Historical Context

Although many factors may have influenced the development of the PA profession at that time, the 1960s witnessed a time of significant change in the health care arena. Beginning in the 1950s, the U.S. health system began to see growth in the numbers of hospitals as innovations in medicine and treatment shifted the role of hospitals from a caretaking role to a curative role. By the 1950s, hospitals employed more people than the steelmaking, rail, and auto industries combined. In July 1965, President Lyndon Johnson signed the Medicare and Medicaid bills into law, which opened the health care doors for many elderly and poor individuals. The original Medicare program provided for hospital (Part A) and outpatient (Part B) insurance that was expected to provide coverage for more than 19 million individuals aged 65 years and older.

The need for more health care providers was recognized as physicians began to be attracted to specialties born out of advances in technology and innovations such as open heart surgery using a heart–lung machine (1953), coronary artery bypass (1967), the beginnings of successful transplant surgeries, and long-term hemodialysis (1960) to name just a few. During the same time, combat medics and corpsmen who served in the Vietnam War were seen as having a strong foundation to fill the gaps in health care.

Physician Assistant Education Events

Although one can find prototypes of the PA profession that were either formally or informally (e.g., apprentice model) prepared, the first formal educational program is generally considered to be the Duke program in North Carolina. Under the leadership of Dr. Eugene Stead, the first class of four PA students began their journey in 1965. Two years later, the first three formally trained PA graduates entered the workforce. Shortly after the first program at Duke launched, Dr. Richard Smith founded the MEDEX model of PA education at the University of Washington in 1969. The MEDEX model combined a short period of classroom study with a longer apprentice-like period with a potential physician employer. Other education models were established at by Dr. Hugh Myers at Alderson-Broaddus (the first baccalaureate program) and by Dr. Henry Silver at the University of Colorado (the first graduate-level program). The University of Colorado was first established as a Child Health Associate program with a 3-year curriculum to prepare individuals to work primarily in pediatrics. Early in the PA profession’s history, specialty PA programs were also developed. In 1967, the first entry-level program in surgery was launched at the University of Alabama. Later surgical programs were initiated at Cornell Medical Center in New York and Cuyahoga Community College in Ohio. There were also other entry-level specialty programs in fields such as orthopedics and urology. These subspecialty programs only existed for a short while, and only the three surgery-focused programs survived past 2000.

Historical Context

During the 1970s, the federal government needed to respond to the increasing demand for health care services spurred on by the enactment of Medicare and Medicaid, as well new health care services available through the advent of technology. In 1970, the National Health Service Corps was established to help address the lack of doctors in rural and inner city areas. In 1971, the Comprehensive Health Manpower Act was passed, creating significant funding for the development of additional PA educational programs. By 1973, the war in Vietnam was coming to a close, which would eventually lead to a decrease in the number of medics and corpsman that would be available to enter the profession. Technological advances in medicine, such as improved antirejection medications for solid organ transplantation, the development of the computed tomography scanner, and the advent of in vitro fertilization, meant that medical care was now available for diseases that previously would have caused death. Increased demand for medical care meant increased demand for medical care providers, such as PAs.

Physician Assistant Education Events

The 1970s could be characterized as the decade for the professionalization of the PA career. During this time, PA advocacy associations were launched, and the foundations were laid for PA education accreditation and the national certification examination. During the same time, the first growth spurt of educational programs was seen, including the launch of the first postgraduate “residency” program for PAs at Montefiore Hospital in 1971.

Early PA leaders and the AMA’s Council on Medical Education recognized the need for some mechanism to evaluate the quality of educational programs. In 1971, the first accrediting body, the JRC-PA, was established under the auspices of the AMA’s CAHEA. The Essentials of Accredited Educational Program for the Assistant to the Primary Care Physician were adopted and approved by the AMA’s House of Delegates to provide a written document, which was used for determining whether or not a program met minimum requirements.

In the early years of the profession, there was also a need to ensure to state regulators, doctors, and patients that PA graduates had the background knowledge and skills to practice in their chosen field. The Registry of Physicians’ Associates, formed in 1970, issued certificates of approved programs and administered examinations to ensure competency of informally trained PAs. Later, the Registry was incorporated into the American Academy of Physician Assistants and was dissolved as the National Commission on Certification of Physician Assistants (NCCPA) began to take on the PA certification role in 1975.

In 1972, the first and only organization for representation and advocacy of PA education was formed with 16 charter members. Through funding by the Robert Wood Johnson Foundation, the APAP (later changed to the PAEA) was able to establish a home with the American Academy of Physician Assistants (AAPA) in Arlington, Virginia. The initial role of APAP was to facilitate faculty development and sharing of ideas about curriculum, teaching, and evaluation. However, the APAP at this time was incorporated into the fabric of the AAPA, and as such the AAPA also took an active role in PA initial and continuing education. One example was The Development of Standards to Ensure the Competency of Physician Assistants, which was a five-volume report funded by the federal government and included a role delineation for PAs. The role delineation provided a foundation for mapping PA program curricula.

Historical Context

In 1980, the widely disseminated report of the Graduate Medical Education National Advisory Committee (GMENAC) to the Health and Human Services was issued. The Committee predicted a physician surplus and recommended that medical schools decrease enrollment in the entering class by 10% to 17%. It further recommended that nonphysician health care provider enrollments be capped and called for further research on PAs, nurse practitioners (NPs), and CNMs. The Graduate Medical Education National Advisory Committee (GMENAC) also contained some positive recommendations regarding PAs, including in the report recommendations to the states to broaden the scope of PA practice and authorize limited prescriptive authority. In addition, the report contained a recommendation that “Medicare, Medicaid, and other insurance programs should recognize and provide reimbursement for the services of NPs, PAs and nurse-midwives in those states where they are legally entitled to provide these services” (recommendation 14 of the nonphysician provider panel).

In 1986, through the Omnibus Budget Reconciliation Act, PL 99-210, PAs and NPs were approved to receive reimbursement under Medicare. Reimbursement for Medicare services was made to the practice that hired the PA, not the provider. PAs were reimbursed at 85% of the physicians’ rate for hospital and nursing home care and 65% of the physicians’ rate for first assistant in surgery services. PAs providing services in certified rural health clinics were reimbursed at 100%. Reimbursement for PA services provided increased job opportunities for PAs. The improved PA job market stimulated interest in the profession by potential PAs and caused universities to develop new PA programs to meet the increasing demand.

Physician Assistant Education Events

During the 1980s, there was a slowing in the growth of PA educational programs in response to GMENAC ( Fig. 4.1 ). PA education at that time was still provided predominantly in academic medical centers. In 1985, 21 of 33 existing PA programs were housed in medical schools ( http://www.arc-pa.org/acc_programs ). In 1985, under the leadership of Dr. Denis Oliver at the University of Iowa, the first national survey of PA education and PA education programs was conducted and published. It has been published consistently since then. In 2015, the 30th program survey report was released by the PAEA.

Growth of physician assistant programs, 1965 to 2014, as represented by year first class enrolled).

(From Physician Assistant Education Association. By the Numbers: 30th Report on Physician Assistant Education Programs in the United States, 2015 . Washington, DC: Author; 2015.)

Historical Context

Although health maintenance organizations (HMOs) can trace their roots back to as early as 1910 in Tacoma, Washington, there was a rapid growth of HMOs in the 1990s. The rise of HMOs was spurred in part by the need to bring down health care costs as they reached 13.4% of gross domestic product in 1993 and were predicted to reach 20% by the end of the decade. Because the financial model is supposed to favor prevention, many HMOs began to use PAs.

In addition, policymakers became increasingly aware that the dramatic increase in health care costs was not matched by improved patient outcomes. In September 1993, President Bill Clinton announced his intention to lead a major health care reform initiative to address these concerns. Unfortunately, his reform plan did not gain the support of Congress.

Physician Assistant Education Events

Beginning in the mid-1990s, there was another spurt in the development of new PA programs. During this decade, an additional 65 programs enrolled their first classes. During the 1990s, there was an increasing realization that the tremendous growth in PA programs was resulting in a high number of PA faculty who were qualified by clinical experience but lacking in teaching skills. The APAP was offering workshops and seminars but formalized these activities in 1998 under the APAP Faculty Development. Initial faculty development workshops were designed primarily to assist faculty with basic skills such as writing better examinations, development of syllabi, and working effectively in the academic environment. There were also extended leadership workshops for individuals new to the program director role. Today, there are at least 15 to 20 different “courses” ranging from clinical coordination skills to use of simulation for teaching and evaluation ( http://www.paeaonline.org/events/pando-workshops ).

In 1998, US News and World Report ( USNWR ) released its first ranking of graduate-level PA programs. Although there was (and continues to be) much skepticism surrounding the USNWR methodology, inclusion of PA programs in the rankings helped legitimize PA education within academia.

Historical Context

The 2000s were marked by continued advancements in medicine, many related to discoveries from the Human Genome Project. Personalized medicine became a real possibility for the first time. The terrorism threats after September 11, 2001, and several subsequent cases of anthrax infection resulted in significant federal funding and research into combating threats related to bioterrorism.

This decade is also marked by a national concern for health care quality as evidenced by the release of the seminal report by the Institute of Medicine (IOM), Crossing the Quality Chasm: A New Health System for the Twenty-first Century , which pointed out the human and financial cost of medical errors. In 2008, Berwick, Nolan, and Whittington proposed a paradigm for improving the nation’s health system. They proposed what is now commonly called the “Triple Aim: improving the experience of care, improving the health of populations, and reducing per capita costs of health care” (IOM, Crossing the Quality Chasm ).

Prompted by concerns about medical errors and patient safety from overworked physician residents as well as a petition by the American Medical Student Association and others to the U.S. Occupational Safety and Health Administration (OSHA) in 2001, the Accreditation Council on Graduate Medical Education (ACGME) began to look at resident and patient issues relative to workload. It was not until 2003 that the ACGME established tighter restrictions on the hours residents could work and be on call. These restrictions were later tightened further in 2011 and contributed in part to the need for more PAs in academic medical centers and teaching hospitals.

Physician Assistant Education Events

One of the seminal events that occurred early in this decade was the endorsement of the master’s degree as the standard entry-level degree to the profession by the PAEA (then the APAP) in October 2000. From 2000, the percentage of graduate-level PA programs increased from 49% to 93%. In March 2000, the ARC-PA left the Commission on Accreditation of Allied Health Educational Programs (CAAHEP) to become an independent organization.

The increased interest in PA education by students helped to spawn the CASPA in 2001. This service allows applicants to PA educational programs to file one application and have it disseminated to as many as programs as they choose. Since the launch of CASPA, the number of applicants to PA schools has increased. In the 2005 to 2006 cycle, there were 7933 applicants, and this rose dramatically to 22,997 by the 2014 to 2015 cycle.

The endorsement of the master’s degree as the proper degree for PAs in 2000 did not end the discussion about degrees. The decision of the NP profession to endorse the Doctor of Nurse Practice (DNP) degree as the entry-level degree for NPs spurred further discussion regarding a clinical doctorate for PAs. In March 2009, representatives of the entire PA community and others came together for the Doctoral Summit. The purpose of the summit was “to develop recommendations to the profession on whether the clinical doctorate is appropriate as an entry-level degree, as a postgraduate degree, or not at all.” The outcome of the summit was that that PA profession unified around four recommendations: (1) opposition of the entry-level doctorate, (2) re-endorsement of the master’s degree as the entry-level and terminal degree for the profession, (3) support of postgraduate clinical doctorates, and (4) recommendation to explore bridge programs to allow PAs advanced standing in medical schools.

Historical Context

One of the most influential events during this decade was the passage of the Affordable Care Act in 2010. This act fundamentally changed health care with provisions that increased access to health insurance for millions, allowed young adults to stay on their parents’ insurance plans until the age of 26 years, outlawed denial of health insurance coverage based on preexisting conditions, and required coverage for preventive health measures. In addition, the law directed the federal agency charged with administering Medicare to find and implement measures to decrease the costs of health care.

Physician Assistant Education Events

The 2010 decade will likely be remembered for the third spike in PA program growth, particularly among private, nonprofit colleges and universities not associated with medical schools. During this decade, there were calls for health care to be increasingly delivered by teams of health professionals. Although physicians and PAs have worked as teams since the inception of the profession, there was a recognition that the team needed to be expanded. Two important reports were released in 2011 by the Interprofessional Education Collaborative: Core Competencies for Interprofessional Practice and Team-Based Competencies: Building a Shared Foundation for Education and Clinical Practice . Unfortunately, the PA profession was excluded from the initial members of the collaborative formed in 2009 but was invited to participate in events and became a member in early 2016. During this decade, PA partnerships were strengthened with organized medicine as evidenced by the joint position statement of PAEA and the Society for the Teachers of Family Medicine. In April 2014, as further evidence of the strengthening of PA and physician partnerships, the PAEA relocated its headquarters to the same building with the Association of American Medical Colleges (AAMC) and the American Dental Education Association (ADEA).