Physician assistants (PAs) and nurse practitioners (NPs) are skilled medical professionals who play an integral part in healthcare delivery. Especially in primary care, PAs and NPs attract and manage a significant following of patients, often in rural communities. Recruitment is challenging in more underserved areas; however, retention is often more important as practices and patients invest in an individual with the hope that they will stay and practice for a considerable amount of time. In my experience in rural North Carolina, it took me more than a year in my first job to attract some patients to our practice. They were afraid to "like me too much" for fear I would leave town and move on to another opportunity. A recent 2011 Physician Retention Survey by the American Group Medical Association (AGMA) shows that the turnover rate for nurse practitioners and physician assistants is 12.6 percent, more than twice the combined, adjusted physician turnover rate of 6 percent. So how do you find AND keep a great PA/NP? I like to summarize with the 3-A approach: Attract I have often said primary care was in my blood. As a student, I was reprimanded on the cardiology service for worrying about a patient's mammogram. Obviously a PA or NP who is passionate about your clinical need is important. Highlighting the type of duties you need performed as well as the type of patient population is critical to the messaging. For example, don't just say "family practice PA/NP wanted in XYZtown, NC." Instead, say: "Dynamic PA/NP wanted for charming, rural underserved area in XYZ, NC. Interested providers will be responsible for healthcare delivery to an appreciative population that has limited resources. Medicare and Medicaid credentialing are a must." Get the picture? Suburban, rural and smaller practices all have the same complaint: They cannot recruit to their area because they cannot pay as much in salary as their competition. However, often these groups are missing the mark as they may qualify for loan repayment within the state, or they might offer flexibility within a clinical work schedule that the provider appreciates. For example, if a PA/NP lives in town where he/she works, it might be agreeable that the provider can leave at 3 p.m. to pick up a child from school and then come back to wrap up the clinical day. Such flexibility is not easily achievable in a larger hospital or health system. Highlighting those "extras" will be important as you list all the reasons why your office is a great place to work. Advance Levels of clinical autonomy will be variable depending on the clinical experience of the PA/NP. New graduates will require additional supervision and training as their clinical judgment grows. Seasoned practitioners may be looking for ways to advance their knowledge and career direction. Often, creative thinking helps in promoting the experienced practitioner within the group. With the advent of Patient-Centered Medical Homes (PCMH) and meaningful use attestation through quality assurance, there are a host of new avenues to explore for PA/NP leadership. As practices explore the shift from volume of patients to value in patient population management, there are additional opportunities for PAs and NPs to take a central role in the incorporation of electronic technology through the electronic health record (EHR). Care delivery is changing, and PAs and NPs as team members can be a clinical "go-to" as changes are initiated. Affirm Merriam-Webster defines affirm as "stating clearly and strongly." Often, PAs and NPs will leave a position if they feel their contributions are not valued. This is referencing not only patient care decisions, but also decisions related to work environment or technology. For example, if the physician does not support the PA/NP care rendered to a patient publicly, or if they do not advocate for the PA/NP within the medical community, these are flags of incomplete acceptance and lack of full incorporation into the team. Recognition is individual and personal to every PA/NP. Some may prefer a public acknowledgement at a staff meeting, while others may greater appreciate a personal note or face-to-face meeting. Supervisors and practice managers should have processes in place to assess communication styles and play to team strengths. It's not always about the money Often, individuals leave a position for reasons that are not financial. Being mindful of the 3-A approach will foster improved communication and result in improved retention of your medical staff. Genuine acknowledgement of value and contribution goes a long way to foster loyalty to the practice and the group and, ultimately, to the patients we serve. References Managing turnover rates key to collaborative care