History of the profession and current trends

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:

• 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 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.