Physician assistant education: Past, present, and future challenges

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 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 (a contract of “Medicine Extension”) combined a short period of classroom study with a longer apprentice-like period with a potential physician employer. Other education models were established 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 time, 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 as 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 use of arthroscopy meant that medical care was now available for diseases and conditions that previously would have caused morbidity and mortality. 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 of 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. At 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 an Accredited Educational Program for the Assistant to the Primary Care Physician standards were adopted and approved by the AMA’s House of Delegates to provide a written document to be used for determining whether or not a program met minimum requirements.

In the early years of the profession, there was also a need to assure state regulators, doctors, and patients that PA graduates had the background knowledge and skills necessary to practice in their chosen field. The Registry of Physicians’ Associates, formed in 1970, issued certificates for approved programs and administered examinations to ensure the competency of informally trained PAs. Later, the Registry was incorporated into the American Academy of Physician Assistants (AAPA) 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 renamed the PAEA) was able to establish a home with the AAPA in Arlington, Virginia. The initial role of the APAP was to facilitate faculty development and the sharing of ideas about curriculum, teaching, and evaluation. The APAP at the time, however, 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 of their collaboration was in the creation of The Development of Standards to Ensure the Competency of Physician Assistants, which was a five-volume report funded by the federal government that 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 certified nurse-midwives. Nevertheless, GMENAC also included some positive recommendations in their report regarding PAs, such as recommendations to the states to broaden the scope of PA practice and to 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 to 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, the growth of PA educational programs plateaued partially in response to the GMENAC report ( Fig. 7.1 ). PA education at the time was still provided predominantly in academic medical centers. 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 ever since. In 2018 the 33rd program survey report was released by the PAEA.

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, policy makers 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.