Delivering High-Quality Primary Care Requires Work That Is Worthwhile for Medical Assistants

Higher Pay Is Not Enough

Because MAs are low-wage workers—their median annual hourly wage in 2020 was $17.23—conventional efforts to retain them may have centered on pay incentives.¹⁶ Pay is important; consider what an MA shared as part of a qualitative study on what MAs value at work⁴:

I had a coworker who is now working at a bar across the way here. She's a medical assistant and she's making more at a bar than she was in an office (primary care practice). So why come back? Unless it was a calling or career, and not just a job.

However, their pay only tells a part of the story. MAs also value using their clinical skills and building meaningful relationships with patients and coworkers.⁴ In fact, subsequent research reveals that having meaningful relationships at work is a more important predictor of an MA’s intention to stay than pay. (manuscript in preparation) Furthermore, while MAs are trained to support clinical and administrative tasks, it is the clinical component that makes their work particularly meaningful.⁴

What Makes Work Worthwhile?

To establish what makes work worthwhile to MAs, we draw on 3 frameworks from the capability approach (in studies on sustainable employability),^15,17 Good Jobs Institute,¹⁸ and Great Jobs Study¹⁹ to distill the following components: adequate pay, benefits, job security, as well as a sense of contribution, growth, social connectedness, and autonomy (see Table 1). These frameworks are grounded in theories used in psychological, occupational, and organization studies and are supported by empirical data. For example, the Good Jobs Institute uses extant theorizing on employee motivation, employee engagement, and work design,²⁰ and the Great Jobs Study was based on a sample of more than 6600 US workers.¹⁹ Collectively, these frameworks reveal that a continuous focus on employee development and the social relationships employees have with others (ie, coworkers and patients) are important for keeping workers engaged.^21,22

What Makes Work Worthwhile for MAs?

Competitive pay and benefits form the foundation of work that is worthwhile for MAs, and health care organizations need to calibrate their compensation packages both within and outside the health care industry. Within the health care industry, the American Association of Medical Assistants has released a national report on MA compensation trends based on region, setting, and specialty that can be used for benchmarking.²³ Because MAs are less “restricted” to working in health care than occupations with higher educational requirements, our research shows they use retail chains such as Target to benchmark their pay.⁴ As non–health care companies change their compensation strategies—Target recently announced a raise in minimum wage to range from $15 to $24 per hour with additional health care benefits—so should health care organizations.²⁴ Failing to do so will likely result in MAs moving into other industries that are seen as viable alternatives.

Matching pay and benefits with non–health care companies is important but not sufficient. For health care organizations to outcompete alternative careers, they must further consider MA contribution, growth, social connectedness, and autonomy and pay attention to huddling, rooming, and career development, which we describe below.

Redesigning Huddles, Patient Rooming, and Career Development

Huddles allow members of the primary care team to discuss patients and anticipate their care needs for a given day and, consequently, lead primary care team members to experience better teamwork and more supportive organizational climates.²⁵ Certain parts of the huddling process can be designed for MAs to play an active role to enable a sense of contribution. For example, MAs can be tasked to flag patients that are behind on screening or vaccination efforts ahead of appointments. MAs can also be invited to contribute meaningful information about patients because they can often connect with patients in a different capacity than other clinicians/staff and therefore uncover unique and relevant information, such as the specific needs of minority populations or housing and transport issues.^4,26,27

The rooming of patients also enables a sense of contribution as MAs can use their clinical skills and knowledge (eg, answering patients’ questions about blood pressure).⁴ Moreover, rooming allows MAs to have direct patient interaction, which enables social connectedness. Pairing MAs with a clinician (ie, the “teamlet” model) and colocating them in the clinic will be beneficial, because it creates systemic opportunities for MAs to provide input while receiving appreciation for their contributions at work.^28,29 Furthermore, regular check-ins between clinicians and MA teamlets to exchange work-related resources such as information or advice to enable work, or interpersonal-related resources such as social support and friendship, will enhance social connectedness.²¹

A strategy to foster a sense of growth among MAs is to help them develop new clinical competencies, in line with evidence on how MAs value using their clinical skills at work.⁴ Health care organizations can align additional clinical training with desired health outcomes for their patient population, such as training MAs as health coaches to facilitate hypertension or diabetes control among patients.³⁰ Over time, as health care organizations gain insight into additional MA competencies that they value, they can also proactively communicate with vocational schools and training programs to ensure that the graduates leave with the required skills.^4,31 For this strategy to succeed, however, a key consideration is whether the new clinical competencies being developed are in line with existing scope-of-practice regulations for MAs, which vary across states and organizations.^31,32

To systematize the development of new competencies, health care organizations can also consider creating career-development programs for MAs to enhance their clinical, educational, and/or administrative skills.³³ MAs can grow in several areas, including panel management and care coordination, documentation support for electronic health record systems, clinical support for patient-centered care delivery, and/or supervision and training of other MAs (see Dill et al³³ for case study examples). While MA career-development programs are nascent, organizations are encouraging career growth by allowing MAs to attend conferences, enroll in university courses, or become a champion for infection control or employee engagement.³⁴ These career-development programs can result in pay increases ranging from $3,000 to $10,000, which are aligned with the competitive pay and benefits components of making work worthwhile.³³

Emerging evidence suggests that MAs do not emphasize the importance of autonomy at work, plausibly because of the norm of seeing their work as primarily providing “assistance.”⁴ However, MAs should have some latitude to make certain decisions on how they approach their work, shape their working conditions to align with their needs and those of the clinic, or set their own work and career goals to make work more worthwhile.³⁵ Because rooming typically comprises the MA and patient only, MAs can be given latitude to decide on the sequence and timing of task performance (eg, taking vital signs, documenting main concerns for visit, reviewing preventive health activities, asking patients for changes in medication intake) as long as they do not interfere with the clinic’s established workflow. Autonomy is experienced when, for example, MAs can articulate their preferred workflows for rooming and have them accepted as part of operational routines. Separately, career development is an area in which MAs can exercise autonomy—building on the examples above, MAs can choose which conference or course they want to attend or which clinic/quality improvement project team they want to join. Fostering autonomy in MA work can be achieved in various ways, but it remains crucial to balance what is beneficial for an individual MA as well as the clinic.

A Multiplier Effect among the Components That Make MAs’ Work Worthwhile

There is a potential multiplier effect among contribution, growth, social connectedness, and autonomy as MAs experience these components. Over time, as MAs get to contribute more toward patient care or population health,³⁶ get to grow more in their career,³³ and/or get to connect more with coworkers and patients in the workplace,²¹ they are likely to become better at recognizing the value of their roles in primary care and/or building self-efficacy.³⁷ In turn, MAs may become more autonomous in seeking out opportunities to contribute, grow, and connect. Alternatively, in growing their careers through courses, conferences, or new quality improvement projects, MAs may become more adept at connecting with others in the occupation or field of primary care and acquire new knowledge that can in turn contribute toward patient care or population health.

The Role of Clinic Managers and Supervising Clinicians

Clinic managers and supervising clinicians have an important role in providing and enabling the components that make work worthwhile for MAs. They do so in at least 2 ways: directly through their decision-making and indirectly through their influence on organizational climate. Clinic managers and supervising clinicians are often in positions to make decisions about MA work (eg, salaries, workflows, career-development opportunities), and they can therefore promote MA work to be worthwhile. Furthermore, they can advocate for any role expansion through huddling, rooming, or professional development to be commensurate with increases in salary. In addition, clinic managers and supervising clinicians can foster organization climates where MAs feel capable of voicing issues, appreciated as a member of the team, and recognized as a member of the MA occupation.^2,4 This is especially because MAs have historically been neglected as an occupational group, so strategies are needed to let MAs become more “visible” or feel safe when speaking up.^4,38 For example, studies have shown that high-performing primary care clinics engage in norms whereby team members who dominate discussions are asked to “step back,” while those who have yet to contribute to “step up.”²⁹

Figure 2 encapsulates the discussion above while adapting from the work design literature.³⁹ Defined as “the content and organization of one’s work tasks, activities, relationships, and responsibilities,” work design is concerned with how work is achieved as well as the improvement of job quality and working environments of workers.⁴⁰ In this diagram, the components that make work worthwhile to MAs are in the center, with the multiplier effect highlighted among contribution, growth, social connectedness, and autonomy. The roles of clinic managers and supervising clinicians are reflected at the top—with a combination of their knowledge, skills, abilities, motivation, and opportunity, they can enable work components through decision-making or resource allocation and the creation of supportive organizational climates. A weaker path to enabling these components is through the individual behaviors of MAs themselves—the bottom of the diagram indicates how MAs may achieve the components, such as through negotiation, voicing needs, or volunteering. Although this diagram shows both top-down and bottom-up processes, research indicates that work design is more heavily influenced by managers.³⁹

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Figure 2.

Schematic diagram of components that make work worthwhile to medical assistants and their surrounding processes. Adapted from Parker SK, Van den Broeck A, Holman D. Work design influences: a synthesis of multilevel factors that affect the design of jobs. Academy of Management Annals 2017;11(1):267–308.