The Physician Assistant Life

Secrets of Successful PA School Letters of Recommendation


Whether we like it or not, other people's opinions matter.

A good letter of recommendation can make your day; a great letter of recommendation can change your life.

Whether it is a dating review on Tinder, a restaurant recommendation on Yelp, a movie review on Rotten Tomatoes or an open request for holiday vacation recommendations on Facebook, we look to our friends, colleagues, and specialists in the field for advice on how to make better choices.

"A good letter of recommendation can make your day; a great letter of recommendation can change your life"

Now don't get me wrong, I am not saying you should let Megan McCrorie ditching you at your high school winter formal establish your self-worth (that wasn't nice Meghan!). But the opinions of those we admire and respect, the ones whom we look to for guidance, the ones who will give us the cold hard truth in all instances – that matters!

Studies show that we value the opinions of our close network of like-minded individuals above other sources and with the availability of social proof and endless rating systems there has been a shift away from trusting the experts and more toward trusting the opinions of the many.

Just look at the sales figures for the latest summer blockbuster action pic!

Choice Overload

Recommendations play a very big role when we are faced with choice overload. Required to make a decision among 100's or 1000's of similar products with similar features and similar price points where does one begin?

For example, when faced with the seemingly simple task of replacing my broken iPhone 6 case I jumped on in order to make a "quick and easy" purchase. I love my current case and figured I would simply get a similar version.

Well, you can imagine how that went down.

Ninety minutes later I was still browsing through the endless array of case options, features, colors and Amazon recommended accessories. How about a new car charger? Dual USB adapter? Lightning cables ? The list goes on and on! Needless to say, it has been two weeks and I still don't have a replacement case. Maybe I will just keep my old one!

And what do we do when we get really stuck?

If you are like me,  you read the reviews! And it is often here that we make our final purchase decision.

Nowhere is this truer than when PA school admission directors are searching among 1000's of PA school applicants.

CASPA - The Amazon Marketplace for PA School Applicants

CASPA is the Amazon marketplace for PA school applicants. Like trying to find that ideal iPhone 6s case or perfect pair of sound isolating earbuds, PA schools have a need to fill.

They have vacant seats in their PA program and they want to find the best, brightest, financially responsible, capable, compassionate, forward thinking, well-prepared, resilient, like-minded candidates to fill their rosters.

The admissions directors place your application in their cart, click to preview, browse through a couple of pages and then if there is any doubt, they scroll down to read reviews.

Or, in this case, your letters of reference.

Secrets of Successful PA School Letters of Recommendation

What are you looking for in a letter:

It is likely that you will not see your letter, your letter writer is submitting a digital letter of reference.

On the CASPA application there is a page where you will submit the name title and email address of the 3-5 people you will be asking to include letters of recommendation to.

CASPA will send an email to your letter writers indicating that they have been selected to submit a letter of reference on your behalf.

Four guidelines to Letters of Reference for PA School


When gathering your letters of recommendation focus on these 4 traits:

  1. Someone who has known you for some time
  2. Someone who practices in some field of medicine
  3. Someone who has seen how you interact with patients
  4. Someone who supports you as an applicant

Try to pick someone who has known you for some time

It is better to get a letter from someone you have known longer than someone you have known for a shorter period of time.

One of the questions asked of the letter writer is how long have you known the applicant? How well could they assess you if they have met you only once or had you in the office for just 2-3 hours of shadowing?

The most desirable is someone who has been witness to your patient care experience. This could be a physician, PA, NP, DO, etc. who have witnessed you work with patients.

You can use nurses and clinical managers although these references may not be as strong as the former. Ideally they want to see a letter from someone who knows what you are getting into and is enthusiastic about you.

Practices in some field of medicine

If you don't have a lot of healthcare experience this can be a hard one and you may not be able to produce a letter from someone who has seen you working with patients in a clinic.

If this is the case you are going to chose someone who knows you well and can speak to them about a domain that is relevant to the PA profession such as your ability to communicate effectively or your science ability.

Who should your letters of recommendation come from?


There is ideal and there is real, what most of us have to work with is something in-between.
If you have decided to apply even though you don't have a ton of experience your options may be more limited and that is fine.

You work with what you've got. There is ideal and there is real, what most of us have to work with is something in-between.

One Academic Letter from an instructor or professor of a prerequisite science:

  • Someone who taught you one of the "big 5 sciences": anatomy, biology, microbiology, physiology, or chemistry. This is someone who can attest to your academic ability specific to the field of science and medicine.

You definitely need a letter from a medical provider where you have volunteered or worked:

  • A provider is the universal term for an MD, PA, NP, DO or anybody who cares for patients somewhat independently. Of course the ideal letter is going to be from a PA but this is not always possible. When I applied to PA school I did not have a letter from a PA, was this a big deal? I don't know I still got into PA school.

A letter from another provider from another discipline or supervisor in a medical setting:

  1. If you received a letter from a PA in #2 you can choose another provider such as an MD, DO, NP, RN who knows you personally and has seen you work directly with patients.
  2. If you don't have another provider you can choose a clinical director, charge nurse you worked under, volunteer coordinator or direct supervisor.
    1. I received a letter from from the supervisor of the medical records department where I worked. She ended up writing me a wonderful letter. You can see a couple of my letters here.
Summary of Ideal situation

Summary of the ideal situation: 

  • Academic letter + 2 provider letters (ideally one from a PA)
  • Academic letter + provider letter + health care work supervisor

What should they demonstrate? Dependability, honesty, and intellectual curiosity!

How good do your letters of reference need to be?


You want the best letter you can get, you want a letter from someone who glows and raves about you. Why?

Anybody who reads letters of recommendation assumes that they will be writing for you because they believe in you, and letter writers who don't know you well will speak in "glowing" platitudes.

What is a glowing platitude?  A platitude is a remark or statement, especially one with a moral content, that has been used too often to be interesting or thoughtful.

Here are a couple examples:

  • Platitude: Stephen has a positive attitude and works well with others
  • Glowing recommendation: I don't ever remember him saying an unkind or angry word. He is the most positive person I have worked with in my Laboratory Medicine career of 25 years.
  • Platitude: Stephen has a strong worth ethic and has experience working in the healthcare field
  • Glowing recommendation: He works hard, but has a balanced life with leisure activities.  I'm impressed with his career development as a student... working in Healthcare information (1.5 yrs), laboratory (1.5 yrs), and a summer camp with special needs children.  he has since trained as an EMT, has a patent pending for a physical therapy machine, and worked at a Blood Bank center. All of these experiences give him a broad base of knowledge for a healthcare career as a physician assistant.
  • Platitude: I think this person would be a good fit and would be capable of performing the relevant duties.
  • Glowing recommendation: I am really sad to see this person go, but you are so much the better for it because they need to be in this field and I am enthusiastic about them.

Moral of the story:

  • Pick someone who is enthusiastic about you!
  • You want someone who can write well and will take the time to write well about you!

How do you go about getting letters or recommendation?

This can be tough, one way is to scout out early who you may want to write your letter and then do your best to impress.

Are you taking a human anatomy course and have a wonderful professor who you feel could provide an excellent reference?

Then do your best to show up early, attend or lead extra study sessions, create study groups, offer to assist the professor in lab setup or clean up. You don't want to be a "kiss ass" you want to be helpful, show that you are a hard worker, a leader, a dedicated student and make yourself stand out. Then at the end of the course, if all seems well, you can gently ask for a letter of recommendation.

Are you working or volunteering? Well, if you are not you should be. Then be the wonderful person you naturally are. Show up on time, offer to help out wherever you can, don't worry about pay, work for free, or pay them :-), always keep a positive attitude, grab every learning opportunity available... again the goal is not to shmooze, it is to be yourself. I know you are a passionate, caring person who obviously is highly motivated and goal oriented. Don't be afraid to take initiative... After 12 months or more of hard work and effort, the letters will be flowing!


  • We are not looking for good letters we are looking for amazing letters!
  • The letters should shout from the mountain tops that they would be stupid not to take you.
  • Quality of letters almost always trump where they come from, in other words don't get so caught up on the ideal letter writers that you choose a less enthusiastic writer in place of someone who adores you but sits outside the "ideal" category.
  • If you are applying a second time ask for new letters or if you know it was a great letter ask the same references to submit the same letter a second time.
  • Don't ever ask for letters from family!
  • Don't ask for letters based on credentials from people who don't know you well. I have had people ask me for letters after a couple of email exchanges through this website. This is not a quality letter and will not work in your favor. It also makes me extremely suspect as a letter writer.

Answers to common CASPA letters of reference questions (from the CASPA website)

  • Q: What is the difference between an evaluation, letter of reference, and a letter of recommendation?
    • A: Nothing. They are all the same thing.
  • Q: How many evaluations must you enter?
    • A: CASPA requires three letters of reference to be listed on your application in order to submit to CASPA, however, you may list up to five. These must then be completed through the CASPA reference website. CASPA will verify your application as long as two of  your evaluations are completed. Any additional references received by CASPA will be available to your schools immediately once they are completed.
  • Q: How long should the letters be?
    • A: The file uploaded by references may not exceed 5 MB (this is a pretty big file). The Evaluator Portal will not allow references to exceed this file size when uploading their assessment.
  • Q: Can I submit more than five references?
    • A: NO. You may not submit more than five references via CASPA, and CASPA can not accept any additional or substitute letters. However, you may want to contact the schools to which you are applying in inquire as to whether they will accept an additional or substitute letter. If so, you would send this additional letter directly to them.
  • Q: Why can I only have five letters? Why are letters restricted to 5 MB in length?
    • A: Restrictions regarding the length and number of references have been determined by the Physician Assistant Education Association (PAEA) and the CASPA Admissions Committee, which is made up of admissions officers from CASPA participating PA programs. These restrictions reflect the PA programs’ desire to receive concise assessments and allow a certain degree of standardization in the amount of consideration given to each applicant’s reference material.
  • Q: Can I have different evaluations sent to individual programs?
    • A: No. Each evaluation is sent to all programs that you applied to.
  • Q: Can I send letters of reference which are on file at Interfolio or a career center?
    • A: NO. All letters of reference must be completed via the CASPA reference website by the evaluator themselves.
  • Q: Does CASPA accept committee letters?
    • A: If you wish to submit a committee letter to CASPA, it must be a single composite letter written by ONE individual (usually an advisor) who will also complete the ratings section. This single evaluator must be listed on your application with the individual’s name. Do NOT label this letter as being from a group; i.e. “Thesis Committee.” The composite letter and ratings still must be submitted electronically through the CASPA Evaluator Portal, and must consist of ONE composite letter which fits within the  5MB upload limit. Do NOT upload a file containing multiple letters. Please note that a committee letter only counts as ONE letter of reference. CASPA applicants using a committee letter must still submit additional individual references, completed by evaluators who were not involved with the committee letter.
  • Q: What do I do if I want to change the person who is sending the reference or edit the information I entered?
    • A: Even after you submit your application, you may edit, delete, or replace references whose status is still listed as “new” or “incomplete.” Once a reference is “completed,” you may not make changes to that reference, regardless as to whether or not you’ve submitted your application.
  • Q: Can I e-submit my application before my references are received by CASPA?
    • A: Yes. Once you have successfully filled out your application, you can e-submit it to CASPA at any time. However, your application will not be processed until CASPA has received all of your official transcripts, at least two letters of recommendation and your payment.
  • Q: How can I view my letters of reference?
    • A: Even if you have not waived your right to view the reference, you still cannot access the reference via CASPA. If you have not waived the right to view your reference, this means that you may ask your reference for a copy of their recommendation, or, once you matriculate into a PA program, you may view the reference in their offices.
  • Q: Can CASPA forward my references to me, my evaluators, or schools not affiliated with CASPA? (i.e can I see what the reference said about me?)
    • A: NO. As per the Family Educational Rights and Privacy Act of 1974 (FERPA), CASPA may not release letters of reference to anyone other than your designated schools, including other schools or the applicant themselves.

For a complete list please visit the CASPA website - letters of reference

Want to see my letters of recommendation for PA school? 

Physician Assistant Application Letter of Recommendation Samples: Applying to PA School

Here are two letters of recommendation I received when applying for PA school. I am not posting them here as a way to fluff my feathers but merely to serve as an example of what I included as part of my actual PA school application. A great letter of recommendation weighs heavily in your favor, I believe this (and a passion filled essay) is the reason that I, an average student from a state university, was able to receive an acceptance letter over many Ivy league applicants with pedigree backgrounds and 4.0 GPA's. A great letter of recommendation must be earned. It comes when you provide a valuable service with the sole intent of doing your job, or providing your service for the benefit of others...[Read More…]


Physician Assistant Postgraduate Residency and Fellowship Programs The Ultimate Guide

Physician Assistant Residency and Felowship Programs - The PA Life

As a new, or even experienced PA, it is normal to feel uncomfortable with the thought of jumping into a medical specialty.

Often we have had little more than 30 days of training in a particular field, and we are joining a team of specialists who expect us to perform at the level of seasoned doctor.

PA training is generalist in nature with the ability to pick and choose among rotations as a student that may help one gain more experience in a particular field of study prior to graduation.

If you have been practicing in a field for some time and want to change directions, it can be very intimidating.

We want to do right by our patients, providing them with the very best care in all situations. While on the job training is fine and dandy, depending on your practice you may receive a lot or very little hand holding. This can be a setup for occupational success, professional and personal growth or, on the flip side, failure!

To help PAs looking to successfully transition into careers of medical specialty postgraduate PA programs began popping up in the early 1970's. As the profession grows and more and more PAs are entering specialty practice, PA residency programs have adapted to fit our needs.

Over the past four decades the PA postgraduate training movement has slowly expanded, and in 2017 there are more than 84 postgraduate PA programs with 70 of those listed on the Association of Postgraduate PA Programs programs (APPAP) website.

All of these postgraduate training programs also referred to as residencies or fellowships, provide some form of advanced learning in various medical and surgical specialties.

PA Residency Program Accreditation

Unlike PA schools across the country which must undergo a rigorous accreditation process through the ARC-PA, PA residency programs do not require a formal accreditation to exist. Although I think this will change with time, here are the two accrediting bodies:

  • ARC-PA: There are currently only 8 accredited clinical residencies for PAs in the US, listed on ARC-PAs website here. Accreditation is voluntary through ARC-PA and does ensure a certain level of educational standards, but it is not required and offers no current benefit. Since 2014 The ARC-PA has placed the accreditation process for clinical postgraduate PA programs in abeyance while it studies a different type of process to recognize program educational quality.
  • Association of Postgraduate PA Programs (APPAP): At the American Academy of Physician Assistants Convention in Los Angeles in May 1988 a group of postgraduate PA programs met to formalize a national postgraduate PA program organization. Bylaws were written and approved by the eight founding programs and the Association of Postgraduate Physician Assistant Programs (APPAP) was formed to further specialty education for PAs. Programs are not required to be registered with APPAP and certain membership criteria must be met to be eligible. While there are benefits to being registered with APPAP, there are also very expensive membership fees that programs may not wish to spend their money on.

Do not be hesitant if the program you find interesting is not on APPA's or ARC-PA website. In 2017 this says very little about the quality of the postgraduate program.

The Pros and Cons of PA Residency Programs

There are pros and cons to completing a residency program, but it is the decision of each individual PA to choose to participate, which greatly depends on the specialty.

PROS of PA Residency Programs

  • Residency programs allow the physician assistant to gain both clinical and didactic knowledge that would take years of on-the-job training to attain.  It provides a faster paced, formalized training program of supervised practice, which allows physician assistants to be utilized much faster than new graduates.
  • The PA can develop the judgment and technical abilities in a specialized practice area, thus increasing their confidence in their chosen specialties.
  • Many employers give preference to residency-trained physician assistants.
  • Residency programs can be a great way to transition to specialty practice for a mid-career PA looking for a new challenge.
  • It is also recognized that most employers are willing to pay more for a physician assistant who completed a residency program.

Emory University Critical Care Residency

PA Surgical Residency Personal Account
PA Cardiology Residency Personal Account

CONS of PA Residency Programs

  • PAs who jump into specialty without residencies claim you can get paid 2-3 x as much, work less, and learn just as much while getting your training on the job.
  • Even though employers are willing to pay more for a PA who completed a residency, the salary maxes out and becomes equal to those who did not do a residency program.
  • Residency requires more education thus increasing duration of school and structuring the profession more like a physician. Tuition for a Physician Assistant Program is around $78,000 for didactic months and the clinical year. If a student has to take out a loan for $36,000 for two semesters, and, with seven total semesters, our total debt at the end of our physician assistant program is around $126,000. This does not include any interested accumulated. Adding on more expenses and loans for residency programs may put the PA graduate in more debt and leave one with more accumulated interest that is more difficult to pay off in a timely fashion.
  • A negative aspect of employers’ rewarding those who complete residency programs with a larger salary is that it could become mandatory for physician assistants to complete specialty residency training in order to compete for the positions since more applicants may apply for higher paying jobs than lower paying ones.
  • Residencies require more education, therefore delaying those practitioners from entering the clinical setting on a full-time basis. This delay limits the number and availability of physician assistants as mid-level practitioners, exacerbating the lack of health care providers to meet the increasing demands of the population for health care.

As you can see, this can turn into a contentious debate! What do you think, are fellowship programs here to stay?

Cast Your Vote: Are PA Residency Programs a Good Idea?

PA program residency quick facts:

  • What about my loans? You can defer student loans during your residency and some programs offer loan repayment.
  • Do I get paid during my residency? Most residencies provide stipends of 40 - 75 k and require 40-80 hours per week up to 6 days per week.
  • How many hours will I be required to work? The average program length is 12 months but some programs are up to 24 months long.
  • How competitive is the process? 10-30 people interview at each program annually and accept on average 1-4 residents.

PA Residency Program offerings

US Postgraduate PA Residency Programs

Checkout the all new PASchoolfinder Postgraduate PA Residency Guide

Below, is an exhaustive list of US PA postgraduate residency and fellowship programs as of January 2017.

I have added a brand new section for Postgraduate PA residency programs as part of the PA School finder website. You can now search by program and specialty via a geographical search console or use the new interactive perfect match tool.

PA Postgraduate Residency and Fellowship Programs by Specialty (Updated January 2017)

Items in Yellow indicate ARC-PA Accreditation

All links will take you to the official PA postgraduate residency/fellowship website.

Name of Program Location Duration Class Size

Acute Care Medicine PA Residency

University of Missouri Columbia, MO 15 months 2
Carolinas Healthcare System Center Charlotte, NC 12 months 28

Cardiology PA Residency

Mercer-Piedmont Heart Atlanta, GA 12 months 2

Cardiothoracic PA Residency

St. Joseph Mercy Hospital Ypsilanti, MI 12 months 1
Dartmouth-Hitchcock Medical Center Lebanon, NH 12 months 2
Methodist DeBakey Heart and Vascular Center Houston, TX 12 months 2 to 3

Critical Care/Trauma PA Residency

Carolinas Healthcare System Center Charlotte, NC 12 months 28
Intermountain Medical Center Murray, UT 12 months 1
Einstein/Montefiore Division of Critical Care Medicine Bronx, NY 12 months
Emory Critical Care Atlanta, GA 12 months 2
Johns Hopkins Hospital Baltimore, MD 12 months 6
St. Joseph Mercy Hospital Ypsilanti, MI 12 months 1
St. Luke's Hospital Bethlehem, PA 12 months 4
Mayo Clinic Arizona Phoenix, AZ 12 months 1
WakeMed Health and Hospitals Raleigh, NC 12 months 3
Winthrop University Hospital Mineola, NY 12 months 1

Dermatology PA Residency

Medical College of Wisconsin Milwaukee, WI 12 months

Emergency Medicine PA Residency

Albany Medical Center Albany, NY 12 months 5
Albert Einstein Medical Center Philadelphia, PA 18 months 2 or 3
Arrowhead Regional Medical Center Colton, CA 14 months 15
Baylor College of Medicine Houston, TX 12 months 4 to 6
Brown Alpert Medical School Providence, RI 12 months
Carilion Clinic Roanoke, VA 12 months 3
Eastern Virginia Medical School Norfolk, VA 12 months 2 to 4
St. Luke's Hospital Bethlehem, PA 12 months 4
Jane R. Perlman / NorthShore University Health System Evanston, IL 12 months 2
Johns Hopkins - Bayview Hospital Baltimore, MD 18 months 1 every 6 months
Lakeland Regional Health Lakeland, FL 12 months 4
Marquette University - Aurora Health Milwaukee, WI 12 months
University of Missouri Columbia, MO 13 months 2
New York Presbyterian-Weill Cornell Medical Center New York, NY 12 months 4
Regions Hospital St. Paul, MN 18 months 2
Staten Island University Hospital Staten Island, NY 24 months 4
Team Health EMAPC Fellowship Oklahoma City, OK 12 months 2 to 3 every 6 months
University of Iowa Iowa City, IA 18 months
University of New Mexico School of Medicine Albuquerque, NM 18 months 2
UCSF Fresno Fresno, CA 18 months 2
The US Army/ Air Force-Baylor Emergency Medicine Physician Assistant (EMPA) Residency

  • Must be Active Duty Army or Air Force, with a minimum of 4 years (Army) or 2 years (Air Force) active commissioned service as a Physician Assistant.
JBSA Fort Sam Houston, TX 18 months
Yale New Haven Hospital New Haven, CT 18 months 2

Family Medicine PA Residency

Carolinas Healthcare System Charlotte, NC 12 months 28 per cohort, variable
Carilion Clinic Urgent Care and Rural Health Daleville, VA 12 months 2

Geriatric Medicine PA Residency

Michael E. DeBakey VA Medical Center - Houston, Texas - Physician Assistant Post-Graduate Residency in Geriatric Medicine

Houston, TX 12 months


Mayo Clinic Arizona Phoenix, AZ 12 months 1
MD Anderson Cancer Center - The University of Texas Houston, TX 12 months 2-Jan

Hospitalist PA Residency

Carolinas Healthcare System Charlotte, NC 12 months 28 per cohort, variable
Mayo Clinic Arizona Phoenix, AZ 12 months 1
Regions Hospital St. Paul, MN 12 months 1

Internal Medicine PA Residency

Carolinas Healthcare System Charlotte, NC 12 months 28 per cohort, variable

Neonatology PA Residency

Children's Hospital of Philadelphia Philadelphia, PA 12 months 2
University of Kentucky Lexington, KY 12 months 2 to 3

OB-GYN PA Residency

Arrowhead Regional Medical Center Colton, CA 12 months 6
Montefiore Medical Center Bronx, NY 12 months 2

Orthopedic Surgery PA Residency

Arrowhead Orthopedics Redlands, CA 12 months 4 to 6
Carilion Clinic Roanoke, VA 12 months 2
Illinois Bone and Joint Institute Park Ridge, IL 12 months 5 to 7
DMC Orthopaedics and Sports Medicine Warren, MI 12 months 2
UCSF Fresno Fresno, CA 13 months 2
Riverside University Health System Moreno Valley, CA 12 months
Navy PA Graduate Training: Orthopedics - Career military physician assistants Portsmouth, VA 12 months 2-4

Otolaryngology PA Residency

Mayo Clinic Arizona Phoenix, AZ 12 months 2

Pediatrics PA Residency

Carolinas Healthcare System Charlotte, NC 12 months 28 per cohort, variable

Primary Care PA Residency

Shasta Community Health Center Redding, CA 12 months 2-3
North Florida-South Georgia Veterans Health System – University of Florida Physician Assistant Residency in Primary Care Gainesville, FL 12 months
The Emory Physician Assistant Program and The Veterans Atlanta Medical Center (VAMC) Atlanta, GA 12 months

Psychiatry PA Residency

Nationwide Children's Hospital Child and Adolescent Psychiatry PA Program Columbus, OH 12 2
University of Iowa Iowa City, IA 12 2
The Cherokee Mental Health Institute (CMHI) Cherokee, IA 12

Surgery PA Residency

Bassett Healthcare Cooperstown, NY 12 months 2
Duke University Medical Center Durham, NC 12 months Varies
Hartford Healthcare Hartford, CT 12 months 2 to 4
Johns Hopkins Hospital Baltimore, MD 12 months Up to 11
Montefiore Medical Center - Albert Einstein College of Medicine Bronx, NY 14.5 months 5
Norwalk Hospital/Yale Norwalk, CT 12 months 12
Texas Children's Hospital Pediatric Surgery Houston, TX 12 months 6
University of Florida Gainesville, FL 12 months 4
University of Pittsburgh Medical Center Pittsburgh, PA 12 months 2

Urgent Care PA Residency

Carolinas Healthcare System Charlotte, NC 12 months 28 per cohort, variable
Carilion Clinic Urgent Care and Rural Health Daleville, VA 12 months

Urology PA Residency

Carolinas Healthcare System Charlotte, NC 12 months 28 per cohort, variable
UT Southwestern Medical Center Dallas, TX 12 months 1

Other Fellowships

Hepatology Physician Assistant Fellowship - Alexandria, VA
  • Department of Veteran Affairs (VA) - Nationwide, including Puerto Rico (paid)
  • Community Health at Drexel University - Philadelphia, PA (paid)
  • HHS/CDC - Atlanta, GA (unpaid)
  • HHS/NIH - Bethesda, MD (unpaid)
  • HHS/Office of Minority Health - Rockville, MD (unpaid)
Public Health Physician Assistant Fellowship - Atlanta, GA

  • Epidemic Intelligence Service (EIS) - Seeks physician assistants with a master of public health (MPH) or equivalent degree with an interest in public health and a commitment to public service. 2-year full-time program in Atlanta. Applications are accepted in May of each year.

 Gastroenterology Fellowship - Phoenix, AZ

By the Numbers - What do the studies say?

According to this PAEA study:

PA postgraduate residency education provides an important educational vehicle for training graduate PAs in specialty care. A substantial proportion of residents proceed directly from entry-level to postgraduate training. Residents report satisfaction with their programs generally and specifically in terms of knowledge and skills acquired. More information comparing the differences between academic and internship models of residency education is needed as is consideration of greater standardization in program record-keeping and support for research into the longitudinal outcomes associated with postgraduate education.

According to this PAEA study:

Although most students (89.3%) were aware of residency training programs, results indicated that few (7%) had definite plans to attend. Two-thirds of students stated that they received no information on residency training programs at school (journal ads were the most popular information source). Student perceptions of residency training programs were mixed. Their opinions varied according to their program level (p<0.03) and intended region of future practice (p<0.007). Additional significant variables related to student perceptions included student graduation date, age, and gender. However, these factors were not as significant as geographic region of intended practice and degree level.

Discussion: Although only one-third of students reported receiving material or information related to residency training programs from their faculty, two-thirds of faculty respondents stated that they provide students with residency information. Of those providing information, only 32.5% of faculty stated that they actually encourage their students to attend postgraduate training. Like their students, faculty members had mixed positive and negative perceptions of residency training programs

Final Thoughts

Personally, I have mixed feelings about residency programs for PAs.

I see the benefits for PAs, supervising physicians and patients. But, I fear that residency programs may become a requirement rather than an option.

This will lead to increase cost and time in school which is one of the key differentiators of the PA and MD profession.

An alternative model would be very short, inexpensive, 2-3 month programs that would allow PAs to gain valuable experience prior to entering specialty.  I would love a quick ER or orthopedic "refresher" if I were to change specialty at this point in my career. I think programs like this would be very popular. Especially as there seems to be less and less preceptorship to new PAs entering specialty.

Like PA schools, long, expensive programs are probably not the solution. I am curious to see how this all plays out.

Do you have an opinion? I would love to hear in the comments section!

Additional resources and links

  • If you haven't already don't forget to check out my Postgraduate PA Residency Section of the PA SCHOOL FINDER website and the new PA School Match Tool that allows you to narrow down your program search in real time!
  • Residency programs can be competitive and often only have 1-2 available seats per application cycle. We are more than happy to help you with postgraduate application materials/essays through our personal statement collaborative.
  • Do you know of additional residency programs not listed in this table? Let me know in the comments section and I will add them ASAP!

Murmur Madness: The Audio PANCE and PANRE Episode 45

Murmur Madness The Audio PANCE and PANRE Board Review PodcastWelcome to episode 45 of the FREE Audio PANCE and PANRE Physician Assistant Board Review Podcast.

Today we are going to take a brief detour away from 10 daily questions and instead cover the murmurs you need to know for your PANCE and PANRE exam.

I have still included an 11 question exam at the end of this post so make sure you scroll down after you listen to the podcast.

There are a total of 17 cardiac conditions that may present on exam day in the form of a descriptive sound/murmur.

You will often be given supporting evidence such as the location of auscultation or radiation which you can use to narrow down your options.

There are total of 51 cardiac topics in the  NCCPA™ Cardiology PANCE and PANRE Content Blueprint which represents 16% of the PANCE and PANRE exam.

(click here to download the FREE NCCPA Content Blueprint cheat sheet)

These cardiac conditions and their associated murmurs cover a whopping 33% of the cardiology section of the PANCE and PANRE exam!

Take a listen to this week's podcast episode

If you can't see the audio player click here to listen to the full episode.

Let's break this all down:

Each of the links below opens the corresponding lesson on SmartyPANCE and is available to members (you must be logged in or join now)

There are 9 valvular disorders associated with murmurs:

Valvular Disorders (PEARLS and Flashcards)

  1. Aortic stenosis (ReelDx)
  2. Aortic regurgitation (Diastolic Murmur)
  3. Mitral stenosis (Diastolic)
  4. Mitral regurgitation
  5. Mitral valve prolapse
  6. Tricuspid stenosis
  7. Tricuspid regurgitation
  8. Pulmonary stenosis
  9. Pulmonary regurgitation

Five congenital heart diseases that have corresponding murmurs

Congenital Heart Diseases (PEARLS)

  1. Atrial septal defect
  2. Coarctation of the aorta
  3. Patent ductus arteriosus
  4. Tetralogy of Fallot
  5. Ventricular septal defect

One murmur associated with cardiomyopathy

  1. Hypertrophic cardiomyopathy

And a pair of conditions nested under the label of "other forms of heart disease" that have associated murmurs/heart sounds worth mentioning

Other Forms of Heart Disease (PEARLS)

  1. Acute and subacute bacterial endocarditis
  2. Acute pericarditis

Making Sense of Murmurs

Let's start with the valvular disorders:

You have 4 heart valves with two main conditions - half are diastolic murmurs and half are systolic murmurs. Here is a helpful mnemonic:

Recalling Common Systolic Heart Murmurs: MR PASS

  • itral
  • egurgitation
  • hysiologic (also known as functional, systolic flow murmur, a heart murmur heard in the absence of cardiac abnormality)
  • ortic
  • tenosis
  • ystolic - All the above murmurs are heard during systole.

MR PASS wins the Most Valuable Player award.

  • itral
  • alve
  • rolapse - Add MVP as another systolic murmur.

MR PASS often hangs around with MS ARD.

  • itral
  • tenosis
  • ortic
  • egurgitation
  • iastolic - All the above murmurs are heard during diastole.

Here are the nine valvular murmurs and their associated descriptions

Remember which are systolic and diastolic this can be very helpful at ruling out or ruling in a condition come exam day.

  1. Aortic Stenosis - Systolic harsh ejection crescendo decrescendo murmur at RUSB (aortic area) with radiation to the neck and apex
  2. Aortic Regurgitation - diastolic - soft high pitched blowing at LSB with patient sitting leaning forward and exhaling
  3. Mitral stenosis - diastolic - low pitched decrescendo rumbling with opening snap at the APEX (the mitral area) enhanced by expiration
  4. Mitral regurgitation - blowing holosystolic murmur loudest at the APEX (the mitral area) with a split S2 that radiates to the axilla and is increased by squatting, handgrip and expiration
  5. Tricuspid Stenosis - diastolic - mid diastolic rumbling at LLSB (tricuspid area) with opening snap
  6. Tricuspid regurgitation - High pitched holosystolic blowing murmur that radiates to the LSB (tricuspid area)
  7. Pulmonic stenosis - harsh midsystolic ejection crescendo-decrescendo murmur with widely split s2 at LSB that radiates to the left shoulder and neck
  8. Pulmonic regurgitation - diastolic -  high pitched, decrescendo murmur at LUSB increase with inspiration
  9. Mitral valve prolapse - Midsystolic ejection click head best at the APEX (the mitral area)

With these valvular murmurs you have 4 auscultation points which can be easily remembered using the mnemonic APT Ment watch this amazing video so you never forget!

Another helpful mnemonic: Aortic Pulmonic Tricuspid Mitral - ll P hysicians T ake M oney!


  1. Aortic area: right 2nd interspace (Right upper sternal border RUSB)
  2. Pulmonic area: 2nd left interspace (Left upper sternal border LUSB)
  3. Tricuspid area: Left lower sternal border LLSB
  4. Mitral area: APEX

You can use the auscultation point to successfully narrow down your murmur and use the designation of systolic or diastolic to narrow down even further.

Five congenital heart diseases that have corresponding murmurs

Congenital Heart Diseases (PEARLS)

  1. Atrial septal defect - Systolic ejection murmur at 2nd left intercostal space with an early to mid-systolic rumble and fixed splitting of the 2nd heart sound (s2) and CXR will show pulmonary vascular markings.
  2. Coarctation of the aorta - Late systolic ejection murmur-posterior or continuous murmur if collateral flow. Will have absent or weak femoral pulses with a delay of palpable femoral pulse and HTN in arms but low or normal blood pressure in the legs
  3. Patent ductus arteriosus - Continuous, rough, machinery-like murmur, heard best in the first interspaces of the LSB
  4. Tetralogy of Fallot - Harsh systolic ejection murmur heard best at the left sternal border. Associated with bluish skin, trouble gaining weight, and sudden loss of consciousness during crying or feeding
  5. Ventricular septal defect - Harsh high pitched holosystolic murmur heard best at the LSB with ride radiation and a fixed split S2

One murmur associated with cardiomyopathy

  1. Hypertrophic cardiomyopathy - Medium-pitched, mid-systolic murmur that decreases with squatting and increases with straining. S4 gallop and apical lift with thick, stiff left ventricle. HCM is the leading cause of sudden death in athletes and may cause angina.

Several of these conditions have a "tell" that make it easy to identify the condition and they are usually always part of the question stem

  • HOCM Sudden death in athlete
  • Atrial Septal Defect Fixed wide splitting of S2
  • Coarctation of Aorta X-Ray, Rib notching, absent or weak femoral pulses with a delay of palpable femoral pulse and HTN in arms but low or normal blood pressure in the legs.
  • PDA Machine like murmur
  • Tetralogy of Fallot Cyanosis with crying or feeding
  • VSD Holosystolic Murmur

And a pair of conditions nested under the label of "other forms of heart disease" that have associated murmurs/heart sounds worth mentioning

Other Forms of Heart Disease (PEARLS)

  1. Acute and subacute bacterial endocarditis  - A new mitral regurgitant murmur in a patient with a history of IVDA, fever (39.0º C),* and a blood culture that reveals 2 out of 2 positive growth
  2. Acute pericarditis - Although this is not a murmur, it is important to identify a pericardial friction rub heard best with patient upright and leaning forward. Chest pain is also relieved by sitting and/or leaning forward

You can listen to all these murmurs and see their associated waveforms at

Here is a wonderful video from the Khan Academy of how to approach murmurs video of murmurs

Murmur Flash Cards

Episode 45 PANCE and PANRE Murmur Quiz

You will see from these questions on the PANCE and PANRE things aren't always so straightforward.

Congratulations - you have completed Murmur Madness. You scored %%SCORE%% out of %%TOTAL%%. Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Shaded items are complete.

Looking for all the podcast episodes?

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ReelDx is now part of SmartyPANCE!

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If you want ReelDx just sign up on SmartyPANCE - It's just a $10 upgrade!  You can Sign up HERE

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  1. iTunes: The Audio PANCE AND PANRE Podcast iTunes
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Does PA Program length matter?


In 2004 I graduated from the UMDNJ (now Rutgers) PA program.

It was a three-year PA program with a nearly 100% PANCE pass rate.  At the time, Rutgers was one of the best ranked PA schools in America and they continue to rank among the top 25 PA schools in the country.

As an avid practitioner of the confirmation bias I fell victim to the "more is better" principal and figured that my 3 year PA school program naturally must provide a more  comprehensive education.  Why else extend the length of a program?

But a recent article published by the PAEA in the Journal of Physician Assistant Education provides a more scientific answer to this question.

Does a longer PA program have any advantage over a standard two-year program?

In March of 2016 the PAEA published this research article examining the relationship between physician assistant educational program length and PA programs' 5-year  average PANCE first time pass rates.

Relationship Between Physician Assistant Program Length and Physician Assistant National Certifying Examination Pass Rates

Fifty years ago Duke University graduated the first class of physician assistants as part of a two-year program whose goal was to rapidly deploy these clinicians to assist physicians in delivering medical care.

During the past two decades, the PA program length has increased to an average of 26 months, with some programs spanning 36 months.

The longer programs were developed to accommodate the extra time needed to complete a master's program senior project.

The "more is better" attitude has some negative consequences including

  • Increased student debt
  • Delayed entry of qualified clinicians into the health care system at a time of practitioner shortage

As longer program became more common, some medical educators questioned whether 2 years was an appropriate length of time to train PAs, especially in light of their expanding scope of practice and the decrease in pre-pa school medical experience which defined the previous generation of PAs.

Since we PAs need to pass the PANCE exam to be eligible to practice and the fact that this is an indicator of entry-level clinical competence, there is an obvious advantage to knowing whether a longer length of training is associated with higher PANCE pass rates.

Time is of the Essence

The Association of American Medical Colleges predicted a shortage of more than 60,000 physicians in 2015, and a shortage of twice as many by 2025.

The PA field is experiencing rapid growth and increased demands.

The Bureau of Labor Statistics has predicted a 30% increase in demand for PAs over the next decade, a much faster than average rate of growth.

In response to the shortage of physicians and the increased demand for PAs, institutions of higher education have recognized the imminent need for more PA graduates.

Encouraged by the high rating of career potential for the profession, these institutions have initiated the development of many new programs.

As of October 2016, there 218 accredited programs (153 with continuing accreditation), with even more applying for provisional accreditation (46 schools) in the United States.

There are also a number of established and developing PA programs in other countries.


Do longer PA programs lead to greater levels of PA competence?

Successful PANCE passage suggests PA graduate competency.

If study results indicated that shorter PA programs prepared students to pass the PANCE as well as longer programs do, then educators might have the incentive to structure shorter programs.

Reducing the length of training while maintaining competent graduates would help to reduce PA student debt, ease clinical site competition, and more expeditiously deploy PA graduates into the health care workforce.

Relationship Between Program Length and PANCE Pass Rates


Median total PA program length is 27 months, with total program length ranging from a minimum of 24 to a maximum of 36 months.

  • Median program's 5-year average first-time PANCE pass rate was 95%.
  • Program PANCE pass rates ranged from a minimum of 73% to a maximum of 100%.

Data on individual phase length (didactic and clinical phase) of programs

  • Median length of the didactic phase was 13 months, with a minimum of 10 and a maximum of 22 months.
  • Median length of the clinical phase was 12 months, with a minimum of 10 and a maximum of 24 months.

Program phase length and PANCE pass rates demonstrated no significant relationship for the didactic phase, and no significant relationship for the clinical phase


Medicine is an ever-changing field that continues to grow in both volume and complexity.

As a result, the amount of information and skills that a PA student must master has become burdensome; this information overload may prompt PA educators to consider lengthening the educational process.

Although increasing the number of PAs graduating each year will help to partially mitigate the physician shortage, the effects of longer length programs on students and educational institutions must be considered.

There are several considerations regarding longer educational programs:

  1. Competition is increased for clinical sites because more new programs are being developed and longer programs require additional clinical training sites
  2. There is an inadequate number of experienced PA faculty to cover the required coursework needed for a longer curriculum
  3. Students incur increased tuition debt, which can exceed $100,000 at private universities. This expense may prompt PA graduates to opt for more lucrative careers in specialty medicine and forego the primary care field where the greatest need exists.
    • It is predicted that only 16% of new PA graduates will fill primary care positions by 2025!

How about shorter Medical School?

In a similar manner, it has been suggested that streamlining medical education for physicians and shortening the length of training would lower student tuition debt and focus attention on team-based medicine.

Several medical schools already offer shorter programs. Although there are limited outcome data on graduates of these schools, there is no evidence that they perform poorly on board examinations.

The authors of the study call for a 30% reduction in medical education length by 2020.

The Results


Study analysis indicated no relationship between total program length or individual didactic or clinical phase length and PA program's average PANCE pass rates.

The implications of this study suggest that shorter PA programs prepare students to pass the PANCE and enter the workforce as effectively as longer programs.

With the anticipated rapid growth of PA programs, these results could influence established and developing program directors' decisions on determining program length.

Since the current average program length is 26 months, program directors may feel the need to replicate this curriculum model; however, as noted, there are drawbacks to longer programs.

Longer PA programs are associated with:

  • increased institutional costs
  • increased demand for faculty
  • increased student debt
  • a delay in deploying clinicians into the workforce
  • increased institutional costs for faculty, advisor, and staff support
  • additional classroom space
  • an additional semester of preceptor stipends for scarce clinical experiential practice rotations

Not to mention, students in longer programs will accrue additional fees as well as housing, transportation, and tuition costs for each additional semester

Owing to clinical site shortages, many programs are now paying for clinical rotations, increasing the cost of operating the program.

Final thoughts

Since grading and joining the workforce, I have had the had the opportunity to work alongside dozens of competent, highly skilled, compassionate, hard-working, and dedicated PAs, most of whom attended 27 month programs.

Each one of them is proof positive that my superiority complex was completely unwarranted.

This article proves my growing suspicions that longer PA programs offer no real benefit with evidence to suggest longer programs have unwanted side effects such as increased student debt, a strain on faculty, institutions, and rotation sites.

The downstream consequences of increased PA school debt are pushing more and more new PA school graduates into specialty practice based on financial necessity.

While I admit PANCE pass rates are not the best predictor of professional acumen my anecdotal evidence supports the research provided in this study.

Also, I completely agree with the authors who support a 30% reduction in medical school education.

In many parts of the world the medical school didactic phase is combined with a two-year undergraduate program resulting in a much shorter and highly focused medical education. Often just five years. This would bring many new applicants (many who currently are on the PA school track) into the role of supervising physician.

Technological advances can not be ignored and will be a huge factor in augmenting and automating our medical knowledge allowing for greater ease of providing  real-time evidence based medicine using the most up to date clinical guidelines without the need to memorize and ever growing web of medical data.

Using knowledge from studies like these along with tools to gather, collect and digest big data we can work together to maintain a highly skilled compassionate medical workforce while decreasing student debt, reducing medical error and driving down healthcare costs.

PAs will continue to be at the forefront of this transition for years to come.

Resources: The Journal of Physician Assistant Education: March 2016 - Volume 27 - Issue 1 - p 3–6

The PANCE and PANRE Content Blueprint Checklist

pance-and-panre-nccpa-content-blueprintYour Blueprint to Success Starts Here!

If you are at all like me the hardest part of studying for your PANCE or PANRE is figuring out where to begin.

There is an ever growing list of review books, podcasts, online programs, in-person review courses, and anecdotal recommendations to choose from.

It is overwhelming!

So the key to success is to choose one or two, set a study schedule and STICK WITH IT!

The NCCPA is kind enough to provide us with a list of topics that will be on the exam in the form of the NCCPA™ Content Blueprint.

They do not deviate from this list of topics. Sometimes their questions are frustratingly complex or convoluted for sure, but, it is a safe bet that if you know the key terms from each of these topics you will pass your exam.

The take home message from the NCCPA is clear: follow the blueprint and your success is guaranteed, but who has time to review and memorize 467 diseases?

The NCCPA™ Content Blueprint Breakdown

  1. Cardiology 16% - 51 topics (diseases)
  2. Pulmonary 12% - 32 topics (diseases)
  3. GI and Nutrition 10% - 41 topics (diseases)
  4. Musculoskeletal 10% - 39 topics (diseases)
  5. ENT 9% - 57 topics (diseases)
  6. Reproductive 8% - 46 topics (diseases)
  7. Genitourinary 6% - 30 topics (diseases)
  8. Neurology 5% - 27 topics (diseases)
  9. Endocrinology 6% - 18 topics (diseases)
  10. Psychiatry 6% - 26 topics (diseases)
  11. Dermatology 5% - 45 topics (diseases)
  12. Hematology 3% - 18 topics (diseases)
  13. Infectious Disease 3% - 35 topics (diseases)

Total: 13 organ systems and 467 topics (diseases)

Some topics are very narrow such as viral croup, other topics are extremely broad such as normal labor and delivery... I mean seriously how do you even begin to wrap your head around this one?

To simplify this process, I am providing you with this interactive content blueprint checklist.

I have also been compiling pearls sets with flashcards to help simplify the review process and help you hone in on the questions stems that should help guide you to the correct answer.

Print it up and start crossing out the topics you understand, marking the ones you don't and making notes of key terms you should remember. The PDF version is interactive and linked directly to the individual lessons on SMARTY PANCE.

Follow this link to download your FREE copy of the Content Blueprint Checklist


FREE Download

This is a completely interactive checklist and unlike a static book I have created a searchable online index of the entire content blueprint as part of the Smarty PANCE/PANCE board review website.

The checklist links to each of these 467 topics, members can simply click on a topic to explore it further.

Also included are 13 topic specific content blueprint exams available to all members, as well as a slough of other exams and review material.

Members of both the PANCE and PANRE Academy and Smarty PANCE receive access to both sites with a single login... Cool!

If you are interested in becoming a member you can sign up here (The PANCE and PANRE Academy) or here (Smarty PANCE + ReelDx)

If you have any questions or need help along the way don't hesitate to drop me a line or leave me a message in the comments.


Stephen Pasquini PA-C

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