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Education: Higher Education

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

Class 4: Physician Assistants among the “Constellation” of Newly Emerging Health Care Providers


At the same time that the physician assistant (PA) profession emerged and grew during the period from the 1960s to the 1990s, other health care providers emerged and their numbers grew – though not as fast as the number of PAs. These other providers were primarily various types of nurse practitioners. Together with PAs, they were referred to as “physician extenders,” “mid-level health care providers,” and “new health practitioners.”

While the PA and nurse practitioner movements have continued to gain momentum, the certified nurse-midwife movement has remained more static. In the nursing profession, autonomy is growing with improved legislation for nurse practitioners. Even the concept of “negotiated dependent performance autonomy” for PAs is now changing. The federal government, as the largest employer of PAs and nurse practitioners, no longer requires direct supervision by physicians and instead has authorized a collaborative relationship among these health care providers.

Suggested class outline:

  1. An overview of other health care providers similar to PAs (nurse practitioners and nurse-midwives); factors that led to the integration of PAs, nurse practitioners, and nurse-midwives into U.S. medical practice in the 1980s and 1990s; their acceptance by patients and the public, and the promise of quality medical care at lower prices
  2. The growing role of other cadres of health care providers
  3. The cost to society of training a physician, compared to cost of training other health care providers
  4. The increasing difficulties in recruiting doctors to rural and geographically remote areas
  5. The potential for PAs and NPs to remain in their local communities after completing their education
Class Resources
Core resources
  • Goolsby, M. J. “2009–2010 AANP National Nurse Practitioner Sample Survey: An Overview.” Journal of the American Academy of Nurse Practitioners 23, no. 5 (2011): 266–268. doi: 10.1111/j.1745-7599.2011.00611.x.
  • Hooker, R. S., D. M. Brock, and M. L. Cook. “Characteristics of Nurse Practitioners and Physician Assistants in the United States.” Journal of the American Association of Nurse Practitioners 28, no. 1 (2016): 39–46. doi: 10.1002/2327-6924.12293.
  • Paine, L. L., et al. “Primary Care for Women. An Overview of the Role of the Nurse-Midwife.” Journal of Nurse-Midwifery 40, no. 2 (1995): 65–73. doi:10.1016/0091-2182(95)00015-C
  • Perry, H., and E. Redmond. “New Health Practitioners in Maine: An Assessment of Their Current Role.” Journal of the Maine Medical Association 71, no. 7 (1980): 208–214.
Supplemental resources
  • Capitulo, K. L. “The Rise, Fall and Rise of Nurse-Midwifery in America.” MCN The American Journal of Maternal Child Nursing 23, no. 6 (1998): 314–321.
  • Carthon, J. M., H. Barnes, and D. A. Sarik. “Federal Polices Influence Access to Primary Care and Nurse Practitioner Workforce.” The Journal for Nurse Practitioners 11, no. 5 (2015): 526–530. doi:10.1016/j.nurpra.2015.01.028.
  • Davis, L. J. “Certified Nurse Midwives: Over Twenty Years of Military Service.” Military Medicine 160, no. 8 (1995): 401–404.
  • Hooker, R. S., R. Potts, and W. Ray. “Patient Satisfaction: Comparing Physician Assistants, Nurse Practitioners, and Physicians.” The Permanente Journal 1, no. 1 (1997): 38.
  • Larkin, G. L., and R. S. Hooker. “Patient Willingness to Be Seen By Physician Assistants, Nurse Practitioners, and Residents in the Emergency Department: Does the Presumption of Assent Have an Empirical Basis?” The American Journal of Bioethics 10, no. 8 (2010): 1–10. doi: 10.1080/15265161.2010.494216.
  • Kuhr, Christian S. “Team obstetrics and the nurse-midwife: issues in patient acceptance.” Primary Care 3, no. 3 (1976):387–398.
  • Record, Jane Cassels, ed. Staffing Primary Care in 1990: New Health Practitioners, Cost Savings and Policy Issues. New York: Springer, 1981.
Discussion Questions
  1. What are the relative strengths and weaknesses of the various members of the emerging “constellation” of health care providers (PAs, nurse practitioners, and nurse-midwives)?
  2. Is the traditional concept of professional autonomy still valid in the 21st century, as more health care services are provided by inter-professional health care teams?
  3. How have physicians regarded the emergence of PAs and nurse practitioners? Do physicians and medical organizations differ with regard to perceptions of one type of provider versus the other?
  4. Identify the ‘turf’ issues that affect the relationships among primary care physicians, nurse practitioners, and PAs. Do nurse practitioners in independent practice compete with family physicians in the delivery of primary care services?
  5. What is the impact of the attainment of doctoral degrees, such as the doctor of nursing practice (DNP), for nurse practitioners in the alignment of physicians and PAs in the practice of medicine?
  6. Should PAs and nurse practitioners be considered interchangeable in most of their roles?
  7. Are new roles emerging which are more appropriate for either PAs or NPs?
  8. If there had there been an adequate number of physicians in most of the regions of the country in the 1960s and 1970s, would the PA profession have emerged?
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