The U.S. Military is us. There is no truer representation of a country than the people that it sends into the field to fight for it. The people who wear our uniform and carry our rifles into combat are our kids, and our job is to support them, because they’re protecting us. Tom Clancy
It is appropriate that any physician assistant (PA) textbook include a chapter covering military medicine because this profession began with four Vietnam veterans (Navy Hospital Corpsmen) being selected to matriculate at the original Duke University PA Program in 1965. Since then, 250 accredited programs have come online here in the United States, with well over 100,000 PAs having faithfully and competently provided patient care over the past half century. The federal government continues to be the largest employer of PAs, with approximately 2800 active-duty PAs currently serving in the armed forces.
History of military physician assistants
Shortages in U.S. health care systems (civilian and military) during the 1960s resulted in needs not being fulfilled by physicians. Shortfalls in military physician recruiting were made more serious by the unpopular war in Vietnam. A decrease in the availability of health care providers to U.S. Department of Defense (DoD) beneficiaries became a reality, and physician scholarship programs were initiated to bring more physicians into the military services. This shortage, however, was not relieved in the 4-year period of time it took for a physician to be educated. Even after a medical student had been selected to receive a scholarship that obligated him or her to military service, it took 5 years for a general medical officer (GMO; who has no residency training) to be educated and up to 9 years for a board-eligible physician or surgeon to be trained. PAs and other physician extenders, such as nurse practitioners, were seen as the short-term answer to a potentially long-term problem.
By 1970 the DoD had initiated plans to start training PAs. In March 1971 the DoD answered a number of questions concerning the nature of the position, training, and degree of PA independence by issuing the following definition :
The military Physician’s Assistant is a skilled health professional who is not a physician but who by experience and formal training has become qualified to perform certain tasks formerly undertaken only by a physician. He works under the supervision of a medical officer, though he may at times serve some distance from the physician and receive instruction and guidance by telephone or other means of communication. He may perform selected tasks delegated to him by the physician supervisor, who is responsible for his actions. His principal duties will involve direct contact with patients to obtain medical histories and to perform physical examinations, order appropriate laboratory and x-ray studies, interpret and record these data, and prescribe limited therapy. He is considered to meet the criteria of the “Type-A” Physician’s Assistant as defined by the Board of Medicine of the National Academy of Science, May 1970.
By 1971 the use of PAs in outpatient care was rapidly on the rise in military and civilian settings, but with only approximately 1800 PAs nationally, it was clear that the military would have to get into the business of training their own. The Army and Air Force established their PA training programs in 1971. The school that Army PA students attended was the Medical Field Services School PA program at Fort Sam Houston, Texas. The Air Force started its training program at the School of Health Care Sciences, Sheppard Air Force Base. The Navy joined the Air Force program by 1972 but also later established its own training sites in Virginia and California, before eventually sending students to train with the Army at Fort Sam Houston. The Coast Guard initially relied on recruiting civilian PAs or sending enlisted personnel to civilian PA programs but eventually joined the Air Force Sheppard program in 1990.
In all cases, those chosen for these programs were enlisted military members with broad military and medical backgrounds. The curriculum at each of these programs consisted of 1 year of didactic training at a military educational facility followed by a 1-year rotational clinical practicum in a military hospital. Upon successful completion of the 2-year programs, these new military PAs were credentialed by either the military hospital to which they were assigned or the military hospital that had medical supervision over their clinical practice. There was a lack of standardization and support in the military respective medical communities, leaving these initial PAs positioned within the enlisted and warrant officer ranks. By 1978 the Air Force began commissioning PAs as officers, followed by the Navy in 1989, the Coast Guard in 1990, and the Army in 1992.
The interservice physician assistant program
In 1996, the military services combined their various PA programs to form the Interservice Physician Assistant Program (IPAP), located at Fort Sam Houston, San Antonio, Texas ( Fig. 50.1 ). The sponsoring institution was the Army Medical Department Center and School (AMEDDC&S), and IPAP was aligned under the Academy of Health Sciences. The AMEDDC&S leadership reached an agreement with the University of Nebraska Medical Center (UNMC) that the latter would provide faculty and administrative support for the IPAP. This was followed by program accreditation through the Commission on Accreditation of Allied Health Education Programs (CAAHEP) in 1997. The Healthcare Interservice Training Advisory Board (HC-ITAB) formally consolidated and approved the new accredited program for the Army (including the Guard and Reserves), Navy (including the Marine Corps), Air Force (including the Air Guard), and Coast Guard. This new program convened its first class in April 1996.
The IPAP mission is to provide the uniformed services with highly competent, compassionate PAs who model integrity, strive for leadership excellence, and are committed to lifelong learning. Graduates are commissioned into the officer corps of their respective service and take their place beside other military health care professionals in providing medical services to active duty military personnel, their dependents, and retirees. It takes a dedicated and cohesive team of Army, Navy, Air Force, Coast Guard, and civilian faculty and staff to successfully lead military students with as few as 60 college semester hours through an extremely intense 29-month curriculum culminating in the Master of Physician Assistant Studies (MPAS) degree and commissioning as a military officer. The IPAP faculty and staff team at phase 1 are composed of PAs, physicians, science officers, and others. Phase 2 is primarily staffed with clinicians who precept and teach the PA students at 22 geographically diverse clinical military training sites.
From 1996 to 2001, the IPAP graduated PAs with a bachelor of science degree. Beginning in 2002, IPAP graduates earned a bachelor’s degree at the end of phase 1 and an MPAS degree at the end of phase 2. In 2009, because of the wartime need for PAs in the DoD and Department of Homeland Security (DHS), the IPAP increased the throughput to up to 240 students per year (up to 80 entering in three classes). This led to a total yearly enrollment of up to 480 (240 in phase 1 and 240 in phase 2), solidifying the IPAP as the largest PA program in existence. Also in 2009, the IPAP was organizationally moved from the PA Branch to the newly created Graduate School located at the AMEDDC&S. The Graduate School is composed of graduate programs in physical therapy, nursing anesthesia, nutrition, social work, pastoral care, and health care administration. This change led to a dynamic graduate-level environment and culture of education, service, and research. When the U.S. News and World Report rankings were published in 2011 (“Best Graduate Schools in America”), all of the programs in the Graduate School were ranked among the best in the country. The IPAP was ranked 13th of PA programs nationally.
In 2010 the IPAP extended the length of the program from 24 to 29 months. This allowed the program to go from an extremely compact, three-trimester didactic format (in 12 months) to a more reasonable four-semester delivery over a 16-month period. The students must successfully complete 100 semester hours of competency-based curriculum in this period before advancing to phase 2. The clinical portion was also extended from 12 months to 13 months to facilitate the change in station move to a phase 2 training site for students and their families, as well as hospital orientation, the Health Insurance Portability and Accountability Act, Advanced Cardiovascular Life Support (ACLS), and other necessary training courses. Upon successful completion of all phase 2 rotations and program requirements, the student is granted another 52 semester hours, for a 29-month program total of 152 semester hours.
IPAP graduates receive a certificate of completion (from the sponsoring institution, AMEDDC&S), which enables them to sit for the National Commission for Certification of Physician Assistants (NCCPA) certifying examination. They are also conferred an MPAS degree from the affiliate university. A competitive bid process determines the affiliate university, which is currently the University of Nebraska Medical Center. Military PAs take great pride in their PA program and rightfully so. The IPAP moved higher in ranking in the March 2015 U.S. News and World Report rankings and is now ranked number 11 in the nation. As of this writing, four of the past five graduating cohorts have scored a first-time pass rate of 100% on the NCCPA certification examination. The NCCPA Physician Assistant National Certifying Exam (PANCE) 5-year first time pass rate average for the IPAP is 97%, which compares very favorably with notable academic programs such as Duke University (96%), which admits students with a minimum of a baccalaureate degree, over 1 year of direct patient care experience, and an annual throughput of 80 students.
The armed forces continue to rely heavily on the IPAP to meet their respective PA inventory shortfalls, and the IPAP works hard to meet that demand by producing an average of 169 new PAs every year. In addition, there are limited scholarship opportunities for civilian PA students who wish to serve as a military PA after graduation and NCCPA certification. Nevertheless, PA attrition remains a significant challenge to force management and has led to the ongoing practice of recruiting fully qualified civilian PAs into military service. This recruitment into active duty or into the National Guard or Reserve components is problematic for several reasons. First, the United States just recently participated in two protracted, active wars going back to 2001, the longest time in our history. During this time, all PAs were guaranteed to be tapped for hazardous duty within 6 months of graduating or being commissioned into the military. This volunteering for harm’s way is analogous to writing a check for “everything up to and including my life.” In addition are the following reasons:
Overall disparity in pay between the military services and the civilian sector:
The base pay of an O1 (second lieutenant/ensign) with less than 2 years of creditable service is $35,211.
The base pay of an O2 (first lieutenant/lieutenant junior grade) with less than 2 years of creditable service is $40,568.
A PA accession may be brought into the military as an O2 if he or she has a master’s degree as a PA along with NCCPA certification.
Since 2009, DOD PAs have been on more competitive footing. By signing a 4-year multiyear contract after completion of an initial service contract, PAs may receive up to $25,000 per year of Incentive Special Pay and Multiyear Specialty Pay. This bonus, however, is subject to change or be eliminated based on the needs of the military. Also, all DoD PAs who have a medically related master’s degree and NCCPA certification receive an additional $6000 per year of board certification pay. DoD PAs are also eligible for an additional $5000 per year of retention bonus pay. These bonuses have contributed favorably to PA retention and recruitment efforts.
The median (50th percentile) salary of a civilian PA within the first year of practice in 2015 was $84,700.
Some civilian-trained PAs may be overwhelmed by military productivity standards, especially when coupled with the military’s clinical support system and rules. The productivity expected (25+ patients per day) is not excessive; however, the support infrastructure (physical, fiscal, and personnel) is not as flexible and efficient as in some civilian health care systems.
Adaptation to the role of a professional military officer first and to the role of medical provider second can be disconcerting and stressful.
The scope and demands of military practice may be broader than some PA roles in civilian practice. Military PAs often practice fairly autonomously in remote and austere environments. It is expected that they will function by providing quality care with minimal support and consultation. It is common for a PA to rarely see the physician supervisor and to have only telephonic or radio contact on an as-needed basis.
Scope of practice
Although military PAs principally work in primary care and family practice settings, they can also be found in acute care and emergency services. Specialization varies by the branch of military, and many specialties are available. Military PAs may specialize in aviation medicine, bone marrow transplantation, cardiovascular perfusion, emergency medicine, occupational medicine, orthopedics, otolaryngology, oncology, public health, and general surgery. The credentials committee and military treatment facility commanders ensure the proper scope of practice for patient care and procedures. Hospital commanders define in writing the scope and limits of the clinical practice for each PA and designate the supervising physicians. Clinical privileges for PAs are determined on initial assignment, are reevaluated after any change of assignment, and are reviewed at least annually. Although military PAs work in a wide variety of settings, the following core scope of privileges applies to all :
The scope of privileges for the PA includes the evaluation, diagnosis, and treatment for patients of all ages with any symptom, illness, injury, or condition. PAs provide medical services within the scope of practice of the collaborating physician(s), including routine primary and preventive care of children and adults. PAs may refer patients to specialty clinics and assess, stabilize, and determine disposition of patients with emergent conditions.
Military PAs must keep abreast of innovations in primary patient care and combat medicine, continually ensuring deployment readiness. Eighty percent of Army PAs are assigned to combat or field maneuver units; the remainder are assigned to outpatient care at installation hospitals or to administrative positions. Historically, most Navy and Air Force PAs were assigned to family practice or primary care clinics, but they are increasingly seen in combat operational roles at remote air bases, aboard ships, and with the Marines because of their participation and outstanding track record in Operations Desert Shield, Desert Storm, Iraqi Freedom, Enduring Freedom, and the global war on terrorism. Specialty-trained PAs must keep their skills current in their respective specialties and in family practice to maintain their interoperability and NCCPA certification.
Role of physician assistants in the military health system
The Military Health System (MHS) is led by the Assistant Secretary of Defense for Health Affairs and includes several organizational areas such as TRICARE (health care program for over nine million beneficiaries worldwide); Force Health Protection and Readiness; military medical departments; and even civilian network facilities, providers, and partners. Within the MHS, military PAs and other health care professionals collaborate to ensure those in uniform are medically ready to deploy anywhere around the globe on a moment’s notice. Not only do they ensure mission readiness, but they also deploy side by side with the warfighter. The MHS is more than just combat medicine; it is a complex system that incorporates health care delivery, medical education, public health, private sector partnerships, and cutting-edge medical research and development.
Military medical centers, hospitals, and clinics are the core of the MHS, and PAs serve at every level. These facilities form an integrated network, although they are located on military bases and posts around the world. The MHS team at these facilities conducts research and provides services for the treatment of exposures, injuries, and diseases related to military service and deployment. Warrior care also includes actively supporting wounded, ill, and injured service members in their recovery and reintegration or transition to civilian life.
In 2015, there were approximately 2800 PAs in all components of the armed forces. A majority of these PAs are working in primary care, family practice, emergency departments, troop medical clinics, or dispensaries ( Fig. 50.2 ). PAs are considered by many to be the “gatekeepers” of the MHS. Having repeatedly been proven cost-effective, PAs both provide high-quality medical care and increase accessibility to medical care for all DoD and DHS beneficiaries. Military PA roles are flexible and are not designed solely for peacetime or wartime. The majority of current military PAs have deployed at least once for 6 to 18 months (in a wartime role) and must remain in a deployment-ready status in between deployments.