistent underfunding and the persistence of racially segregated education for Black
students.
Interview participants reported that significant barriers were faced when applying to PA
schools. Limited exposure to science and math education in the early stages diminished the
51

ability to meet prerequisites for entry and proved difficult for many. Students in this study with
greater exposure to science and math curriculum and early primary school access allowed years
of content mastery and better prepared them for enhanced test-taking ability. Students in this
study who learned about the profession late in the undergraduate academic process found the
need to backtrack to meet entry requirements. Students who switched majors added significant
educational time and resources to their collegiate experience. Delays in finding out about the
profession lead to a four to ten-year delay in meeting the entry requirements, which can be costly
for prospective students and patients. Decreases in Black students meeting entry requirements
can ultimately lower the number of Black practitioners capable of treating patients. Nearly 86%
of practitioners' survey responses agreed that having more Black healthcare providers would
attract more Blacks into the profession (Figure 4).

Figure 4
Having More Black Providers Would Attract More Blacks to the PA Profession

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Equally, over 95% of PA practitioner survey participants agreed that Black PA
practitioners are needed to ensure that the Black patient community is treated equitably (Figure
5).

Figure 5
Black PA Practitioners Are Needed to Ensure That the Black Patient Population Is Treated
Equitably

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Additionally, all surveyed practitioners said that increasing the number of Black
practitioners will positively impact Black patients (Figure 6).

Figure 6
Increasing the Number of Black Practitioners Will Positively Impact Black Patients

54

Furthermore, all faculty survey participants agreed that increasing the number of Black
faculty would positively impact recruitment and the number of Black PAs in the field.
Theme 3: Academic Counseling Fueled the Soft Bigotry of Low Expectation
Over 71% of student survey participants report having had poor, inadequate, or biased
counseling experiences that often changed their life trajectories and were a deterrent to PA
school entry. Previous students report subtle deterrence from early access to science and math
curriculum, while students with greater access had science and math exposure in early schooling.
A lack of appropriate counseling where many counselors did not know about the profession, and
most times, incorrect advice added delays and several years to applying to PA school. Student
interview participants who obtained excellent early counseling were better equipped and had
positive educational trajectories with specific execution of career pursuits. However, those who
had negative or unsupportive career counseling felt discouraged. Daniella said,
I was really interested in science and wanted to get into those classes, and my counselor
responded by saying, well, I don’t really think that that’s something you would be
interested in doing. So, my counselor was deterring me from even thinking about going
into these classes because I wasn’t in the magnet program.
Bibiana agreed with the conviction that there is a subtle and overt discouragement from
counselors- who often seem like gatekeepers. The discouragement added a weighty feeling of not
only fighting to learn the science curriculum that wasn’t presented, and fighting against a system
that didn’t encourage or wants you to reach your full potential in the PA field. Bibiana recounted,
A counselor said with a straight face, I know that this is more arbitrary than anything,
but we have to go through the checks and balances of why, you know, you failed those
classes and how you’re going to better prepare yourself academically going forward. … I
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mentioned that I’d really like to be a PA, and she said with a straight face, “I don’t think
I’ve ever seen an African American PA. Maybe you should try something else.”
Harriet also reported having negative career counseling, which set her back years and delayed
her PA program entrance. Inaccurate counseling can lead to significant delays in applying to PA
school amid more stringent requirements each application cycle and could deter admittance in an
earlier cohort. Harriet said,
My counselors were kind of, I’m sorry, useless. They didn’t know much about the PA
profession. When I initially started pursuing PA, one counselor told me not to apply to a
PA school that awarded a bachelor's degree. I needed to apply to the PA schools awarded
a master's degree because the bachelor's programs weren’t accredited. By that time, I
could have entered PA school earlier.
Less than 30% of student participants reported having good counseling, but all who
reported excellent counseling said these experiences made a considerable difference in their
academic and career planning. Of the students who reported poor academic advising, some
counselors were noted to have no knowledge about the PA profession and thus could not provide
correct information to prospective students or delineate from other medical careers. Poor
counseling often provides students with inaccurate information, deterring students from a vital
chance to enter the profession earlier rather than later. Improper medical educational options or
the lack thereof may be provided, leading to significant missteps. Subtle deterrence from early
exposure to science and math curriculum adds to delays in mastering science and math content.
With students’ reports of attending poorly funded schools with limited access to science and
math classes and poor academic advising, this may shed light on why Blacks report increasing
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difficulty with mastery of science and math curriculum and test-taking. Poor academic advising
or inadequate counseling can significantly deter students from pursuing a PA career.
Poor, inadequate, and biased counseling, coupled with subtle and overt discouragement
of counselors, generated feelings of fighting a system that does not encourage Black presence in
the field. The feeling of gatekeeping to the medical/PA profession by counselors made the first
CRT tenet realized: racism is ordinary and pervasive in society regardless of the profession one
enters. There will be someone who will inherently deter one’s goals.
Theme 4: Lack of Representation, PA Mentorship, and a Pathway for Protégé
Development
Nearly 65% of student participants reported that they had no Black faculty members in
their PA program, and few had the opportunity to be taught by a Black teacher years before PA
school. When students do not see anyone who looks like them, they may be less likely to
consider that a viable career for themselves. Over 92% of student survey participants agreed that
having Black faculty members in PA programs improves the overall learning experience of all
PA students, and nearly 77% agreed that having Black faculty improves the performance of
Black PA students. The lack of presence of Black faculty impacted the student's overall
experience during PA school. Nearly 65% of surveyed faculty felt it was their responsibility to
recruit and retain Black students in their PA program. Laura stated,
For Black students, it’s very hard to go through a program and develop professionally
when you don’t see people who look like you. I think it’s an added stressor and not
knowing it will be received by my patients because I don’t necessarily have someone on
our faculty who’s Black that I can ask for guidance in that way towards racial things.
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They're doing a great job at trying to promote the profession, but there’s still so much
work to be done.
Bibiana agreed with the need for representation in the field. The feelings of added stress and
discouragement are a perceived reality, and having no one at the table who looks like you
heightens those feelings. Bibiana stated,
You know you’re not gonna get in, or we get discouraged very quickly because we are
not fully represented like other races, and if you feel like you see more people that look
like you doing this, then it gives you confidence that okay, well maybe, I can do it too.
Student participants noted mentorship by family members and other non-PA professionals, but
PA mentorship is lacking and much needed. Laura stated this as one of the reasons she felt was a
potential cause of the underrepresentation of Blacks. She said,
I didn’t really have a mentor specifically for PA school. Otherwise, it was a classmate or
peers in college who told me their process, and I just kind of tried to emulate that. Maybe
there is a lack of mentorship and lack of guidance.
Cierra discussed the importance of being a protégé (mentee) taught or trained by a PA who looks
like them, takes an interest in them, and helps to better them. Cierra stated,
The same way that I want someone to look up to me and say, oh my God, this is a Black
medical provider; I want to look up to one of my teachers, who teaches me about
something that I love so much, is Black like me.
Barbara agreed to the idea of being a PA protégé. The experience fueled her confidence and
encouraged her career pursuits. Barbara stated,
It made a huge difference because seeing someone who looked like me in that field just
made me more encouraged and more confident to pursue my career goals.
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Harrison candidly commented on how Black PA students long to be supported like those of other
racial backgrounds. He also discussed feeling like he was on an island and standing out:
You see how well other people (other races) are doing and how well they can support
one another (throughout the PA School process). And you just long for that; you really
wish you had that. … Some things in PA school make it even more difficult. You know,
kind of just feeling like you’re on an island. … Everyone was talking to each other,
communicating, where you get into these groups of people who have all these things in
common, and some [of us] kind of get left to the side. It has happened to me,
overwhelmingly, because you know, I hate to say it, but it is kind of the elephant in the
room… I’m Black. So the things I am interested in, my background and things I talk
about are completely different.
Kezzia, similar to Harrison, discussed that the Black perspective is different and personalized.
The lived experiences, interests and perspectives that Black people are exposed to are different
from other races. Kezzia stated, “It would be nice to hear from somebody with a different
perspective in terms of, like, my own personal stories about their clinical areas and stuff like
that.”
Most significantly, student participants in this study did not see Black PA representation
in all aspects of the PA career process. Lack of representation in PA educators and faculty
members may lead to a lack of Black representation in the PA educational process across the
United States. Lack of representation is related to diminished access to mentorship. Student
survey respondents showed that 64% of students had no PA mentorship. PA student surveys
revealed that over 95% of students agreed that mentorship of qualified Black students should
begin before entering college (Figure 7).
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Figure 7
Mentorship of Qualified Black Students Should Begin Before Entering College

PA practitioner survey responses reported that over 68% of practitioners did not have
Black mentors in their current employment (Figure 8).

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Figure 8
Black Mentors Are Available at my Current Workplace

Surveyed PA faculty shows that nearly 85% felt that Black PA students and Black faculty
mentorship are fostered when present in the same program. Harrison discussed the challenges of
mentorship and finding his own specialty rotations. It was not impossible to find preceptors
when one did not have connections and while studying. Harrison stated,
As a minority, my family members are not doctors. My biggest issue was getting in
contact with as many people as possible, which was difficult. I reached out to everyone I
knew that knew somebody. The same things that hurt me in undergrad continue all the
way up to PA school. I love orthopedics, but it has been impossible to find anyone who
wants to be a preceptor. Whereas, you know, there are so many people who know people
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personally, and they can find rotations left and right, and I am in desperation mode to find
anyone I can.
Carrie reported that the limitations of mentorship placed on Black students are tremendous.
Clinical rotations are usually 4 to 6 weeks, and students spend time learning as medical team
members while supervised by a medical provider. Some cannot attain better rotations because of
barriers to adequate mentorship opportunities. Carrie stated, “When you don’t have people who
know how to get into these spaces, another barrier is when you don’t have people whom to
network with or people to shadow.”
With the low numbers of Black physicians and even lower numbers of Black PAs in
society, finding a mentor to help guide the younger generation into the medical field can be
challenging. Study participants reported it was difficult to find Black medical professionals to
learn the essentials of the profession, potential obstacles to avert, and best practices to navigate
the medical arena appropriately. Producing protégés who are protected, trained, and allowed to
establish essential, meaningful learning experiences that improve and strengthen their medical
foundation is necessary. Student participants in this study were challenged with obtaining
mentors, shadowing hours, letters of recommendation, and simply finding people who know
medical practitioners to help navigate their career concerns.
Theme 5: Economic Barriers and Opportunity Gaps
Student participants in this study reported limited financial resources for educational
efforts, including PA school. Participants had to take out substantial loans to complete their
schooling on top of what was owed for their undergraduate endeavors. Survey results showed
that over 45% of students stated that their financial aid package/ financial resources were
inadequate to complete PA schooling (Figure 9).
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Figure 9
My Financial Aid Package/Financial Resources Are Adequate to Complete My PA Schooling

Additionally, nearly 64% of students surveyed disagreed that their PA program had
adequate educational support to ensure the successful matriculation of Black students (Figure
10).

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Figure 10
Black PA Students Received the Same Level of Educational Support As Non-black PA Students

Student study participants said that they did not have enough financial resources in their
PA programs, and loans were predominantly taken out to get through their program. Carrie said,
We cannot overlook the financial barriers to PA school, whether it be money for the
GRE or CASPA or if you have to retake courses to get higher grades; it’s not free to
retake classes when you are already struggling financially. I did two years and then
dropped out again because poverty in my family couldn’t afford to help me continue
going to school, so I started working and worked at one company for seven (7) years. It
was hard for me because I was working full-time, crazy hours. Working that amount of
time, a lot of my other classmates had time to devote to studies, in addition to reentering
college 7 years later, switching from a communication major to a science major.
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Kezzia discussed that having no money was hard and that working so many hours and
still not having any money was stressful and an economic barrier. Kezzia stated,
It was hard, definitely, in terms of, like, no finances. It’s a lot of money. Working in PCE
[patient care experience] jobs has not been paying me the hours to apply, essentially. The
financial burden was really stressful, and I paid extra money for a service providing mock
interviews and personal statement editing.
Laura noted the complexity of being financially impoverished and that difficulty getting into PA
school was a discouraging and unsustainable process when one is poor. Laura said,
It’s not easy to get into PA school and to have to work a minimum wage job for multiple
years as you’re trying to get in, it can be a deterrent, or it can be a big disservice and very
discouraging because, after a while, you realize you just can't afford it. And you have to
do something that’s more sustainable.
Christian discussed the need for financial assistance and was thankful to have parents to help
when financial aid was delayed, which could last nearly a month after the scheduled financial
disbursement. Christian stated, “It all boils down to finances. If I didn’t have help from my
parents, it would be tight for me because you don’t get financial aid until, like, 10–20 days after
the start of school.”
The collective voice of the student participants was powerfully significant and gave a
space to tell their lived experiences, which made the CRT tenet of counter-storytelling
actualized. The power of the individual voices fights against the cultural narrative about Black
students. This narrative often lacks the wisdom of cultures, traditions, struggles, and needs of the
Black community.

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Conclusion
This study sought to understand the barriers hindering the number of Black students,
practitioners, and faculty in the PA profession and to find students’ racialized, lived experiences.
The findings from the integrated analysis of quantitative data, the analyzed participant surveys,
and the qualitative student interviews were documented in this chapter.
Most student study participants reported racial inequity in exposure and branding of the
PA profession. More significantly, many noted being unaware of the PA profession despite being
in existence for nearly 60 years and being one of the top-rated careers for years (US News &
World Report, 2021). With over 125,000 PAs in clinical practice in the US in over 65 areas of
medicine, the most visible being in primary care (Hooker, 2021). In student accounts, the data
revealed that delays in finding out about the PA profession slowed the ability to meet entry
requirements for 4 to 10 years.
Limited access to science and math curriculums decreased eligibility for Black students
to meet requirements. Attending poorly funded schools and inadequate academic and career
counseling was fueled by the soft bigotry of low expectations. The lack of Black faculty,
mentorship, and protégé development was found to be significant. Not having someone in the
field to help navigate the pitfalls of the recruitment process, mentorship, and finding someone
who looks like them made it difficult to succeed.
Considerable resources were utilized in achieving a bachelor’s degree, and study
participants were challenged to find a high-paying job while meeting the PA entrance
requirements if entry requirements were not completed during the undergraduate process. Entry-
level jobs pay significantly lower wages, particularly in the medical field. Graduates had to move
from higher-paying positions to jobs that allowed flexible schedules while meeting entrance
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requirements. Student debt, retaking classes, and changing majors lead to delays in admission.
Professional interview attire, interviewing costs, and testing with the GRE, PA-CAT, and
CASPA applications played a significant role in skyrocketing debt and achieving career goals.
Overall, the student participants felt these were the most significant reasons causing the
underrepresentation of Blacks in the PA field.

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Chapter Five: Discussion and Recommendations for Practice
This study sought to understand the barriers that lead to the underrepresentation of Black
students, Black practitioners, and Black faculty members in the PA profession and to learn the
racialized, lived experiences of PA students. This understanding will help better understand how
the historical racial exclusions of Blacks from education have affected the field.
Although the number of Physician Assistant (PA) programs in the United States has more
than quintupled in the last 30 years, growing from 52 programs in 1991 to 300 in 2022 (ARC-
PA, 2022a; PAEA, 2022). However, Black PA program graduates have continually declined and
reached an all-time low of 4.7% in 2015 and 3.0% in 2020 (Hamann, 2015; PAEA, 2020). Low
Black student admissions to PA schools have reduced the pipeline for increasing Black
practitioners in the field and faculty in PA programs. This chapter will discuss the theoretical
framework, recommendations for practice, and potential future research.
Discussion of Findings
This study found that student participants were unaware of the PA profession. Even more
evidence of the lack of awareness and differentiation from other medical professions was noted
when a college student who attended an HBCU, which housed a well-known PA Program, was
oblivious to PA as a career choice. This finding aligns with a recent study of PA practitioners
that also noted, "The decision to pursue a PA career was not made until they were well into, or
just past, their undergraduate studies, or comparable time” (Skaggs et al., 2021, p. 127). Lack of
PA professional branding across the nation was a common theme even during the COVID-19
pandemic. Medical professionals, such as doctors, nurses, and pharmacists, were as identified as
heroes who led the effort to manage COVID-19. However, the PA profession was not identified
as a group contributing to caring for patients during the COVID-19 pandemic. According to
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AAPA, a survey revealed that over 10 weeks, nearly 16% of PAs were rapidly redeployed in
specialties and practice settings where they were needed most in the COVID-19 pandemic
(AAPA, 2020a). National branding was reported to be lacking.
Lack of academic preparation was challenging for Blacks at both the undergraduate and
graduate levels, and Blacks often received lower grades in undergraduate science and math
classes (i.e., “gateway courses”) because they were not as well prepared as their classmates
(Alexander et al., 2009). Study participants who attended poorly funded schools deficient in
higher-level science courses and science and math curricula created wide educational disparities.
Study participants with early access to science, math, and medical classes had greater exposure,
broader science knowledge, and better testing ability and were better prepared to meet entrance
requirements sooner. During college, these students had a greater understanding of higher-level
science concepts due to years of science and math exposure. Early access to science and math
curricula benefitted one study participant who moved from Detroit to a predominantly White
suburb that had better schools, better educational options, and a wealth of medical exposure that
changed that participant’s life/career trajectory by increasing the college readiness and ability
met PA program requirements at a younger age.
The budgets for academic advising are often limited, and career centers at universities
often do not have expertise in healthcare careers and often provide poor or incorrect advice
(Toretsky et al., 2018). Student participants reported that excellent academic/career counseling
was hard to obtain. With under-resourced junior and senior high schools, receiving poor
counseling was customary. Most college counseling was riddled with bias, soft bigotry, and
inaccurate advice. Nearly three-quarters of study participants reported having had poor,
inadequate, or biased counseling experiences that often changed their life trajectories and were a
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deterrent to achieving PA school entry. Study participants reported choosing not to continue
seeking advice, compounding the number of years delaying entry into the profession.
A barrier for Black students is the lack of mentors who are racially and ethnically
concordant (Sullivan, 2004). Decreases in the number of Black PAs fueled the lack of
representation, and mentorship was difficult to find for study participants. The lack of mentors
reported in prior studies was evident here as well. Study participants reported difficulty finding
Black PA professionals to learn the essentials of the profession, identify potential obstacles to
avoid, and find best practices to navigate the medical arena appropriately. Genuine mentorship
was virtually non-existent, and increased feelings of inadequacy, loneliness, and isolation were
often felt. Study participants felt like they were on an island and that being Black was like being
the elephant in the room. Study participants often felt left out during their educational experience
simply because there are so few Black students; they experience the “odd-man-out”
phenomenon- where the person who differs from the other group members is often left out. This
may heighten the personal feeling of doubting their skills, talents, or previous accomplishments
leading to internalized fear of being exposed as a fraud or “imposter syndrome.”
Financial challenges are more pronounced within the Black community, as this
population had the lowest median income of $39,490 (US Census Bureau, 2017b). Black
students often relied on student loans to finance their education and had the highest pre-medical
school debt compared to White matriculants (AAMC, 2015). Similarly, in this study, participants
reported fewer familial finances to assist with college. This study also noted reports of dropping
out, repeating classes, and restarting college, delaying the pursuit of PA school from 4 to 10
years. Black families often have fewer resources for children to attend better private schools and
often attend poorly managed and under-funded neighborhood public primary and secondary
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schools, which decreases college readiness, particularly in the science and math field (Alexander,
2009). Decreased readiness hindered the inability to apply complex science-related concepts for
the first time, leading to poor science GPA and the need to repeat classes to improve or eliminate
the primary GPA. Students’ debt grew due to retaking classes and changing majors, leading to
graduation and PA matriculation delays. Poor financial management and inappropriate or
unneeded financial aid/loan expenditures played a significant part in indebtedness. Study
participants reported that considerable time and resources were utilized when achieving a
bachelor's degree, and after graduation, finding high-paying jobs with little experience was
difficult. Science majors often need additional schooling or training to meet professional school
entrance requirements if they have not accomplished the undergraduate process (AAMC, 2016).
Preparing for professional school- interview attire, travel costs, and CASPA applications added
additional financial burdens. White counterparts often do not experience the same challenges
making it easier to focus on pure schooling.
Theoretical Framework
Critical race theory (CRT) looks at the relationship among race, racism, and power
dynamics and calls attention to racism and its connection to the larger social context and
ideological forces of domination. The theory considers racism a norm so fully enmeshed within
American society that it cannot be seen as aberrant within our cultural context (Ladson-Billings,
1998; Taylor, 2009). There are five major tenets of CRT: the notion that racism is ordinary and
not aberrational, the idea of interest convergence, the social construction of race, the idea of
storytelling and counter-storytelling, and the notion that Whites have benefitted from civil rights
legislation. The essence of storytelling and counter-storytelling is used to magnify
underprivileged communities' stories, experiences, narratives, and truths. Powerful and
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persuasive storytelling gave breath to the interviewees’ lived experiences. Their explanatory
beliefs of those narratives that were real and perceived as truth helped illuminate the participants’
voices. Many gave thanks for the opportunity to express their experiences throughout their
journey, schooling process, needs, and achieving their goal of becoming certified PAs. Giving
power to the interviewees’ voices fights against the dominant cultural narratives about the
minority individuals that lack the depth of knowledge and wisdom of their traditions, cultures,
communities, home, struggles, and needs. Another tenet found in the data was interest
convergence, where Whites will allow and support racial justice/progress to the extent that there
is something positive in it for them, or a “convergence” between the interest of Whites and non-
Whites (Bell, 1980). Bell observed changing demographic patterns, White flight, after Brown v.
Board of Education. From this, there were racial inequities in education, such as school funding
inequities, including the persistent underfunding of property-poor districts affecting primarily
children of color and the persistence of racially segregated education. The study participants
reported nearly 70 years after Brown, similar depictions of the Detroit public school system
where the White flight from public schools has created a two-tiered system. Students who cannot
flee have been left in poorly run and poorly funded neighborhood schools.
Recommendations for Practice
The following recommendations are offered to address this issue of the
underrepresentation of Blacks in the PA profession.
Recommendation 1: Improve Racial Inequity Through PA Branding Through Literature
To increase racial equity in exposure to and branding of the PA profession and increase
Black students’ awareness of the PA field, there needs to be ongoing outreach to these students
at different ages. There are over 100 HBCUs in the United States. The AAPA will spearhead a
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national education campaign at each HBCU’s college of science to increase awareness of the
profession. Additionally, in 2020 ARC-PA implemented a new diversity, equity, and inclusion
(DEI) standard in its accreditation standards, which hold programs accountable to the profession
and provide the basis on which the ARC-PA will confer or deny program accreditation. The
ARC-PA expects all accredited programs to comply with the standards. PA programs can meet
that new standard by impacting students in each local area through volunteerism at the
elementary, junior high, high school, and early undergraduate levels. Outreach, volunteers, and
free clinics can be provided to the community in each local PA program area so that the
community is aware of the PA profession and thereby impact all communities.
Recommendation 2: Develop National PA Protégé Program
This study reported a lack of representation, mentorship, and a pathway for protégé
development. A national mentoring program through the National Society of Black PAs can
increase ways to promote and develop Blacks in this area. As the number of Black PAs in the
profession increase, naturally, there will be an increase/ influx of adequate mentors who can
provide necessary guidance to have the student navigate the process. Mentorship is critical and
serves as an essential factor in developing Blacks in the PA field. Organize a Black PA pathway
process for education, counseling, and successful pre-entry. The PA profession must examine the
decreasing number of Blacks in the field and provide educational opportunities to increase PA
education leaders by mentoring, supporting, and coaching underrepresented Blacks. If a Black
student graduates from the program, that student should be mentored to assist/teach in that or
other PA programs to ensure the legacy continues.

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Recommendation 3: Provide a Mandatory Economic Freedom Class Through- A Wealth
Building Academy During PA School
Economic barriers and opportunity gaps were commonly identified in this study. Early
financial management classes should be provided to students as soon as they enter the
profession. Scholarship information can be provided early to give students the best education
financing options. A free online 10-week (1–2 hours weekly) economic freedom class during the
last term and sponsored through each program through a wealth-building academy can help
change Black students’ life trajectories.
Recommendation 4: Develop a National PA Program Mapping Pamphlet and Career
Accountability
Career counseling fueled by the soft bigotry of low expectations was commonplace in
this study. Educating the professional advising/counseling staff about navigating the educational
process is imperative. This group of individuals must maintain ongoing education regarding the
PA requirements as they differ from other medical programs. Additionally, screening processes
must be in place to weed out the negative/ill-meaning counselors. Further, a national network of
medical advisors/counselors should provide better education on attaining proper PA certification.
A national PA mapping pamphlet will be designed and updated annually for communities and
colleges with inquiring students. Poor counseling can increase unnecessary setbacks along the
educational journey for prospective students. PA education curriculum should include bias
training, cultural sensitivity training, and solutions for creating a diverse workforce.
Evaluation Plan
An evaluation framework developed by Kirkpatrick and Kirkpatrick (2006) will be used
to address the progress of the four recommendations. This framework has four levels of
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evaluation to track the advancement of results and help to build upon the outcomes at each level.
The first level is reaction, which determines how the intended stakeholders respond to the
intervention. At this level, implementation on addressing satisfaction and engagement with
intervention strategies was used, and the expectation of success was addressed. The second level
of evaluation is learning. This level determines if the stakeholders “change attitudes, improve
knowledge and/or increase skill” because of the intervention (Kirkpatrick & Kirkpatrick, 2006,
p. 22). Assessing learning, commitment, and confidence are addressed. The third level evaluates
changes in behavior as a result of the intervention. Assessments on behavior change and learning
applications were addressed. Critical players and organizations were considered during all phases
to ensure the success of the desired outcomes. And lastly, the fourth level assesses the results that
occurred due to the intervention, and the impact was assessed. The four levels of evaluation can
help leadership understand specific problems at each level, and solutions can be implemented for
barriers to success. An example of monitoring the evaluation of the four recommendations and
the progress of each of the proposed solutions can be found in Appendix E.
Future Research
The limited research on the underrepresentation of Blacks in the PA field suggests a need
for continued focus on this topic. Based on the interview and survey findings, future research
should include a qualitative and quantitative study of Black faculty at all 300 U.S. PA
schools/programs to gain insight into their life experiences and journey from student to
practitioner to faculty member. The current study incorporated interviews of Black PA students
solely. Learning from the lived experiences and journeys of Black faculty members contributing
to the field is essential. A deeper understanding of this information may promote greater
numbers of Blacks in the field.
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Another opportunity would be to conduct a quantitative survey regarding the knowledge
level of high school curriculum counselors regarding BS/PA college programs. The current study
found PA awareness late in undergraduate years, with discrepancies in counseling. High schools
promoting PA education to high school students about accelerated programs may challenge
students early to fulfill the requirements needed for successful entry to one of the 40 dual-degree
programs, decreasing program and college financial burdens and promoting the efficiency of
early education in senior High School populations about healthcare professions, including the PA
profession.
Lastly, future research may involve conducting a qualitative and quantitative survey of all
300 PA school/program directors with Black faculty staff members about the impact of career
and student (protégé) mentoring. In this study, there were limited mentors among students,
practitioners, and faculty members. Future research should investigate the promotion of
mentoring of Black faculty before adding student mentorship.
Limitations and Delimitations
The study was limited to Black PA practitioners, faculty members, and students. The
study did not seek other people or races outside of this demographic. Other limitations could
include the lack of truthfulness of respondents, unintentionally misleading, or not being fully
truthful in answering the questions.
Concluding Thoughts
With fewer Black faculty members, fewer Black students admitted to PA schools, and
fewer Black practitioners able to provide care to the underserved, there is a misalignment
between the Black PA workforce and the communities they serve. Major declines in Blacks in
the PA field will drive the need to address the lack of Black PA representation in the profession
76

to impact better health access ultimately for Black patients. During the COVID-19 pandemic, the
Black community had the highest death rates compared to other races. The lack of Black
representation may have exacerbated disproportionate health outcomes increasing morbidity and
mortality rates in the Black community, further reducing access to healthcare. Reversing this
trend requires a swift implementation of recommendations for new concepts that will change the
trajectory of the declining numbers of Black PAs.

77

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Appendix A: Survey Protocol
Survey Questions
Demographic questions:
1) What is your race?
a. Black (African descendants), African American,
b. Other
c. Decline to state
2) What is your age?
3) What is your highest degree earned?
4) What is your role in the Profession?
a. PA faculty member
b. PA practitioner
c. PA student
d. None of the above

PA Student Survey Questions:
1) What year are you in PA school?
a. First Year
b. Second Year
c. Third Year
d. Other
2) How many PA students are in each cohort in your program?
3) Approximately how many Black students do you have in your cohort?
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4) Approximately how many Black students do you have in the PA program (all years)?
a. 0-2
b. 3-5
c. 6-8
d. 9 or more
5) My high school curriculum prepared me to be academically competitive in college.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
6) My undergraduate curriculum prepared me to be academically competitive in PA school.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
7) I had access to an equitable, high-quality education prior to PA school.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree
Strongly Agree
8) Mentorship of qualified Black students should begin before entering college.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree
Strongly Agree
9) Lack of awareness about the PA profession reduces the chances of entering the field.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree
Strongly Agree
10) Black PA students received the same level of educational support as non-Black PA
students. Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat
Agree Strongly Agree
11) I have experienced racism or racial microaggressions in my PA program. Strongly
Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly Agree
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12) Having Black faculty on the roster influenced me to apply to specific PA schools. Strongly
Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly Agree
13) Black PA students are more confident and perform better when trained by Black PA
faculty.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
14) My PA program has adequate support to ensure the successful matriculation of Black
students.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
15) My PA program is a culturally affirming environment to learn.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
16) My PA program is a culturally marginalizing environment to learn.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
17) My PA program does an effective job fostering strong relationships between Black
students and Black faculty.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
18) My PA program curriculum does an effective job preparing me to understand and address
racial disparities in health care.
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Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree
Strongly Agree
19) My financial aid package/ financial resources are adequate to complete my PA schooling.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
20) Would you be willing to participate in a brief interview for this study?
a. Yes; please provide your phone number and email address
b. No

PA Faculty Related Questions:

1) How many years have you been in the PA profession?
a. 3-5 years
b. 6-10 years
c. 11-20 years
d. 21 years or more
2) What is your current position?
a. Instructor
b. Assistant Professor
c. Associate Professor
d. Professor
e. Current/former Program Director
3) Currently, how many Black faculty members do you have on staff?
a. 0-1

b. 2-3
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c. 4-5

d. 5 or more

4) Competitive Salaries are the primary factor in the recruitment and retention of Black
faculty.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
5) Having Black faculty members in PA programs improves the overall learning experience
of all PA students.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
6) Having Black faculty in PA programs improves the performance of Black PA students.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
7) When present in the same program, Black PA students and Black faculty mentorships are
fostered.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
8) The hiring of Black faculty is often for the appearance of diversity.
9) Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree
Strongly Agree
10) My work/PA program has a strong commitment to promoting diversity.
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Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
11) I have experienced racism and racial microaggressions as PA faculty in my program.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
12) My work/PA program culture and interracial experience are key to remaining as a PA
faculty member.
13) Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree
Strongly Agree
14) Increasing the number of Black faculty will positively impact recruitment and the number
of Black PAs in the field.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
15) I feel that it is my responsibility to recruit and retain Black students in my PA program.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
16) As a Faculty member, I am empowered to be a voice to address racial inequities in my
PA program.
17) Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree
Strongly Agree
18) My PA program does a good job addressing racial disparities in health care.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree
Strongly Agree
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19) Would you be willing to participate in a brief interview for this study?
a. Yes; please provide your phone number and email address
b. No

PA Practitioner Survey Questions:
1) Currently, how many Black practitioners do you work with at your current location?
a. 0-1
b. 2-3
c. 4-5
d. 6 or more
2) Approximately what percentage of Black patients do you provide care for?
a. 1-10%
b. 11-30%
c. 31-50%
d. 51% or more
3) Generally, my Black patients are in good health.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
4) Black mentors are available in my current workplace.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
5) I have adequate support in place to ensure success at my job.
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Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
6) My workplace is a culturally affirming environment.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
7) My workplace is a culturally marginalizing environment.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
8) The opportunity to serve the Black community is important to me.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
9) The opportunity to serve the Black community would attract more Blacks to the PA
profession.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
10) Increasing the number of Black practitioners will positively impact Black patients.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
11) Black PA practitioners are needed to ensure that the Black patient community is treated
equitably.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree Strongly
Agree
12) My organization does a good job addressing racial disparities in health care.
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Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree
Strongly Agree
13) I feel that it is my responsibility to recruit and retain Black practitioners in my place of
employment.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree
Strongly Agree
14) As a PA practitioner, I am empowered to be a voice to address racial inequities in my
place of employment.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree
Strongly Agree
15) The hiring of Black PA practitioners is often for the appearance of diversity.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree
Strongly Agree
16) My place of employment has a strong commitment to promoting diversity.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree
Strongly Agree
17) I have experienced racism and racial microaggressions as a PA practitioner in my place
of employment.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree
Strongly Agree
18) My work culture and interracial experience are key to remaining as a PA practitioner in
my place of employment.
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Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree
Strongly Agree
19) Racism has affected my journey toward becoming a PA practitioner.
Strongly Disagree Somewhat Disagree Neither Agree/Disagree Somewhat Agree
Strongly Agree
20) Would you be willing to participate in a brief interview for this study?
a. Yes; please provide your phone number and email address
b. No

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Appendix B: Semi-Structured Interview Protocol

Introductory Script-
“Hi,
Thank you for being willing to be interviewed as part of this study focused on “Examining the
Underrepresentation of Black students in the Physician Assistant Profession.” This interview will
be recorded and will require approximately 45 minutes. For this study, I will interview Black
students currently attending PA school. All interviews will be similar; however, your current role
in the profession will determine the specific questions asked. All of your responses will be
confidential, and once this interview is transcribed, all recordings will be destroyed. The details
of this interview will be included in the final study; however, your name and your
employer/school affiliation will not be included in the study. Do you have any questions before
we get started?”

PA STUDENTS
1. What year is this for you in your PA program?
2. What influenced your decision to attend PA school?
a. When did you start taking classes to prepare for PA school?
b. How easy or difficult was it for you to meet the entry requirements? Explain.
3. Describe your experience working with counselors in high school or college.
a. What type of careers were you encouraged to pursue?
b. How well do you think they knew you and your particular interests? Explain.
c. Do you feel they were really concerned about you? Why or why not?
d. Did they talk about medical careers? Specifically, becoming a PA?
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4. Who were some of the mentors or people who supported or encouraged you to pursue a
career in this profession?
a. Were any of these people Black? If so, what difference did it make for you?
b. Were any of these people medical professionals, or specifically PA’s? How did
you meet them?
5. Describe your experience as a Black student in PA school.
a. What are the things you have enjoyed about the program?
b. What are some of the challenges you have faced?
6. Have you taken any classes taught by Black faculty members?
a. Is this important to you?
b. How has the presence or lack of presence of Black faculty impacted your overall
experience?
7. Tell me how connected you feel to your peers and the faculty in your program?
8. How do your non-Black teachers interact with you?
a. Do you think that racial bias affects how your teachers who are not Black interact
with you? Explain or give examples
9. How would you describe your interaction with Black faculty? Explain.
10. How would you describe your interaction with other students?
a. Do you think your cohort is diverse?
b. How does race affect how students learn or work together, if at all?
11. Have you ever experienced racial bias in your PA program? Explain or describe.
12. Have you ever felt that being Black has been an asset or beneficial to you as a PA student
in your particular program? Explain.
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13. Do you consider yourself as being successful in your PA program? Why or why not?
a. Has volunteerism been achievable for you? Provide details.
b. How would you describe yourself as a student?
14. What impact does the underrepresentation of Black PA students have on the overall
profession?
15. Is there anything else you want to share?

105

Appendix C: Information Sheet for Exempt Research

STUDY TITLE: Examining the Underrepresentation of Black Students, Practitioners and
Faculty in the Physician Assistant Profession

PRINCIPAL INVESTIGATOR: Sonya Earley PA-C, MA, CDCES

FACULTY ADVISOR: Tracy Tambascia, Ed.D.

You are invited to participate in a research study. Your participation is voluntary. This document
explains information about this study. You should ask questions about anything that is unclear to
you.

PURPOSE
The purpose of this study is to understand the barriers that lead to the underrepresentation of
Black PA students, Black practitioners, and Black faculty members in the PA profession and to
understand what is needed to increase the number of Black PA students, practitioners, and
faculty studying, working and teaching in the field. You are invited as a possible participant
because your feedback is highly valued, greatly appreciated, and will help me capture essential
research data.

PARTICIPANT INVOLVEMENT

I will be conducting a survey, which will be disseminated via PAEA for PA faculty, the National
Society of Black PAs for practitioners, PA student social media websites, and through snowball
sampling. The survey will take approximately10 minutes to complete. Some survey participants
will be selected for an interview, which will take place one on one, via audio or video
conferencing, and will be recorded. Interview questions will be related to participants’ roles as
Black PA students. The interview will take approximately 45 minutes. Your responses will be
audio/video recorded for transcription and analysis. All study information will be securely
maintained in a password-protected computer for confidentially. Participants will be assigned a
unique participant number throughout the study.

Your participation is voluntary, your input will remain confidential, and you will have the
opportunity to opt-out at any time.

PAYMENT/COMPENSATION FOR PARTICIPATION
There is no compensation associated with this study. However, as a token of appreciation, a
small gift card will be given to interview participants.

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CONFIDENTIALITY
The members of the research team, and the University of Southern California Institutional
Review Board (IRB) may access the data. The IRB reviews and monitors research studies to
protect the rights and welfare of research subjects.

When the results of the research are published or discussed in conferences, no identifiable
information will be used. All data will be kept confidential and will be secured and password-
protected to ensure there are no breaches in data. The data will be kept for the minimal amount
of time allotted by the USC IRB department and subjects will be notified of the maximum length
of data storage.

Audio/ video recordings will take place and information will be transcribed personally or by a
transcribing service. The participant will have the right to review/edit the transcripts to ensure
the participant’s perspective is captured. Personal identities will be shielded and all information
will be aggregated and themes and codes will be used to disseminate findings. Audio/video
recordings will be held for the minimal amount of time necessary by the USC IRB department.

INVESTIGATOR CONTACT INFORMATION
If you have any questions about this study, please contact Sonya Earley PA-C, MA, CDCES at
earley@usc.edu and faculty advisor Tracy Tambascia, EdD, USC email, tpoon@usc.edu.

IRB CONTACT INFORMATION
If you have any questions about your rights as a research participant, please contact the
University of Southern California Institutional Review Board at (323) 442-0114 or email
irb@usc.edu.

107

Appendix D: Recruitment Letter
Dear Participant,

I would like to invite you to participate in a brief survey that will take 10 minutes. Your
feedback is greatly appreciated and will help me capture essential research data. You will
participate in a mixed-methods research study to understand "What is causing the low
representation of Blacks in the PA profession. " The purpose of this study is to understand the
barriers that lead to the underrepresentation of Black PA students, Black practitioners, and Black
faculty members in the PA profession and what is needed to increase the number of Black PA
students, practitioners and faculty studying, working and teaching in the PA field? This research
study fulfills my doctoral degree requirements in the USC Global Executive Doctoral Education
Program at Rossier School of Education. Participation is voluntary, your input will remain
confidential, and you will have the opportunity to opt out at any time. There is no compensation
associated with this study. However, as a token of appreciation, a small gift card will be given to
interview participants.

I will be conducting a survey, which can be found here. Additionally, some survey participants
will be selected for an individual interview. The interview may be in person if COVID
conditions permit but may also take place online using a web-based video platform such as
Zoom and will be recorded. All information collected for this study will be handled in a
confidential manner.

If you are willing to participate in this research study, please review the information sheet
enclosed and complete the survey. If you qualify for the study, I will reach out to you within one
week to set up an appointment for the interview. If you have any additional questions or
concerns, please feel free to contact me at earley@usc.edu during the research process or my
dissertation chair, Dr. Tracy Tambascia, tpoon@usc.edu.

I greatly appreciate your support.

Sincerely,

Sonya Earley
Doctoral Student
University of Southern California

If the hyperlink does not allow access, please use the link provided below:
https://usc.qualtrics.com/jfe/form/SV_2o961NLAJOp5fqC

108

Appendix E: Evaluating Recommendations 1–4
Intervention
proposed
How you will
assess
Satisfaction and
engagement
with your
intervention
(Level 1)
How you will
assess learning,
commitment,
confidence
(Level 2)
How you will
assess behavior
change,
application of
learning
(Level 3)
How you will
assess impact
(Level 4)
1. Improve
racial
inequity
through PA
branding
through
literature (to
increase
awareness to
the field)
• AAPA
(American
Academy of
Physician
Associates) to
create a
Collaborative
Website
targeted
toward
HBCUs’
Science/ Pre-
Med Majors
• Collect and
monitor data
from
Collaborative
Website
• AAPA to
produce and
publish PA
literature to
encompass
data
• Pre and post-
test on
created
Website
about PA
knowledge
and what was
learned on
Collaborative
Website for
participants

• Collaborative
Graduation/ 1-
year survey to
access the PA
goal trajectory
of HBCU
participants

• AAPA and
Collaboration
Website team
will create a
database and
monitor survey
results/trends and
the acceptance
rates of PA
programs.
• Review data and
make
recommendations
based on data
from the
collaboration
team.

2. Develop
National PA
Protege’
(Mentor)
Program
• Assess and
monitor the
need for
projected PA
student
Protégé and
PA mentor
engagement
through
National
Society of
Black PAs
• NSBPA’s to
administer Pre-
Test Survey of
student and
mentor
participants
about
commitment
and desired
outcomes
• Rules of
engagement
are
• NSPBA to
administer post-
survey of
students and
mentor
participants
regarding
experience,
future
enhancements,
achieved
outcomes and
commitment to
• NSBPA’s to
create active
database of
mentors and
prospective
graduate mentors
ready for active
program service
109

administered
to students and
Mentors
become a
graduate PA
mentor
• Follow-up with
students and PA
Mentors to
discuss
adherence to
rules of
engagement
3. Free online
10-week (1-2
hour weekly)
economic
freedom class
through
wealth
building
academy
during last
term of PA
school
* Note:
funding
provided by
local PA
program
• Perform a
Debt Analysis
• Monitor
Attendance
• Class taken
during last
term of PA
school
• Pre- Test Class
Survey of
desires to
achieve debt
free living,
manage school
debt and
prospective
income
• Monitor course
grades (B or
above
mandatory)
• Monitor Class
evaluations
• Monitor student
feedback
• Post-Test Survey
to Assess and
monitor Debt
cessation plan at 6
months and 1 year
post-graduation
• Wealth Academy
to review Data
and strategic plan
for success
implemented for
US Black PA
students in last
term. Data to be
published and sent
to PA programs
and AAPA.
4. Develop a
National
program
mapping
pamphlet on
career
accountability
• Develop a
pamphlet and
disseminate
nationally
through the
AAPA
• AAPA to
develop
national PA
awareness
program for
strategic
planning for
professional
outreach as a
program goal
(for primary,
secondary and
• AAPA to
monitor and
survey PA
Program goals
annually.
• PA schools to
provide
documentation
of problem
area.
• Follow-up
needed by PA
programs site
and AAPA
• PA schools will
survey and assess
outreach efforts of
entering students
to see if
prospective
applicants had
experienced a PA
Career Exposing
School and or
received the
Pamphlet
• Feedback from
surveys will be
provided to
AAPA annually to
direct future
programing.
110

collegiate
schools)

• Data will be
tracked to
colleges attended
by PAs. Data
provided to the
college C-suite
executives for
knowledge and
corrective
implementation.

Abstract (if available)

Abstract The fast-growing number of physician assistant/associate programs in the United States has more than quintupled in the last 30 years. Yet Black PA graduates have continually declined. This mixed-method study aims to understand and examine the barriers that lead to the underrepresentation of Black students, practitioners, and faculty studying, working, and teaching in the PA field in the United States. Using critical race theory as a theoretical frame, interview and survey data investigate and explore the Black PA experience in medicine and build on the growing public health momentum toward achieving health equity. The study revealed that despite the PA profession existing for nearly 60 years, it is yet to be widely known, and most learned of at the end of their undergraduate education or later. Limited access to science and math curricula, inadequate academic counseling, lack of representation and mentorship via protégé development, and economic barriers significantly decreased the threshold for study participants meeting PA program entrance requirements. The study offers recommendations for practice to alleviate the underrepresentation of Blacks in the PA field in the United States.

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Asset Metadata

Creator Earley, Sonya Lorain (author)

Core Title Examining the underrepresentation of Black students, practitioners, and faculty in the physician assistant/associate profession

School Rossier School of Education

Degree Doctor of Education

Degree Program Global Executive

Degree Conferral Date 2023-05

Publication Date 04/17/2023

Defense Date 01/11/2023

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag counseling,mentorship,OAI-PMH Harvest,physician assistant,physician associate,protégé development,underrepresentation

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Tambascia, Tracy Poon (committee chair), Maddox, Anthony (committee member), Seli, Helena (committee member)

Creator Email earley@usc.edu,sonyaL.earley@med.usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113017568

Unique identifier UC113017568

Identifier etd-EarleySony-11628.pdf (filename)

Legacy Identifier etd-EarleySony-11628

Document Type Dissertation

Format theses (aat)

Rights Earley, Sonya Lorain

Internet Media Type application/pdf

Type texts

Source 20230418-usctheses-batch-1024 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu