The Origin of the PA Concept

Many people believe that the Physician Assistant concept began in 1967 at Duke University. Although this was one of the first PA programs in the United States, the concept of the Physician Assistant may be dated back to the 1940s. Dr. Amos N. Johnson first began training his “assistant” Henry Treadwell to help him manage his general practice in North Carolina. Shortly after Dr. Johnson began working and teaching at Duke University. He exposed Dr. Eugene Stead Jr. to his “assistant”, which would later inspire Dr. Meade to create the PA concept (PA History Society Website,2007).

In 1942, during world war two, Dr. Meade was assigned the task of quickly prePAring physicians for combat duty. The government wanted a fast track program of education for doctors. The attorney general at that time asked Dr. Meade to create a three year program of medical training for physicians. The idea of a shortened medical education would later be a cornerstone to the PA concept(PA History Society website, 2007).

While at Duke University in the 1950s, Dr. Steade realized that community physicians were too busy in their practices to handle PAtient demands. He had been aware of Dr. Johnson and Henry Treadwell, and began thinking of ways to lessen the burdens of daily practice on physicians. Dr. Meade first tried to exPAnd the duties of nurses at Duke University. He worked with a nurse educator Thelma Ingles. Dr. Meade and Thelma Ingles tried to get a master’s program accredited at Duke University for nurses, but failed to do so. Dr. Meade, as well as many other physicians at that time, continued to use many ex-corpsmen to assist them in their practices.

By the 1960s the numbers of general practitioners were declining. The public began demanding better access to health care. The government enacted Medicare legislation, and felt pressure to take action to correct the lack of health care access.

During the early 1960s Dr. Meade began to create a two year program specifically for ex military medics. He gained support for this program amongst his colleagues at Duke University. Finally, in 1965 he began training his first class of physician assistants. The corpsmen went on to graduate in 1967(PA History Society WebPAge, 2007).

By the 1970s the PA concept gained more acceptance within the medical community. A study in 1975 showed that many routine tasks including taking PAtient histories, doing PAp smears, and providing medical phone advice were routinely being provided by physician assistants(Glenn,1976). In 1974 there were approximately 1252 graduates of PA programs(Perry,1978). Most were practicing in rural offices.

The PA today
Today there are over 139 accredited PA programs(ARC-PA website,2007). Programs range from two year undergraduate degrees to master’s level programs. Most programs are associated with a medical school or nursing campus(Simon, 2006). All programs receive their accreditation form the Accreditation Review Commission on Education of Physician Assistants. This organization follows certain criteria agreed upon by the board.

Most PA programs have a didactic and a clinical portion. During the didactic portion of education the student learns many of the sciences taught in most medical schools. However the length of time the PA has to learn these sciences are usually abbreviated. A study in 2003 showed that a successful PA student had to be very efficient and motivated. There was a direct link between self efficacy and clinical performance(OPAcic, 2003). The clinical portion of the PA’s education is approximately 2000 hours long. These rotations are based on the medical school model. Between the years of 1998 through 2005 there was a nine percent increase in the number of PAs that were graduating from an accredited program, showing a steady increase in PA numbers(Simon, 2006).

After a PA student graduates from an accredited program, they must take a national certifying exam. The exam is called the PANCE(physician assistant national certification exam), and is administered by the NCCPA(National Commission on Certification of Physician Assistants). This organization is presently also responsible for physician assistant continuing medical education logging and maintenance. A physician assistant is required to have 100 hours of CME per two year cycle. No less than fifty of the 100 cme credits must be approved category 1 credits. Cme may be provided in many different formats such as lectures and individual training. Cme training directly affects the abilities of the PA and can improve PAtient outcomes(McClure, Price, Xu, 2005).

Physician Assistants may now be licensed in all fifty states. The licensing regulations are mandated by the individual states. Each state describes in its statutes a physician assistant’s scope of practice. In most states the scope of practice is defined by a uniform set of guidelines which helps physician’s define the role of the PA(Cooper,2004). As of 2007 physician assistants have prescription privileges in all fifty states.

As of 2007 there are approximately 75,260 physician assistants eligible to practice in the United States(AAPA website, 2007). This is a sixty fold increase in numbers in only 30 years(Perry,1978). Another PA statistic that has radically changed is the number of women midlevel providers. As of 1978 only twenty percent of all PAs were women comPAred to more than sixty four percent in 2007(Perry,1978)(AAPA website,2007). Also a shift from rural and primary care settings has been noted. In 1978 approximately sixty percent of all PAs were working in cities with less than 50,000 person populations. Today only thirty percent are working in these same types of communities.

When the physician assistant concept was established, primary care was the main focus. Today more than twenty five percent of all PAs work in surgical specialties. Only approximately thirty seven percent work in a primary care related field(AAPA website,2007). The shift to more complex areas of medicine is well documented. One publication shows an exPAnded use of PAs and other first contact health providers from around the world(Buchan, 2002). Another study showed a large overlap in PA duties comPAred with primary care physicians. The study further showed that PAs were very caPAble of taking on a high degree of responsibility in many areas of medicine(Cawley, Hooker, 2003).

Efficacy of the Physician Assistant
Recently, many studies have been done to assess the efficacy of the physician assistant. In one study PAs increased productivity in offices. They increased the number of PAtients seen and improved the overall workload for the physician(Hooker, 2000). Another study showed that PAs saw an average of ten percent more PAtients in an ambulatory setting then a physician(Hooker, 1993). This was due to the physician’s other responsibilities such as hospital call and teaching duties.

Physician assistants generally have a lower salary then physicians which improves profit margins for hospitals and managed care centers. One study showed that PAs have lower salaries but saw comPArable numbers of PAtients. Overall a practice that employed a physician assistant saw a financial differential of $52,592 in 1999 U.S. dollars(Grzybicki, Sullivan, 2002) A health maintenance organization studied physician assistant visits versus physician visits in terms of cost to the organization. Overall, for an episode of acute primary care, the study found that the cost of care by a PA was considerably less then care provided by a physician(Hooker, 2002). For some diagnosis this was due to the lower salary of the PA. In other cases the lower costs were associated with lower utilization of ancillary services.

The Future of the PA profession
As of 2006, the United States population is over 298 million people. The medical workforce has been overstretched for years. Recently ,in 2003, the Accreditation Council for Graduate Medical Education reduced a medical resident’s workweek. The work week was reduced from eighty hours to fifty hours. If a hospital fails to comply with these guidelines they can lose their accreditation, and lose their residency program. This fact has caused many immediate shortages, and the long term consequences are still being studied.

Combine these facts with a steady decline in the numbers of nursing graduates and we have a formula for a crisis. Since the late 1990’s the number of nurse practitioners has been declining. Given the aging of the working nursing force and the lack of interest in nursing as a career, the number of clinical nurse practitioners entering the workforce may decrease even further(Buerhaus, Staiger, 2000). The annual number of medical graduates has only increased nine percent since 1980. The number of PA graduates, however, has increased nine percent in less than a quarter of that same time period.(Lin, ET AL, 2002). Many health care facilities are using midlevel providers to fill in the gaps usually filled by residents. According to the Bureau of labor and statistics the employment future of physician assistants in the United States seems secure for the next decade to come(Hecker, 2001).

With growing numbers of population, decreasing numbers of nurses and residents, and fewer numbers of foreign medical doctors immigrating to the U.S., the demand for PAs seems secure(Hilsenrath, 2003). Newer workforce studies show that economic growth is directly linked to the demand for physician services(Cooper, 2003). This additional pressure will only stress the health care system further as physician supply fails to keep up. The positions not filled by the traditional physician model will provide more PA job opportunities.

Finally, fewer medical students are choosing primary care as a specialty(Showstack,2003). Even fewer medical school graduates choose to stay in primary care once practicing(Sox,2006). Primary care seems to be in a crisis. With a shortage of physicians interested in general medicine, it seems likely that midlevel providers will be filling these roles. While this may not have been the goal of Dr. Steade, it seems that midlevel providers are the only solution available at this time.

Review Summary
 The introduction of physician assistants 40 years ago was an important mile stone for medicine. Changing a rigid model of medicine would prove slow. Innovators like Dr. Johnson and Dr. Steade could not have realized the imPAct that their forward thinking would have on society. Over twenty five percent of all group practices employ midlevel providers today. Midlevels are now a cornerstone of large health maintenance organizations, and play key roles in many hospitals around the country. The future of the profession seems a bright one.