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Education: Higher Education

The Physician Assistant Profession: Reflections on Its Past, Present, and Future

Class 1: Physician Assistants, a Human Resource Innovation in the Practice of Medicine

Introduction

The physician assistant (PA) profession emerged in the 1960s in response to a growing demand for health care services that could not be met by a medical profession that was, at that time, in short supply and maldistributed, both geographically and by specialty. After World War II, dramatic changes occurred in the way American medicine was practiced and financed. With the proliferation of new medical technologies and clinical knowledge, there was a shift from office-based to hospital-based care and from generalist to specialist care in many regions of the country. Health Maintenance Organizations (HMOs) created more efficient models of care and federally funded community health centers provided care to medically underserved populations. Despite these changes, many communities still lacked access to primary care services. Employer-provided health insurance became the preferred means to cover the rising cost of health care. These forces, along with growing social unrest, led to the enactment of Medicare and Medicaid legislation in 1965, thereby providing the elderly and the poor with some health insurance coverage. The demand for health care and its costs skyrocketed, producing a crisis in the United States. Given the lengthy process associated with physician education, producing more physicians would not solve the immediate crisis, and it would be very expensive. Innovative, non-traditional solutions were needed. Could some medical tasks that traditionally had been performed only by physicians be delegated to new types of clinical support personnel?

The PA profession emerged out of the social, political, and professional milieu of the 1960s and 1970s, as an innovative solution that first relied upon an untapped source of trained health care workers: former military corpsmen. Large numbers of them returning from Vietnam were highly skilled but had no ready entry into a similar position in the civilian sector. Federal, foundation, and other private funding gave priority to the education of PAs as generalists to work in primary care settings, especially in medically underserved communities. In addition, PA programs were incentivized by these financial supporters to provide equal opportunities for women and underrepresented groups.

A multitude of legal and regulatory issues had to be addressed. The American Medical Association and the National Board of Medical Examiners took the lead in establishing processes for accreditation and certification of PAs that allowed flexibility in training and continued growth of clinical knowledge and skills. Instead of separate licensure acts, a team of lawyers and physicians designed model legislation to amend state medical practice acts to allow PAs to practice under physician supervision. Many states’ boards of medical examiners became involved in regulating PA practice. These innovative approaches to program accreditation, national certification, and state regulation have insured quality educational standards and public accountability.

Accordingly, the supervising physician and PA were authorized to define the PA’s scope of practice on a case by case basis. This flexibility allowed the supervising physician to expand the PA’s scope of practice as the PA gained more knowledge and skills, thereby providing opportunities for professional growth. The inherent flexibility of the process of negotiated autonomy, along with the standardized approach to training and certification are unique attributes of the PA profession that have allowed PAs to be integrated into all aspects of American health care.

A consensus regarding the formal name for the new profession gradually emerged during this same period. Some used the term “MEDEX” (Med-icine Ex-tension), and others placed an apostrophe after physician, referring to these new professionals as “physician’s assistants.” The Duke University PA program adopted the term “physician associate” to distinguish its’ two-year university-based program from other less structured, on-the-job training programs that were emerging and using the term “physician assistant” generically. The leaders of university-based programs established the American Registry of Physicians’ Associates to register graduates from their Type A physician associate programs designated by the National Academy of Sciences in 1970. The “Type A,” “Type B,” and “Type C” terminology used by the National Academy of Sciences was later abolished when universal accreditation and certification standards were established for the PA profession and endorsed by the American Medical Association. The Johns Hopkins University developed a program in the 1970s and 1980s to train PAs and called its graduates “Health Associates.” During the same period, the University of Colorado developed a Child Health Associate Program. However, during the 1980s and early 1990s, a consensus emerged around the term “physician assistant” or PA, which remains at present.

Suggested class outline:

  1. Problems in the health care division of labor
    1. Reasons for rigidity in the health care workforce
    2. The health care workforce crisis of the 1960s and 1970s
    3. Decline in the number of general practitioners as a result of growing medical specialization
  2. Pressures and opportunities in the 1960s and 1970s
    1. Solutions being proposed
    2. Constraints imposed by physicians, nurses, and the public
    3. New technology creating new jobs and functions for the heath workforce
    4. The PA as a solution
  3. Emergence of a consensus on the role and function of PAs and the legal foundation for their practices
    1. Early versions of PAs, role delineation studies, and efforts to define the PA role
    2. Innovation "on the margin": the emergence of physician delegation of heretofore “physician-only” medical tasks
    3. Political, legal, and social issues, and the creation of a legal framework for PA practice in a fuzzy and sometimes hostile environment
    4. The idea of “autonomy” and “negotiated autonomy” for PAs and other legally dependent providers
    5. Development of PA role delineation within emerging standardization of medical practice
Class Resources
Core resources
  • American Academy of Physician Assistants. “History of the PA Profession.” YouTube video, 5:53. Posted June 13, 2013. https://www.youtube.com/watch?v=iuxUNDW7wBg.
  • Carter, Reginald D. “Sociocultural Origins of the PA Profession.” Journal of the American Academy of Physician Assistants 5, no. 9 (1992): 655–662.
  • Holt, Natalie. “Confusion’s Masterpiece: The Development of the Physician Assistant Profession.” Bulletin of the History of Medicine 72, no. 2 (1998): 246–278. https://muse.jhu.edu/journals/bulletin_of_the_history_of_medicine/v072/72.2holt.html (accessed 10/7/2016).
  • Hudson, Charles. “Expansion of Medical Professional Services with Nonprofessional Personnel.” Journal of the American Medical Association 176, no. 10 (1961): 839–841. doi:10.1001/jama.1961.03040230005002.
  • Sadler, Alfred M., Blair L. Sadler, and Ann A. Bliss. The Physician’s Assistant: Today and Tomorrow. 2nd ed. Cambridge, MA: Ballinger Publishing Company, 1975. http://pahx.org/pdf/SadlerSadlerBliss2ndEd.pdf (accessed 10/7/2016).
Supplemental resources
  • Carter, Reginald D., and Thomas Clark. “Amos Johnson, MD and Mr. Henry Lee “Buddy” Treadwell: A Prototypical MD/PA Practice.” Physician Assistant History Society. http://pahx.org/pdf/BuddyTreadwell.pdf (accessed 10/7/2016).
  • Cawley, James F., Elisabeth Cawthorn, and R. S. Hooker. “Origins of the Physician Assistant Movement in the United States.” Journal of the American Academy of Physician Assistants 25, no. 12 (2012): 36–40.
  • Estes, E. H. and Reginald D. Carter. “Accommodating a New Medical Profession: The History of Physician Assistant Regulatory Legislation in North Carolina.” North Carolina Medical Journal 66, no. 2 (2005): 103–107.
  • Kress, Laura M. “Let’s Look at the PA, A New Member of the Health Team [1971].” PA-0199, MEDSpace Digital Repository. Duke University Medical Library. https://medspace.mc.duke.edu/lets-look-pa-new-member-health-team (accessed 10/7/2016).
  • Lawrence, D., Wilson, W. M. Castle, and C. H. Castle. “Employment of MEDEX Graduates and Trainees: Five-Year Progress Report for the United States.” Journal of the American Medical Association 234, no. 2 (1975): 174–177.
  • Lee, P. R. “New Demands for Medical Manpower.” Journal of the American Medical Association 198, no. 10 (1966): 1091–1093. doi:10.1001/jama.1966.03110230107023.
  • National Academy of Sciences. “New Members of the Physician’s Health Team: Physician’s Assistants [May 13, 1970].” PA-0004, MEDSpace Digital Repository. Duke University Medical Library. https://medspace.mc.duke.edu/new-members-physicians-health-team-physicians-assistants (accessed 10/7/2016).
  • Physician Assistant History Society. “Charles L. Hudson, MD.” September 12, 2007. http://pahx.org/hudson-charles-l (accessed 10/7/2016).
  • ———. “Henry K. Silver, MD.” http://pahx.org/silver-henry-k (accessed 10/7/2016).
  • ———. “Richard A. Smith, MD, MPH.” http://pahx.org/smith-richard (accessed 10/7/2016).
  • ———. “Eugene A. Stead, Jr., MD.” http://pahx.org/stead-jr-eugene (accessed 10/7/2016).
  • Physician’s Assistant Program, Duke University. “A Resume of Proceedings of the Conference on Legal Status of Physician’s Assistants [October 26, 1969].” PA-0310, MEDSpace Digital Repository. Duke University Medical Library. https://medspace.mc.duke.edu/resume-proceedings-conference-legal-status-physicians-assistants (accessed 10/7/2016).
  • Schneller, E. S. “The Design and Evolution of the Physician’s Assistant.” Work and Occupations 3, no. 4 (November 1976): 455–478. doi:10.1177/009392857634004.
  • Smith, R. A. “MEDEX— An Operational and Replicated Manpower Program: Increasing the Delivery of Health Services.” American Journal of Public Health 62, no. 12 (1972): 1563–1565. //www.ncbi.nlm.nih.gov/pmc/articles/PMC1530549/ (accessed 10/7/2016).
  • Stead, E. A., Jr. “Conserving Costly Talents–Providing Physician’s New Assistants.” Journal of the American Medical Association 198, no. 10 (1966): 182–183. doi:10.1001/jama.1966.03110230124028.
Discussion Questions
  1. What factors in post-World War II America contributed and led to a health care crisis in the 1960s? How did civil unrest help shape health care policy and change Americans’ views about access to health care services?
  2. How did Dr. Amos Johnson’s solution to meet the growing demands for his general medicine practice become codified into national policy? What were the legal and professional limitations of this model becoming a long-term solution for America’s health care needs?
  3. Why were leaders of organized nursing reluctant at first to expand the clinical knowledge and skills of nurses in the 1950s and 1960s, thereby providing an opportunity for former military corpsmen to be formally educated and to work as PAs in the mid-1960s? What are examples of successful nurse practitioner programs, and examples of how nurse practitioners and PAs have worked effectively together in clinical settings?
  4. Why was it important for the American Medical Association (AMA) and the National Board of Medical Examiners (NBME) to be involved in establishing the framework for the PA profession? What were the pressing issues for the AMA that had to be resolved as the PA concept developed?
  5. Three educational models originated in the 1960s: the two-year academic model to educate PAs at Duke University, the two-year Child Health Associate model at the University of Colorado, and the 18-month community-based model to educate MEDEX at the University of Washington. How were these models similar and different in philosophy and in practice?
  6. What steps did different organizations, associations, and people take to establish a system of accreditation for PA programs and to develop a uniformed national examination for PA graduates?
  7. Looking more broadly at the concept of “professions” in societies, what is the nature of work we define as professional work? What are the characteristics of a profession, and what is the process by which such a status is achieved?
  8. What is professional autonomy? Why did the term “negotiated performance autonomy” emerge for PAs?
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