Learning objectives
Adopt a historic and international view toward the development of PAs and PA-like medical careers.
Describe some of the conditions in the U.S. health system that led to the development of the PA profession.
Identify the five physicians generally recognized as the founders of the PA profession.
Describe the specific roles of each of the four organizations that lead and monitor the physician assistant profession in the United States.
International origins—Russia and China
What is now the physician assistant (PA) profession has many origins. Although it is often thought of as an “American” concept—recruiting former military corpsmen to respond to the access needs in our health care system—the PA has historical antecedents in other countries.
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, 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 often located in the same institutions as medical and nursing schools, took 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. 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.”
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 when they were first introduced. 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.” PAs are now an integral part of the American health care system. In contrast, the numbers of both feldshers and barefoot doctors have declined in their respective countries because of 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’s mates to provide health care on merchant ships. The program was later discontinued, and by 1965, fewer than 100 purser’s mates continued to provide medical services.
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 Physician Assistant History Society 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 at the University of Colorado, 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, a practical definition of the PA concept awaited the 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, ( Fig. 4.1 ) developed a program to extend the capabilities of nurses at Duke University Hospital under the leadership of Thelma Ingles, RN. This program, which could have initiated the NP movement, was opposed by the National League of Nursing (NLN). The League expressed concern that such a program would move these new providers from the ranks of nursing and into the “medical model.” Interestingly, Duke University also had simultaneous 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:
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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.
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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.
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Heightened concern about the supply of physicians, their geographic and specialty maldistribution, and the workloads they carried.
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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.
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The availability of nurses and ex-corpsmen as potential sources of manpower.
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Local circumstances in numerous hospitals and office-based practice settings that required additional clinical-support professionals.
The first four students—all former Navy corpsmen and all employees of the Duke University Hospital—were chosen for 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 to 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 philosophic 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 but extensive clinical skills. 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. Locked hospital medical libraries were the exclusive property of the hospital’s physician staff and no others were allowed. 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—such as NPs—were quick to follow.
Fifty years later, it is common to see medical textbooks written for PAs, NPs, and other clinicians. 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. This PA textbook (now in its 7th edition) was originally developed and published by the editors at the W.B. Saunders company who recognized—and took a risk—on the interest and value of the first PA textbook.
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 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 their skills as needed in specific practice settings. In fact, the adaptability of PAs has had both positive and negative effects 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 concerns 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.
Now, as we move past our 50th anniversary, the differences between PA and MD/DO education are more clear. The PA competency-based education model works backward from determining the knowledge, skills, and attitudes that PAs must have in their innovative role and builds a curriculum that provides clear messages to students about what they “need to know.” Students receive learning outcomes/objectives before each course and specific lecture that guides their learning. Frequent assessments (quizzes, demonstration-by-checklist of clinical skills, the assessment of simulated patients, and regular feedback) guide the PA’s learning.
An emphasis on relationships with physicians are built into clinical rotations to expand communication and documentation skills.
As PAs and NPs entered educational programs and the clinical job market in the 1960s and 1970s, there were massive changes in the delivery system brought about by new medical technologies developed during the Korean and Viet Nam War and “the Space Race.” Although Emergency medical services (EMS) had been nonexistent before the 60s, now there were emergency medical technicians (EMTs) and paramedics, as well as high-tech intensive care units (ICUs), coronary care units (CCUs), and even neonatal monitoring that were new and pervasive. The new in-hospital roles of intensivists, respiratory therapists, electronic technicians, and hyperbaric medical technicians, as well as added nursing roles, led to the reconfiguration of work at all levels. Fortunately, returning medical corpsmen and corpswomen were some of the best and most experienced people to take on these roles. The newly created and rapidly expanding roles of PAs and NPs were just one part of this revolution!
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 point out, “The political appeal of providing a useful civilian health occupation for the returning Vietnam medical corpsman is enormous.” ( Fig. 4.2 ).
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 the 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 ( Fig. 4.3 ):
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 9 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 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, at his request, 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 ( Fig. 4.4 ). 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 ( Fig. 4.5 ). 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. Interestingly, the University of Alabama’s Surgical PA curriculum was conveyed by founder cardiac surgeon, John Kirklin MD, to Dr. M.K. Cherian in Madras, India who created the PA surgical model in India ( Fig. 4.6 ).
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. Dr. Henry Silver at 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” and even “associate” should be avoided as potentially demeaning. Smith was also concerned that all of these complex titles had too many syllables and would be difficult to pronounce! 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 at Yale, Emory, 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 involved 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. In addition, the decision by PAs in the United Kingdom to change their title to “physician associate” has escalated this discussion. The U.K. decision was sharply influenced by the Royal Colleges of Physicians who cautioned that the term “assistant” is too demeaning and doesn’t convey the level of responsibility held by PAs and the MD/PA team.
In addition, in Britain and throughout the Commonwealth, “PA” is the term used for “personal assistant” or “secretary.” Although the title physician associate still has the same initials as physician assistant, the removal of the word “assistant” better represents the role in the eyes of the British medical community.
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 expensive, labor intensive, and time consuming. 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 because NP educational programs are awarding a “doctor of nursing practice” degree. In 2011, the 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.
In the meantime, there was increasing use of the abbreviation PA rather than the spelled-out words for physician assistant to facilitate the transition if needed. After considering this for several years, in 2018, the AAPA hired external consultants to research and recommend a possible name-change. This movement—combined with an approach toward expanded autonomy—has led to the term “optimal team practice,” which is a major—although controversial—AAPA advocacy campaign.
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 opened; however, 25 of them later closed. Reasons for the closure of these early programs ranged from withdrawal of accreditation to lack of funding 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 health care systems, 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—now the PAEA) 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.
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 as replacements for medical residents in academic medical centers, 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 continue to drive the expansion of current programs and the development of new ones. By 2019, there were more than 246 PA programs with more than 135,000 PAs having graduated from U.S. PA programs, according to data from the National Commission on Certification of Physician Assistants (NCCPA).
Unfortunately, much of the concern about the health care workforce has focused primarily on physician supply without including PAs and NPs in workforce projections. As a result, American medical and osteopathic schools have expanded their class size and created new campuses to expand the number of doctors in training. PA programs are concerned about the impact of medical school growth on access to clinical training sites, as well as the development of appropriate PA jobs. Overall, however, it appears that new models of medical training that include an increased emphasis on interdisciplinary teams and greater integration of medical students, residents, and PA students on most patient care services can be beneficial for the PA profession.
Funding for programs
The success of the first PA programs was initially tied to federal or foundation 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 and hospital-based practice models.
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, some 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 a PA representative—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.
Accreditation
Accreditation of formal PA programs became imperative because the term physician assistant was being used to label a wide variety of formally and informally trained health personnel. Leaders of the Duke program—E. Harvey Estes, MD, and Robert Howard, MD—asked the AMA to determine educational guidelines for PAs. This request was consistent with the AMA’s position of leadership in the development of new health careers and its publication of Guidelines for Development of New Health Occupations.
The National Academy of Science’s Board of Medicine had also become involved in the effort to develop uniform terminology for PAs. It suggested three categories of PAs. Type A was defined as a “generalist” capable of data collection and presentation and having the potential for independent judgment; type B was trained in one clinical specialty; type C was determined to be capable of performing tasks similar to those performed by type A but not capable of independent judgment.
Although these categories were quickly rejected and dismissed as descriptors of the PA profession, they helped the medical establishment move toward the support of PA program accreditation. Also helpful were surveys conducted by the American Academy of Pediatrics and the American Society of Internal Medicine determining the acceptability of the PA concept to their respective members. With positive responses, these organizations, along with the American Academy of Family Physicians and the American College of Physicians, joined the AMA’s Council on Medical Education in the creation of the “educational essentials” for the accreditation of PA training programs. The AMA’s House of Delegates approved these essentials in 1971.
Three PAs—William Stanhope, Steven Turnipseed, and Gail Spears—were involved in the creation of these essentials as representatives of the Duke, MEDEX, and Colorado programs, respectively. The AMA appointed L.M. Detmer to be the administrator of the accreditation process. In 1972, accreditation applications began to be processed, and 20 schools were visited in alphabetical order, 17 of which received accreditation. Ultimately, the accreditation activities were carried out by the Joint Review Committee, which was a part of the AMA’s Committee on Allied Health Education and Accreditation (CAHEA). Physician assistant John McCarty became the administrator of the Joint Committee in 1991 and was the first PA to serve in this role. Later, the Joint Committee was renamed the Accreditation Review Committee (ARC).
In 2000, the ARC became an independent entity, separate from the CAHEA, and changed its name to the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). Current members of the ARC-PA include the Physician Assistant Education Association (PAEA), AAPA, American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American College of Surgeons, and AMA. In 2016, upon the retirement of John McCarthy, Sharon Luke, MSHS, PA-C, became the new Executive Director.
Certification
Just as an accreditation process served to assess the quality of PA training programs, a certification process was necessary to ensure the quality of individual program graduates and become the “gold standard” for the new profession. In 1970 the American Registry of Physician’s Associates was created by programs from Duke University; Bowman Gray School of Medicine; and the University of Texas, Galveston. The first certification examination, for graduates from eight programs, was administered in 1972. It was recognized, however, that the examination would have greater credibility if the National Board of Medical Examiners administered it. During this same period, the AMA’s House of Delegates requested the Council of Health Manpower to become involved in the development of a national certification program for PAs. Specifically, the House of Delegates was concerned that the new professional role be developed in an orderly fashion, under medical guidance, and be measured by high standards. The cooperation of the AMA and the National Board of Medical Examiners ultimately resulted in the creation of the NCCPA, which brought together representatives of 14 organizations as an independent commission. Federal grants contributed $715,000 toward the construction and validation of the examination.
In 1973, the first NCCPA national board examination was administered at 38 sites to 880 candidates. In 1974, 1303 candidates took the examination; in 1975, there were 1414 candidates. In 1992, 2121 candidates were examined. In 1997 the examination was administered to 3728 candidates. In 2002, 3995 first-time candidates took the Physician Assistant National Certifying Examination (PANCE). In 2018, 9220 first-time candidates sat for the initial certifying examination. In January 2014, Dawn Morton Rias, the new NCCPA CEO, announced the certification of the 100,000th physician assistant (PA-C) in the nation since the organization’s inception nearly 40 years before.
Now administered only to graduates of ARC-PA–accredited PA programs, the NCCPA board examination was originally open to three categories of individuals seeking certification:
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Formally trained PAs, who were eligible by virtue of their graduation from a program approved by the Joint Review Committee on Educational Programs for Physician’s Assistants—now the ARC-PA.
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NPs, who were eligible provided that they had graduated from a family or pediatric NP/clinician program of at least 4 months’ duration, affiliated with an accredited medical or nursing school
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Informally trained PAs, who could sit for the examination provided that they had functioned for 4 of the past 5 years as PAs in a primary care setting. Candidate applications and detailed employment verification by current and former employers provided data for the determination of eligibility.
Since 1986, only graduates of accredited PA programs have been eligible to take the NCCPA examination.
The NCCPA’s scope of work includes not only the initial PANCE examination, but also a recertification process and the provision of technical assistance to state medical boards on issues of certification. The NCCPA’s website includes a readily available and easily searchable listing of all currently certified PAs as a resource for employers and state licensing boards.
To remain a certified PA, the NCCPA requires PAs to document 100 hours of continuing medical education (CME) every 2 years and to pass generalist recertification examinations on a specified schedule. Originally, PAs sat the examination every 6 years. In 2014 the NCCPA began a transition from a 6- year recertification and exam cycle to a 10-year recertification and exam cycle.
Throughout 2019 and 2020 the NCCPA is conducted a pilot program of a new testing process that could replace the current formal recertification exam now administered at regional testing centers. The pilot, which began in January 2019 , requires PAs participating in the program to answer 25 test questions each quarter for 2 years, from January 2019 through December 2020. The questions can be answered all at once or throughout the quarter and “from any device, anywhere.” According to the NCCPA, this new testing modality requires no advance preparation and participants receive immediate feedback on their performance. As with other NCCPA tests, a standard-setting diverse group of PAs will be convened to help determine the passing standard for this pilot assessment.
Another relatively recent NCCPA development is the creation of voluntary recognition for specialty training and education. Called Certificates of Added Qualification (CAQ), the process is modeled after similar awards in Family Medicine. The NCCPA’s decision to create the CAQ was based on a long process that involved requests from PA specialty groups, a history of inquiries from institutional credentialing and privileging bodies, a series of meetings involving partnerships between specialty PAs and supportive parallel physician organizations, and a long exploration of possible options.
The final decision—to try the CAQ process with five specialties requesting this service—was sharply criticized by the AAPA, who feared that any specialty credentialing could threaten the ability of PAs to change specialties. Ultimately, the NCCPA decided that it was better for them to offer these certificates rather than have external for-profit organizations create certification processes without PA input. The initial five specialties chosen were cardiovascular surgery, orthopedics, nephrology, psychiatry, and emergency medicine. Teams composed of representatives of MD and PA specialty organizations worked together to create the CAQ process. Subsequently, CAQs in pediatrics and hospital medicine have been added.
In 2005, the NCCPA created a separate NCCPA Foundation to promote and support the PA profession through research and educational projects. Now known as the NCCPA Health Foundation, it supports the work of the NCCPA for the advancement of certified PAs and the benefit of the public. Foundation activities have included a research grants program, the PA Ethics Project with the PAEA, the Best Practice Project focusing on the relationships between PAs and their supervising physicians, an oral health project, and a current collaborative mental health project in conjunction with other PA organizations.
The PA History Society also became part of the NCCPA’s infrastructure in 2010 when it transitioned to become an NCCPA-supported organization and moved into the Commission’s offices in Johns Creek, Georgia. Originally founded in 2002 as a free-standing organization for educational, research, and literary purposes, the Society’s mission is to serve as the leader in fostering the preservation, study, and presentation of the history of the PA profession. The Society meets its mission by creating and presenting an online virtual repository of historic and current information on the PA profession. The Society’s projects include an archive of PA historic items, an extensive website on PA history designed to serve as a resource for PA students, practicing PAs and researchers, as well as the PA History Center and Veterans Memorial Garden housed at the North Carolina Academy’s headquarters in Raleigh-Durham, North Carolina. An 11-member board governs the Society and provides leadership for history activities with support from NCCPA staff.
Organizations
American academy of physician assistants
What was to become the AAPA was initiated by students from Duke’s second and third classes as the American Association of Physician Assistants. Incorporated in North Carolina in 1968 with E. Harvey Estes, Jr., MD, as its first advisor and William Stanhope serving two terms as the first president (1968–1969 and 1969–1970), the organization’s original purposes were to educate the public about PAs, provide education for PAs, and encourage service to patients and the medical community. With initial annual dues of $20, the Academy created a newsletter as the official publication of the AAPA and contacted fellow students at the MEDEX program and at Alderson-Broaddus.
By the end of the second year, national media coverage of emerging PA programs throughout the United States was increasing (see Fig. 4.2 ), and the AAPA began to plan for state societies and student chapters. Tax-exempt status was obtained, the office of president-elect was established, and staggered terms of office for board members were approved.
Controversy over types of PA training models offered the first major challenge to the AAPA. Believing that students trained in 2-year programs based on the biomedical model (type A) were the only legitimate PAs, the AAPA initially restricted membership to these graduates. The Council of MEDEX Programs strongly opposed this point of view. Ultimately, discussions between Duke University’s Robert Howard, MD, and MEDEX Program’s Richard Smith, MD, resulted in an inclusion of graduates of all accredited programs in the definition of physician assistant and thus in the AAPA.
At least three other organizations also positioned themselves to speak for the new profession. These were: (1) a proprietary credentialing association, the American Association of Physician Assistants; (2) The National Association of Physician Assistants (a group representing U.S. Public Health Service PAs at Staten Island); and (3) the American College of Physician Assistants from the Cincinnati Technical College PA Program. AAPA President Paul Moson provided the leadership that “would result in the emergence of the AAPA as the single voice of professional PAs” (W.D. Stanhope, C.E. Fasser, unpublished manuscript, 1992).
This unification was critical to the involvement of PAs in the development of educational standards and the accreditation of PA programs. During Carl Fasser’s term as AAPA president, the AMA formally recognized the AAPA, and three Academy representatives were formally appointed to the Joint Review Committee.
During the AAPA presidency of Tom Godkins and the APAP presidency of Thomas Piemme, MD, the two organizations sought funding from foundations for the creation of a shared national office. Funding was received from the Robert Wood Johnson Foundation, the van Ameringen Foundation, and the Ittleson Foundation. Because of its 501(c)(3) tax-exempt status, APAP was eligible to be the recipient of funds for the cooperative use of both organizations. “Discussions held at that time between Piemme and Godkins and other organizational representatives agreed that in the future, because of the limited size of APAP . . . funds would later flow back from the AAPA to APAP” (W.D. Stanhope, C.E. Fasser, unpublished manuscript, 1992). Donald Fisher, PhD, was hired as executive director of both organizations, and a national office was opened in Washington, DC. According to Stanhope and Fasser, “a considerable debt is owed to the many PA programs and their staff who supported the early years of AAPA.”
AAPA constituent chapters were created during President Roger Whittaker’s term in 1976. Modeled after the organizational structure of the American Academy of Family Physicians, the AAPA’s constituent chapter structure and the apportionment of seats in the House of Delegates were the culmination of initial discussions held in the formative days of the AAPA. The American Academy of Family Physicians hosted the AAPA’s first Constituent Chapters Workshop in Kansas City, and the first AAPA House of Delegates was convened in 1977.
Throughout its development, the AAPA has been active in the publication of journals for the profession. As the first official journal of the AAPA, Physician ’s Associate was originally designed to encourage research and to report on the developing PA movement. With the consolidation of graduates of all programs into the AAPA, the official academy publication became the PA Journal, A Journal for New Health Practitioners. In 1977, Health Practitioner became the official magazine of the AAPA followed by Physician Assistant in 1983 and the Journal of the American Academy of Physician Assistants (JAAPA) in 1988. Later, a monthly publication, PA Professional, was created by the AAPA to feature news, policy issues, and the successes of individual PAs. Clinician Reviews and Physician Assistant, published by external publishers, also offer medical articles and coverage of professional issues for PAs. In addition to formal publications, the AAPA’s website and social media structures provide the most current information and networking about current practice, policy, and advocacy issues for PAs and their employers.
Governed by a 13-member board of directors, including officers of the House of Delegates and a student representative, the AAPA’s structure includes standing committees and councils. Specialty groups and formal caucuses bring together academy members with a common concern or interest.
The AAPA’s Student Academy is composed of chartered student societies from each PA educational program. Each society has one seat in the Assembly of Representatives, which meets at the annual conference and elects officers to direct Student Academy (SAAPA) activities.
The Academy also includes a philanthropic arm, the Physician Assistant Foundation, whose mission is to foster knowledge and philanthropy that promotes quality health care.
The annual AAPA conference serves as the major political and continuing medical education activity for PAs, with an average annual attendance of 7000 to 9000 participants. A history of conference locations is given in Table 4.1 . (Many PAs mark the “history” of their own career by the year and locations of their national conference attendance.)
