Feldshers in Russia

The feldsher concept originated in the European military in the 17th and 18th centuries and was introduced into the Russian military system by Peter the Great. Armies of other countries were ultimately able to secure adequate physician personnel; however, because of a physician shortage, the large numbers of Russian troops relied on feldshers for major portions of their medical care. Feldshers retiring from the military settled in small rural communities, where they continued their contribution to health care access. Feldshers assigned to Russian communities provided much of the health care in remote areas of Alaska during the 1800s. In the late 19th century, formal schools were created for feldsher training, and by 1913, approximately 30,000 feldshers had been trained to provide medical care.

As the major U.S. researchers reviewing the feldsher concept, Victor Sidel and P.B. Storey described a system in the Soviet Union in which the annual number of new feldshers equaled the annual number of physician graduates. Of those included in the feldsher category, 90% were women, including feldsher midwives. Feldsher training programs, which were located in the same institutions as nursing schools, required 2 years to complete. Outstanding feldsher students were encouraged to take medical school entrance examinations. Roemer found in 1976 that 25% of Soviet physicians were former feldshers.

The use of Soviet feldshers varied from rural to urban settings. Often used as physician substitutes in rural settings, experienced feldshers had full authority to diagnose, prescribe, and institute emergency treatment. A concern that “independent” feldshers might provide “second-class” health care appears to have led to greater supervision of feldshers in rural settings. Storey describes the function of urban feldshers—whose roles were “complementary” rather than “substitutional”—as limited to primary care in ambulances and triage settings and not involving polyclinic or hospital tasks. Perry and Breitner compare the urban feldsher role with that of U.S. physician assistants (PAs): “Working alongside the physician in his daily activities to improve the physician’s efficiency and effectiveness (and to relieve him of routine, time-consuming tasks) is not the Russian feldsher’s role.”

China ’ s Barefoot Doctors

In China, the barefoot doctor originated in the 1965 Cultural Revolution as a physician substitute. In what became known as the “June 26th Directive,” Chairman Mao called for a reorganization of the health care system. In response to Mao’s directive, China trained 1.3 million barefoot doctors over the subsequent 10 years.

The barefoot doctors were chosen from rural production brigades and received their initial 2- to 3-month training course in regional hospitals and health centers. Sidel comments that “the barefoot doctor is considered by his community, and apparently thinks of himself, as a peasant who performs some medical duties rather than as a health care worker who performs some agricultural duties.” Although they were designed to function independently, barefoot doctors were closely linked to local hospitals for training and medical supervision. Upward mobility was encouraged in that barefoot doctors were given priority for admission to medical school. In 1978, Dimond found that one third of Chinese medical students were former barefoot doctors.

The use of feldshers and barefoot doctors was significantly greater than that of PAs in the United States. Writing in 1982, Perry and Breitner noted:

Although physician assistants have received a great deal of publicity and attention in the United States, they currently perform a very minor role in the provision of health services. In contrast, the Russian feldsher and the Chinese barefoot doctor perform a major role in the provision of basic medical services, particularly in rural areas.

The “discovery” in the United States that appropriately trained nonphysicians are perfectly capable of diagnosing and treating common medical problems had been previously recognized in both Russia and China. We can no longer say that PAs “perform a very minor role in the provision of health services.” In contrast, the numbers of both feldshers and barefoot doctors have declined in their respective countries owing to a lack of governmental support and an increase in the numbers of physicians.

Developments in the United States

Beginning in the 1930s, former military corpsmen received on-the-job training from the Federal Prison System to extend the services of prison physicians. In a 4-month program during World War II, the U.S. Coast Guard trained 800 purser mates to provide health care on merchant ships. The program was later discontinued, and by 1965, fewer than 100 purser mates continued to provide medical services. Both of these programs served as predecessors to those in the federal PA training programs at the Medical Center for Federal Prisoners, Springfield, Missouri, and Staten Island University Hospital, New York.

In 1961, Charles Hudson, MD, proposed the PA concept at a medical education conference of the American Medical Association (AMA). He recommended that “ assistants to doctors” should work as dependent practitioners and should perform such technical tasks as lumbar puncture, suturing, and intubation.

At the same time, a number of physicians in private practice had begun to use informally trained individuals to extend their services. A well-known family physician, Dr. Amos Johnson, publicized the role that he had created for his assistant, Mr. Buddy Treadwell. The website for the Society for the Preservation of Physician Assistant History provides detailed information on Dr. Johnson and tells more about how Mr. Treadwell served as a role model for the design of the PA career.

By 1965, Henry Silver, MD, and Loretta Ford, RN, had created a practitioner-training program for baccalaureate nurses working with impoverished pediatric populations. Although the Colorado program became the foundation for both the nurse practitioner (NP) movement and the Child Health Associate PA Program, it was not transferable to other institutions. According to Gifford, this program depended “. . . on a pattern of close cooperation between doctors and nurses not then often found at other schools.” In 1965, therefore, practical definition of the PA concept awaited establishment of a training program that could be applied to other institutions.

Developments at Duke University

In the late 1950s and early 1960s, Eugene Stead, MD, developed a program to extend the capabilities of nurses at Duke University Hospital. This program, which could have initiated the NP movement, was opposed by the National League of Nursing. The League expressed the concern that such a program would move these new providers from the ranks of nursing and into the “medical model.” Simultaneously, Duke University had experience with training several firemen, ex-corpsmen, and other non–college graduates to solve personnel shortages in the clinical services at Duke University Hospital.

The Duke program and other new PA programs arose at a time of national awareness of a health care crisis. Carter and Gifford described the conditions that fostered the PA concept as follows:

• 1.
  

  An increased social consciousness among many Americans that called for the elimination of all types of deprivation in society, especially among the poor, members of minority groups, and women

  
  
• 2.
  

  An increasingly positive value attached to health and health care, which produced greater demand for health services, criticism of the health care delivery system, and constant complaints about rising health care costs

  
  
• 3.
  

  Heightened concern about the supply of physicians, their geographic and specialty maldistribution, and the workloads they carried

  
  
• 4.
  

  Awareness of a variety of physician extender models, including the community nurse midwife in America, the “assistant medical officer” in Africa, and the feldsher in the Soviet Union

  
  
• 5.
  

  The availability of nurses and ex-corpsmen as potential sources of manpower

  
  
• 6.
  

  Local circumstances in numerous hospitals and office-based practice settings that required additional clinical-support professionals

The first four students—all ex-Navy corpsmen—entered the fledgling Duke program in October 1965. The 2-year training program’s philosophy was to provide students with an education and orientation similar to those given the physicians with whom they would work. Although original plans called for the training of two categories of PAs—one for general practice and one for specialized inpatient care—the ultimate decision was made to focus on skills required in assisting family practitioners or internists. The program also emphasized the development of lifelong learning skills to facilitate the ongoing professional growth of these new providers.

Concepts of Education and Practice

The introduction of the PA presented philosophical challenges to established concepts of medical education. E. Harvey Estes, MD, of Duke, described the hierarchical approach of medical education as being “based on the assumption that it was necessary to first learn ‘basic sciences,’ then normal structure and function, and finally pathophysiology . . . .” The PA clearly defied these previous conventions. Some of the early PAs had no formal collegiate education. They had worked as corpsmen and had learned skills, often under battlefield conditions. Clearly, their skills had been developed, often to a remarkable degree, before the acquisition of any basic science knowledge or any knowledge of pathologic physiology.

The developing PA profession was also the first to officially share the knowledge base that was formerly the “exclusive property” of physicians. Before the development of the PA profession, the physician was the sole possessor of information, and neither patient nor other groups could penetrate this wall. The patient generally trusted the medical profession to use the knowledge to his or her benefit, and other groups were forced to use another physician to interpret medical data or medical reasoning. The PA profession was the first to share this knowledge base, but others were to follow—such as the NP.

Fifty years later, it is common to see medical textbooks written for PAs, NPs, and other nonphysician providers. Such publications were relatively new approaches for gaining access to medical knowledge at a time when access to medical textbooks and reference materials was restricted to physicians only. The legal relationship of the PA to the physician was also unique in the health care system. Tied to the license of a specific precepting physician, the PA concept received the strong support of establishment medicine and ultimately achieved significant “independence” through that “dependence.” In contrast, NPs, who emphasized their capability for “independent practice,” incurred the wrath of some physician groups, who believed that NPs needed supervisory relationships with physicians to validate their role and accountability.

Finally, the “primary care” or “generalist” nature of PA training, which stressed the acquisition of strong skills in data collection, critical thinking, problem solving, and lifelong learning, made PAs extraordinarily adaptable to almost any patient care setting. The supervised status of PA practice provided PAs with ongoing oversight and almost unlimited opportunities to expand skills as needed in specific practice settings. In fact, the adaptability of PAs has had both positive and negative impacts on the PA profession. Although PAs were initially trained to provide health care to medically underserved populations, the potential for the use of PAs in specialty medicine became “the good news and the bad news.” Sadler and colleagues recognized this concern early on, when they wrote (in 1972):

The physician’s assistant is in considerable danger of being swallowed whole by the whale that is our present entrepreneurial, subspecialty medical practice system. The likely co-option of the newly minted physician’s assistant by subspecialty medicine is one of the most serious issues confronting the PA.

A shortage of PAs in the early 1990s appeared to aggravate this situation and confirmed predictions by Sadler and colleagues :

Until great numbers of physician’s assistants are produced, the first to emerge will be in such demand that relatively few are likely to end up in primary care or rural settings where the need is the greatest. The same is true for inner city or poverty areas.

Although most PAs initially chose primary care, increases in specialty positions raised concern about the future direction of the PA profession. The Federal Bureau of Health Professions was so concerned about this trend that at one point, federal training grants for PA programs required that all students complete clinical training assignments in federally designated medically underserved areas.

Military Corpsmen

The choice to train experienced military corpsmen as the first PAs was a key factor in the success of the concept. As Sadler and colleagues pointed out, “The political appeal of providing a useful civilian health occupation for the returning Vietnam medical corpsman is enormous.”

The press and the American public were attracted to the PA concept because it seemed to be one of the few positive “products” of the Vietnam War. Highly skilled, independent duty corpsmen from all branches of the uniformed services were disenfranchised as they attempted to find their place in the U.S. health care system. These corpsmen, whose competence had truly been tested “under fire,” provided a willing, motivated, and proven applicant pool of pioneers for the PA profession. Robert Howard, MD, of Duke University, in an AMA publication describing issues of training PAs, noted that not only were there large numbers of corpsmen available but also using former military personnel prevented transfer of workers from other health care careers that were experiencing shortages:

. . . the existing nursing and allied health professions have manpower shortages parallel to physician shortages and are not the ideal sources from which to select individuals to augment the physician manpower supply. In the face of obvious need, there does exist a relatively large untapped manpower pool, the military corpsmen. Some 32,000 corpsmen are discharged annually who have received valuable training and experience while in the service. If an economically sound, stable, rewarding career were available in the health industry, many of these people would continue to pursue such a course. From this manpower source, it is possible to select mature, career-oriented, experienced people for physician’s assistant programs.

The decision to expand these corpsmen’s skills as PAs also capitalized on the previous investment of the U.S. military in providing extensive medical training to these men.

Richard Smith, MD, founder of the University of Washington’s MEDEX program, described this training:

The U.S. Department of Defense has developed ways of rapidly training medical personnel to meet its specific needs, which are similar to those of the civilian population. . . . Some of these people, such as Special Forces and Navy “B” Corpsmen, receive 1400 hours of formal medical training, which may include nine weeks of a supervised “clerkship.” Army corpsmen of the 91C series may have received up to 1900 hours of this formal training. Most of these men have had 3 to 20 years of experience, including independent duty on the battlefield, aboard ship, or in other isolated stations. Many have some college background; Special Forces “medics” average a year of college. After at least 2, and up to 20, years in uniform, these men have certain skills and knowledge in the provision of primary care. Once discharged, however, the investment of public funds in medical capabilities and potential care is lost, because they work as detail men, insurance agents, burglar alarm salesmen, or truck drivers. The majority of this vast manpower pool is unavailable to the current medical care delivery system because, up to this point, we have not devised a civilian framework in which their skills can be put to use.

Other Models

Describing the period of 1965 to 1971 as “Stage One—The Initiation of Physician Assistant Programs,” Carter and Gifford have identified 16 programs that pioneered the formal education of PAs and NPs. Programs based in university medical centers similar to Duke emerged at Bowman Gray, Oklahoma, Yale, Alabama, George Washington, Emory, and Johns Hopkins and used the Duke training model. Primarily using academic medical centers as training facilities, “Duke-model” programs designed their clinical training to coincide with medical student clerkships and emphasized inpatient medical and surgical roles for PAs. A dramatically different training model developed at the University of Washington, pioneered by Richard Smith, MD, a U.S. public health service physician and former Medical Director of the Peace Corps. Assigned to the Pacific Northwest by Surgeon General William Stewart, Smith was directed to develop a PA training program to respond uniquely to the health manpower shortages of the rural Northwest. Garnering the support of the Washington State Medical Association, Smith developed the MEDEX model, which took a strong position on the “deployment” of students and graduates to medically underserved areas. This was accomplished by placing clinical phase students in preceptorships with primary care physicians who agreed to employ them after graduation. The program also emphasized the creation of a “receptive framework” for the new profession and established relationships with legislators, regulators, and third-party payers to facilitate the acceptance and utilization of the new profession. Although the program originally exclusively recruited military corpsmen as trainees, the term MEDEX was coined by Smith not as a reference to their former military roles but rather as a contraction of “ Med icine Ex tension.” In his view, using MEDEX as a term of address avoided any negative connotations of the word assistant and any potential conflict with medicine over the appropriate use of the term associate . MEDEX programs were also developed at the University of North Dakota School of Medicine, University of Utah College of Medicine, Dartmouth Medical School, Howard University College of Medicine, Charles Drew Postgraduate Medical School, Pennsylvania State University College of Medicine, and Medical University of South Carolina.

In Colorado, Henry Silver, MD, began the Child Health Associate Program in 1969, providing an opportunity for individuals without previous medical experience but with at least 2 years of college to enter the PA profession. Students received a baccalaureate degree at the end of the second year of the 3-year program and were ultimately awarded a master’s degree at the end of training. Thus, it became the first PA program to offer a graduate degree as an outcome of PA training.

Compared with pediatric NPs educated at the same institution, child health associates, both by greater depth of education and by law, could provide more extensive and independent services to pediatric patients.

Also offering nonmilitary candidates access to the PA profession was the Alderson-Broaddus program in Philippi, West Virginia. As the result of discussions that had begun as early as 1963, Hu Myers, MD, developed the program, incorporating a campus hospital to provide clinical training for students with no previous medical experience. In the first program designed to give students both a liberal arts education and professional training as PAs, Alderson-Broaddus became the first 4-year college to offer a baccalaureate degree to its students. Subsequently, other PA programs were developed at colleges that were independent of university medical centers. Early programs of this type included those at Northeastern University in Boston and at Mercy College in Detroit.

Specialty training for PAs was first developed at the University of Alabama. Designed to facilitate access to care for underserved populations, the 2-year program focused its entire clinical training component on surgery and the surgical subspecialties. Even more specialized training in urology, orthopedics, and pathology was briefly provided in programs throughout the United States, although it was soon recognized that entry-level PA training needed to offer a broader base of generalist training.

Controversy about a Name

Amid the discussion about the types of training for the new health care professionals was a controversy about the appropriate name for these new providers. Silver of the University of Colorado suggested syniatrist (from the Greek syn , signifying “along with” or “association,” and iatric , meaning “relating to medicine or a physician”) for health care personnel performing “physician-like” tasks. He recommended that the term could be used with a prefix designating a medical specialty and a suffix indicating the level of training (aide, assistant, or associate). Because of his background in international health, Smith believed that “assistant” or even “associate” should be avoided as potentially demeaning. His term MEDEX for “physician extension” was designed to be used as a term of address, as well as a credential. He even suggested a series of other companion titles, including “Osler” and “Flexner.”

In 1970, the AMA-sponsored Congress on Health Manpower, attempted to end the controversy and endorse appropriate terminology for the emerging profession. The Congress chose associate rather than assistant because of its belief that associate indicated a more collegial relationship between the PA and supervising physicians. Associate also eliminated the potential for confusion between PAs and medical assistants. Despite the position of the Congress, the AMA’s House of Delegates rejected the term associate, holding that it should be applied only to physicians working in collaboration with other physicians. Nevertheless, PA programs, such as those at Yale, Duke, and the University of Oklahoma, began to call their graduates physician associates, and the debate about the appropriate title continued. A more subtle concern has been the use of an apostrophe in the PA title. At various times, in various states, PAs have been identified as physician’s assistants, implying ownership by one physician, and physicians’ assistants, implying ownership by more than one physician; they are now identified with the current title physician assistant without the apostrophe.

The June 1992 edition of the Journal of the American Academy of Physician Assistants contains an article by Eugene Stead, MD, reviewing the debate and calling for a reconsideration of the consistent use of the term physician associate .

The issue concerning the name resurfaces regularly, usually among students who are less aware of the historical and political context of the title. More recently, however, a name change has the support of more senior PAs who are adamant that the title assistant is a grossly incorrect description of their work. Although most PAs would agree that assistant is a less than optimum title, the greater concern is that the process to change it would be cumbersome, time consuming, and potentially threatening to the PA profession. Every attempt to “open up” a state PA law with the intent of changing the title would bring with it the risk that outside forces (e.g., other health professions) could modify the practice law and decrease the PA scope of practice. Similarly, the bureaucratic processes that would be required to change the title in every rule and regulation in each state and in every federal agency would be incredibly labor intensive. The overarching concern is that state and national PA organizations would be seen by policymakers as both self-serving and self-centered if such a change were attempted. This has become a particularly contentious issue among PAs since NP educators have chosen to move to a “doctorate in nursing practice” by 2015. In 2011, American Academy of Physician Assistants (AAPA) President Robert Wooten sent a letter to all PAs describing a formal process for collecting data regarding PA “opinions” about the “name issue” on the annual AAPA census for review by the AAPA’s House of Delegates.

The “name” is currently back on the list of PA “hot topics” as new PA programs in other countries have adopted the name “physician associate.” The United Kingdom PAs were the first to make this change based on advice from medical organizations that “physician assistant” was not a correct description. In addition, the fact that personal secretaries were termed “personal assistants” further muddied the waters. In 2013, the United Kingdom PAs became physician associates, and the New Zealand PAs followed them. Other non-U.S. PA programs and organizations are considering this change, which may make the term “physician associate” easier to support in the United States. Currently, U.S. PA organizations are promoting the use of the term PA rather than the spelled out words for physician assistant to facilitate the transition if needed.

Program Expansion

From 1971 to 1973, 31 new PA programs were established. These startups were directly related to available federal funding. In 1972, Health Manpower Educational Initiatives (U.S. Public Health Service) provided more than $6 million in funding to 40 programs. By 1975, 10 years after the first students entered the Duke program, there were 1282 graduates of PA programs. From 1974 to 1985, nine additional programs were established. Federal funding was highest in 1978, when $8,686,000 assisted 42 programs. By 1985, the AAPA estimated that 16,000 PAs were practicing in the United States. A total of 76 programs were accredited between 1965 and 1985, but 25 of those programs later closed ( Table 2.1 ). Reasons for closure range from withdrawal of accreditation to competition for funding within the sponsoring institution and adverse pressure on the sponsoring institution from other health care groups.

Physician assistant programs entered an expansion phase beginning in the early 1990s when issues of efficiency in medical education, the necessity of team practice, and the search for cost-effective solutions to health care delivery emerged. The AAPA urged the Association of Physician Assistant Programs (APAP) to actively encourage the development of new programs, particularly in states where programs were not available. Beginning in 1990, the APAP created processes for new program support, including new program workshops, and ultimately a program consultation service (Program Assistance and Technical Help [PATH]) to promote quality in new and established programs. These services were ultimately disbanded as the rate of new program growth declined.

The PA profession has engaged in an ongoing and lively debate about the development of new PA programs. The difficulty lies in the impossibility of making accurate predictions about the future health workforce, a problem that applies to all health professions. By 2011, 159 programs were accredited compared with 56 programs in the early 1980s. Expanded roles of PAs in academic medical centers (as resident replacements), in managed care delivery systems, and in enlarging community health center networks have created unpredicted demand for PAs in both primary and specialty roles. The major variable, aside from the consideration of the ideal “mix” of health care providers in future systems, has to do with the number of people who will receive health care and the amount of health care that will be provided to each person. When, for example, the Affordable Care Act, signed into law by President Obama in 2010, was fully implemented on schedule in 2014, the demand for all types of clinicians rose dramatically. These projections are driving the expansion of current programs and the development of new ones. By 2015, there were more than 200 PA programs with more than 100,000 PAs having graduated from U.S. PA programs.

Unfortunately, much of the concern about the health care workforce has focused primarily on physician supply (see “Physician Supply Literature” in the Resources section) without including PAs and NPs in economic formulas. As a result, American medical and osteopathic schools have been urged to expand their class size and to create new campuses to serve underserved groups. PA programs are concerned about the impact of medical school growth on access to clinical training sites, as well as on the development of PA jobs. Overall, however, it appears that new models of medical training that include increased emphasis on interdisciplinary teams and greater integration of medical students, residents, and PA students on most patient care services will be beneficial for the PA profession.

Funding for Programs

The success of the Duke program, as well as that of all developing PA programs, was initially tied to external funding. At Duke, Stead was successful in convincing the federal government’s National Heart Institute that the new program fell within its granting guidelines. Subsequently, Duke received foundation support from the Josiah Macy, Jr. Foundation, the Carnegie and Rockefeller Foundations, and the Commonwealth Fund.

In 1969, federal interest in the developing profession brought with it demonstration funding from the National Center for Health Services Research and Development. With increasing acceptance of the PA concept and the demonstration that PAs could be trained relatively rapidly and deployed to medically underserved areas, the federal investment increased. In 1972, the Comprehensive Health Manpower Act, under Section 774 of the Public Health Act, authorized support for PA training. The major objectives were education of PAs for the delivery of primary care medical services in ambulatory care settings; deployment of PA graduates to medically underserved areas; and recruitment of larger numbers of residents from medically underserved areas, minority groups, and women to the health professions.

Physician assistant funding under the Health Manpower Education Initiatives Awards and Public Health Services Contracts from 1972 to 1976 totaled $32,669,565 for 43 programs. From 1977 to 1991, PA training was funded through Sections 701, 783, and 788 of the Public Health Service Act. Grants during this period totaled $87,927,728 and included strong incentives for primary care training, recruitment of diverse student bodies, and deployment of students to clinical sites serving the medically underserved. According to Cawley, as of 1992 “This legislation . . . supported the education of at least 17,500, or over 70% of the nation’s actively practicing PAs.” Unfortunately, this high level of support did not continue and with lesser funding for primary care, programs followed medical schools into specialty practice models. Today the majority of the nation’s PAs—and the programs from which they graduated—have unfortunately not been exposed to the primary care values and experiences that characterized and defined the early PA concept.

During the period of program expansion, the focus of federal funding support became much more specific, and fewer programs received funding. Tied to the primary care access goals of the Health Resources and Services Administration (HRSA), PA program grants commonly supported less program infrastructure and more specific primary care initiatives and educational innovations. Examples of activities that were eligible for federal support included clinical site expansion in urban and rural underserved settings, recruitment and retention activities, and curriculum development on topics such as managed care and geriatrics.

An important trend was the diversification of funding sources for PA programs. In addition to federal PA training grants, many programs have benefited from clinical site support provided by other federal programs, such as Area Health Education Centers (AHECs) or the National Health Service Corps (NHSC). Also, many programs now receive expanded state funding on the basis of state workforce projections of an expanded need for primary care providers.

Unfortunately, federal Title VII support for all primary care programs (including family medicine, pediatrics, general internal medicine, and primary care dentistry) began to erode in the late 1990s. Federal budget analysts believed that the shrinking number of graduates choosing primary care employment was a signal that federal support was no longer justified. The federal Title VII Advisory Committee on Primary Care Medicine and Dentistry—which includes PA representatives—was formed to study the problem and recommend strategies. Title VII and Title VIII Reauthorization was delayed until the passage of overarching health reform legislation in 2010.

Physician assistant programs immediately benefited from available funding through traditional 5-year training grants and two one-time only grant programs for (1) educational equipment, including simulation models and teleconferencing hardware, and (2) expansion grants to add more training slots for students who were willing to commit themselves to primary care employment. For the first time, PA training grants were expanded from 3 years to 5 years but were limited to $150,000 per grant.