Marzucco, Joseph PA-C, PhD; Hooker, Roderick S. PhD, PA; Ballweg, Ruth M. MPA, PA-C
Few will have the greatness to bend history itself; but each of us can work to change a small portion of events, and in the total of all those acts will be written the history of this generation.
—Robert F. Kennedy
The introduction of physician assistants (PAs) into American society was intended to offset the scarcity and maldistribution of physicians.1 That movement grew out of three universities—the University of Washington, the University of Colorado, and Duke University. In 1969, the MEDEX Northwest program at the University of Washington, under the development of Richard A. Smith, MD, MPH, created an apprentice-protégé model and distributed students to many parts of the Pacific Northwest. (MEDEX is a contraction of the words medicine and extension.) The MEDEX movement grew from a vision that the healthcare needs of many medically underserved Americans could partially be met with veterans, trained for more general medicine roles, to assist overworked physicians.2
A 1971 evaluation of the MEDEX Demonstration Project for its federal contract described the program: “MEDEX is not a training program for health manpower. MEDEX is a technological tool to develop and deploy manpower for specific needs. The MEDEX approach evaluates need [and] develops a receptive framework for manpower that is then trained towards those needs within a competency based training program. On completion of training the appropriate manpower is deployed to areas of low accessibility. This predetermined deployment to areas of need is one of the distinguishing characteristics of the MEDEX approach. The system assures placement of trainees by involving the practitioners in the total process from the very beginning.”3
Alaska is unique in PA history. As of 2010, it is the state with the largest ratio of PAs per capita: 75 per 100,000 (three times the national average). Alaska also has more far-flung populations than any other state (comparable to the provinces and territories of Canada) and many of the providers are in rural health settings.4
BACKGROUND OF THE ALASKA PA EXPERIMENT
Smith's vision was based on three premises: a perceived physician shortage, that substitutes to the physician were well regarded and historically substantiated, and that Navy corpsmen and Army medics, with advanced training and recently separated, were available in large numbers.5
Alaska, isolated from the contiguous United States, had developed Alaska Community Health Aides (CHAs) in the 1940s and '50s, while still a US territory. CHAs had been viewed largely as a success but were also unheralded. The CHA program trains local residents to provide emergency and primary care services in villages that are frequently without roads and hundreds of miles away from the nearest medical facility. These CHAs use procedures in manuals and consult by telephone or radio with hospital-based physicians.6 The concept of a trained clinician serving in historical semi-autonomous medical roles was not new to Alaska.
Following World War II, Alaska had one of the leanest ratios of physicians per capita of any state. Although the three major cities in Alaska had little difficulty attracting physicians, the rural areas suffered scarcity. Smith had graduated three classes of MEDEX for deployment in Washington State and the project was going well.5 The program's leaders saw an opportunity to expand into other areas of the Pacific Northwest.
In 1971, the Alaska Health Manpower Corp. entered into an agreement with Smith to place MEDEX students in Alaska. This initiative was funded by the Washington/Alaska regional medical program as outlined in an October 1971 letter from Robert Ogden to Donald Freedman, MD, director of the Alaska Division of Public Health. Ogden was executive secretary of the Alaska State Medical Association (ASMA) and explained that all expenses of the commission for the MEDEX experiment would be borne by ASMA until program funding started in January 1972. Jointly, the State of Alaska and MEDEX worked to complete the necessary arrangements to receive students from Class IV. Ogden requested one of Freedman's staff, Maurice Messer, to work with the Health Manpower Corp. to assist in this project. Messer had been involved in the formation of the Alaska Health Manpower Corp. and was ideal to help identify physician preceptors.
Messer developed a roster of prospective physician preceptors, arranged MEDEX staff site visits, and completed arrangements for the selection conference. Although Messer's duties were minimal after the selection conference, as a retired noncommissioned officer in the Air Force, he felt a kinship with the ex-corpsmen and medics that formed the first seven MEDEX in Alaska, maintaining close ties throughout their training.
Initially when Class IV was being formed in 1971, all applicants were to be placed in the Northwest. A number of the applicants, expecting instructions to appear in Seattle for interviews, were contacted by phone by MEDEX Northwest. In author Marzucco's case, Lorna Dilly, an administrative assistant, contacted him via telephone. The following conversation is paraphrased:
“... Hi, this is MEDEX Northwest. I'm aware you are preparing to come to Seattle for the selection conference, however we [MEDEX Northwest] have just received permission to place PAs in Alaska. Your ticket to that selection conference in Anchorage is already in the mail. Are you interested? There are seven preceptorship sites and you are one of 14 chosen to be interviewed.”
Marzucco (Figure 1) recalls: “I had only been home 4 months from Vietnam and was standing in my mother's living room talking to MEDEX staff about the adventure of a lifetime. Having been a Special Forces medic with Vietnam combat experience, I knew this program was designed for people with my training and skill, and my only obstacle to getting in was the interview. I accepted and packed.”
ACCEPTANCE, TRAINING, AND DEPLOYMENT
MEDEX had 19 seats available for Class IV: 12 for Washington State and 7 for Alaska. In November 1971, 14 applicants arrived at the Anchorage Holiday Inn on a Friday. On Saturday, the preceptors and MEDEX staff interviewed the 14 (Figure 2). The physicians were Peter Hansen (Kenai); James Ivey (Palmer); James Lundquist, Joseph Ribar, Robert Roth, and Charles Townsend (Fairbanks); Thomas Sims (Cordova); and Jerry Little (Anchorage) (Figure 3). Before the final preceptor matching, Arthur Tilgner replaced Sims in Cordova.
Sunday morning, following the interviews, seven students were selected for an Alaskan preceptorship. The final matching of students with preceptors was still being decided. The seven were put into groups and assigned a guide. Marzucco recalls that a veterinarian for the State of Alaska took his group on a tour that included notable people, physicians, and the medical facilities of Anchorage, Fairbanks, and Nome via Kotzebue (Figure 4). After a week of touring, they returned home, packed, and moved their families across the country. MEDEX Northwest Class IV started in early December 1971, just a few weeks after the Anchorage interview.
MEDEX students selected for Alaska were John M. “Mike” Brown, Aaron Bucholz, James L. Eales, Michael Grogan, Joseph Marzucco, George B. Randall, and John Winklmann (Table 1). Recalls Marzucco, “Our ages and experiences varied widely, from Randall, a 50-year-old World War II chief hospital corpsman, to me, a recently separated 23-year-old combat medic.”
THE EDUCATIONAL MODEL
From the beginning, Smith was clear that the MEDEX philosophy was to fill a need, and was not to be confused with being educated through a degree-granting program. The MEDEX collaborative model relied on recruiting military medics and corpsmen who had significantly advanced medical training, and adding them to the resources of MEDEX Northwest and receptive preceptors. At the end of the 16-month training, the graduates were presented with a certificate of accomplishment. (The program now awards a graduate degree in addition to a certificate, and uses a standardized 24-month model consistent with all other US PA programs.)
Early in the development of MEDEX, the applicants were male medics and corpsmen with various military training programs and experiences. MEDEX staff distilled medical curriculum to a core set that could be added to areas in which students had attained proficiency from military experience. The MEDEX education model at this time adapted to the backgrounds of those who were available and changed as the supply of extensively trained military personnel dwindled. As an indication of the shortage of ex-medics, the first women were admitted in 1975 to MEDEX Class VII at the University of Washington.
MEDEX Class IV consisted of a 4-month didactic training program in Seattle and a 1-year preceptorship. Classes were held on campus in converted student residence quarters known as the Carriage House. Funding from federal and private sources meant that tuition was waived. As veterans, all were eligible for the GI Bill in addition to a monthly stipend supplied by the program.
Marzucco recalls: “I obtained a degree in architecture in 1968 and shortly thereafter volunteered for the Army. A Special Forces soldier is a triple volunteer—first for the Army, second for Airborne, and third for Special Forces. After advanced training, I became an independent duty Special Forces medic. Because of that training and experience, I was an eligible veteran the MEDEX program was seeking.
“Special Forces medical training was 48 weeks long; including advanced surgical skills to deal with battlefield injuries, general medical problems, tropical diseases and parasites, dental procedures, sanitation, and veterinary medicine. It was a life-changing experience and I knew that I would not be returning to architecture. Medical school had been a possibility, but in less than 2 years of MEDEX training, I could be doing what I wanted to do and what I had done for a year in Vietnam. I felt privileged to be allowed into this fraternity, formerly inhabited only by doctors.”
CLASSROOM TRAINING AND OBSTACLES
Classroom time consisted of lectures, hands-on physical examinations, and learning procedures. Students were required to complete rotations in certain areas of medicine, and sometimes had to find potential clerkship sites through their own initiative (the program had no clinical coordinator). A list of sites was contained in a large loose-leaf binder maintained by the MEDEX program. Marzucco recalls that “when we arrived at a physician's office, we'd hear something like, ‘...When we signed up for this MEDEX program clinical rotation, of course, we thought you were medical students in a new program. We're not sure who you are and what you should be doing.’ That created some impromptu advocacy and diplomacy on the student's part to reassure the supervising physician they could handle the rotation. Also, not all topics were taught. One experience that still stands out in my mind is when I informed a surgeon that our program did not permit us to do pelvic exams. That remark was ignored and I was informed all medical people do pelvic exams—and I did.
“Because the PA training was a federal initiative, a number of activities were in place to document how it was being implemented. It was not unusual to come to class and start the day with a questionnaire, or even a manual dexterity test. One day I arrived at class to find a board with metal pegs and different size washers to place in a special order and sequence as part of an occupational assessment test. We also underwent Minnesota Multiphasic Personality Inventory profiling.”
THE PRECEPTORSHIP IN ALASKA
Early in the development of the MEDEX trainee, a preceptorship was 1 year long. Students were matched to physicians who had promised a training experience unique to the needs of their community and were likely to hire their trainee at the completion of training. The MEDEX faculty and the Alaska Health Manpower Corp. screened physicians for their willingness to teach.
Each preceptorship experience was tied to the medical services of the community. For instance, Anchorage had a well-developed medical and hospital system complete with specialists. More isolated areas like Kenai and Cordova developed specific care models based on the talents and limitations of physicians. For example, Tilgner from Cordova was a general surgeon, so his student learned more surgery than others. The ability of a PA to deal with trauma at the level of a general surgeon had a positive effect for a remote Alaskan community. Kenai's needs were also different; although isolated, the community was connected by road with Anchorage, so surgical cases could be transferred by ambulance.
Marzucco recalls: “The multispecialty Alaska Clinic was the employer of my mentor, Jerry Little, MD. The clinic was housed within the Anchorage Community Hospital. In my case the Alaska Clinic designed a comprehensive experience with exposure in family medicine, internal medicine, pediatrics, gynecology, and general surgery.
“By the early part of 1973 questions in the Alaska Clinic arose concerning the clinic's need for a PA on staff. This uncertainty was unsettling for me and I began to think about what a PA in a state without regulations does for job security. Many in my class believed that we had to ‘sell ourselves,’ but there was little public information on PAs. The selling of our expertise and opening the market depended on what we could convince a physician we could bring to a medical practice. In the early days of the PA profession, existence depended as much on the personality and risk-taking profile of its members as it did on their medical knowledge.
“William De'ak, MD, was the executive director of the Alaska Health Manpower Corp. in 1973 (Figure 5). Located in Anchorage, De'ak negotiated a contract with one of the first federally funded neighborhood health clinics. Upon completion of my PA education, he invited me to work with him. He had been a public health officer in Bethel, Alaska, then was invited to the Lower 48 to start the Stony Brook PA program in New York. He was grounded in the fundamentals of PAs, was on the editorial board of the first PA journal, had helped inaugurate an early PA program, and had a vision about their future. But Alaska drew him back, first to the Alaska Health Manpower Corp., then to the Fairview Family Service Center in Anchorage. I was employed as the clinic's first PA. Within a year, my classmate Mike Grogan joined the clinic.”
Enabling legislation for PAs in Alaska was passed in 1972. Alaska state legislator and Speaker of the House Jalmar M. Kerttula proposed the PA legislation in 1971. The influences that led to the drafting of this legislation are not documented. De'ak believes that the Alaska Division of Public Health and the newly formed Alaska Health Manpower Corp. had some involvement with welcoming MEDEX perhaps in 1970. Coincidentally or purposefully, the draft of PA enabling legislation was submitted in January 1971—preceding the introduction of PAs by a whole year.
The 1971 legislation directed the Alaska State Board of Medical Examiners to promulgate regulations and licensure requirements for PAs. The legislature granted that PAs could exist in the state, but how and under what regulatory authority was left unwritten until regulations were created.
After a legislative start in 1971, the lack of response by the Board of Medical Examiners to create regulations made the development of the PA concept in Alaska uncertain. Not only had regulations not been promulgated, the resistance to do so seemed obvious. All attempts to get PAs established in Alaska could easily have faded away as a failed experiment if some regulation did not take place. Consequently, the early members of the Alaska PA community believed the stakes were high and action was needed. The seven Alaska MEDEX students believed, according to Marzucco, that “we were not just sent to learn medicine, but were the vanguard of a profession, and picked for our skill, maturity, and ability to get work done. All of us felt we were under scrutiny as an experiment creating a new type of health professional and believed we were under a mandate to set a good precedent. Furthermore, many of us believed that early PAs were, in part, selected for the ability to provide independent reasoning, self-reliance, and persistence in task.
“Without regulations and licensure, many of us tried to give the impression that rules and policies were already established based on the legislation. For example, on the first day of my preceptorship in the office of Dr. Little at the Alaska Clinic, a pharmacist was handed a prescription by a patient I had just seen. He wondered if I had the authority to write prescriptions. The pharmacy was in the same building as the Alaska Clinic and the hospital. I replied, “of course, I have a copy of the legislation if you'd like to see it,” hoping he did not want to read it. Similar challenges happened frequently as we were confronted with various policy ambiguities that had not been defined because the state Board of Medical Examiners had not promulgated regulations as directed by the enabling legislation. These included prescriptions, scheduled drugs, procedures, hospital regulations, bylaws, and orders. Clearly legislation was not enough and the regulations for PA employment were needed.
“Many of us believed that the stature of the physician preceptors in the community permitted these ambiguities to be moved temporarily to the margins. While many issues were provisionally settled and defined at a later date, they were issues that were not going away. PAs had to be defined in Alaska if their role was to be secured.”
THE NEED FOR AN ORGANIZATION
Marzucco recalls: “The AKAPA was formed in 1975 in Fairbanks, with Jim Eales from MEDEX Class IV as its first president. From the moment the AKAPA was organized, it attempted to work with the Board of Medical Examiners, as directed by the Alaska State Legislature, to regulate PA licensure. Neither the Board of Medical Examiners nor some physicians in the state seemed ready to define and regulate the functions of the PA in Alaska. In addition, there was resistance by nursing to formalizing a PA existence. Their hope was that we would, if not nourished by a regulatory body, simple wither on the vine.”
Jack Richardson wrote the first draft of regulations. In 1977, Marzucco was elected president of the AKAPA and with a small team organized a medical education conference in Fairbanks. During the early development of the AKAPA, the main mission was to get a set of regulations passed. The conference was an avenue to bring all Alaska PAs together for collaborative efforts to obtain PA licensure regulations.
Recalls Marzucco: “As president, I invited Donald Fisher, the executive director of the American Academy of Physician Assistants, and David Glazer, the executive director of the newly formed National Commission of the Certification of Physician Assistants, to Alaska. These national experts were invited to testify at public hearings held in Anchorage and Fairbanks on the first draft of regulations for PAs submitted to the Alaska Board of Medical Examiners.”
In a June 2013 letter, Donald Fisher writes: “We testified in Fairbanks and Anchorage. We also had a funny story about the nurses' opposition and their testimony. By accident, when David and I were checking in to testify David accidentally picked up their [nurses'] testimony, giving us complete access to what they were going to say. Needless to say it was a trip I will always remember.”
David Glazer writes in June 2013: “As you can see, Don has shared your email exchanges with me, so thanks for stimulating a bit of nostalgia. I think you have accurately described the history of our trip to Fairbanks, as I remember it. It was really enjoyable and we learned a great deal about Alaska during our brief visit. As I recall, the nurses had expressed opposition to PA activity in the state by attacking the supervision issue. My recollection is that you folks had included face-to-face physician-supervisor/PA connection at least once every 2 weeks or perhaps monthly (weather and travel permitting) with 24/7 radio communication as needed. The nurses objected to this and were arguing for over-the-shoulder supervision, thus negating any possibility of PAs deploying to remote settings.”
Resistance to PA regulation was intense, and the Board of Medical Examiners blocked every draft year after year. However, in 1978, a break occurred. Marzucco recalls: “In that year, a state ombudsman in Anchorage informed me that a new Alaska sunset law had been enacted that had substantially increased his business. A provision of the sunset law stated that agencies that failed to accomplish legislative mandates, such as promulgating regulations, could be formally closed. The PA law came under this sunset proviso. Using this law as leverage for action, the AKAPA was meeting with the Board of Medical Examiners within 2 months, and regulations were approved in 1979.” The regulations took effect January 13, 1980, and according to the Board of Medical Examiners, the first PA license was issued on March 5, 1980, to James L. Taylor. John Winklmann, license number 20, has continuously practiced in Alaska from his preceptorship to date (Figure 6).
THE TRANS-ALASKA PIPELINE SYSTEM
The 800-mile Trans-Alaska Pipeline System was built between 1974 and 1977. A rise in oil prices at the time made exploration of the Prudhoe oil field economically feasible. The discovery of oil at Prudhoe Bay in 1968 was considered a windfall, and a consortium of oil companies wanted to start drilling. However, development of the oil field moved very slowly until an oil crisis in the early 1970s; legislation was then passed to remove legal challenges to the project. Between early 1974 and July 22, 1977, when the first barrel of oil reached Valdez, tens of thousands of people worked on the pipeline.
A huge system of logistics and infrastructure was built to accommodate the workers. Physicians were hard to come by and the concept of PAs was taking hold in Alaska. Jonathan Wainwright, MD, of Bechtel Corp., recruited George Randall, from the first MEDEX class sent to Alaska, as the first PA administrator of the pipeline and charged him with beginning a stateside recruitment effort. The time was serendipitous as a recession was under way in the Lower 48 and PAs were clamoring for jobs in various parts of the country. The enticement to work a few months in Alaska, then take a paid furlough back home with a paid round trip was alluring.7 Each of the pipeline's 25 construction camps and 12 pumping stations was supposed to have a dispensary and be serviced periodically by a clinician (physician, PA, or paramedic). At least 20 PAs were recruited initially. When Randall returned to private practice in Tok, Alaska, Jack Richardson, PA, followed him as PA administrator for the pipeline. As a PA now in charge of medical recruitment and administration for the pipeline, Richardson may have contributed to the abundance of PAs on the project over its 3-year construction period. Other resources included paramedics, nurses, and former corpsmen or medics.
An expanding necessity to put health personnel in rural Alaska, as well an approaching need for medical coverage on the pipeline, prompted a need to legitimize PAs to work in Alaska. The draft PA legislation submitted in 1971 probably had some oil pipeline influence, but no documentation has been found to support this assumption. The Alaska Division of Public Health and the newly formed Alaska Health Manpower Corp. also may have been involved.
How many formally trained PAs worked on the pipeline is not known, but the number is probably less than 25 at any one time, as there were only 25 dispensary sites. Marzucco remembers, as a PA in Fairbanks taking referrals from the pipeline, that all the personnel were referred to as PAs. Mike Grogan, a member of Class IV, writes in an August 2013 letter about the Randall book:
“... I think that he [George Randall] overstates the hiring of PAs. He refers to them as PAs, but never mentions ‘registered’ PAs except for his own position. ... After my initial 8-week stint at the Dietrich camp, where I covered two additional camps, Coldfoot and Chandalar, I was tasked with visiting all the camps on the northern end of the pipeline, from Fairbanks to Deadhorse. During these visits, I never encountered another registered PA. All the medical personnel were ex-military with most being former Special Forces or retired Navy Chiefs [and not PAs]. When I was transferred to the Valdez Terminal site, there were six medical personnel at the terminal and two across the bay at the pipe yard. Of these, only one was a registered PA and he was out of the Duke program.”
In George Randall's book of his life as PA and an article for “News Line for Physician Assistants” in which Randall is quoted, he states there were three female PAs working on the pipeline.8 Debra Younger, PA, MD, MEDEX Class IX, writes in an August 2013 letter that she did her preceptorship in Alaska in 1975 and later was employed by Alyeska Corp. at the Valdez pipeline terminal in 1976. She knew of two other female PAs.
Because of the high turnover on the project, more than 70,000 people worked on at least a part of the pipeline. Considering the harsh conditions and isolation of these outposts, the medical personnel needed to be experienced and able to contend with the mundane as well as medical emergencies. Younger recalls hearing that by the end of pipeline construction in 1977, about 200 PAs were in Alaska.
The other influences in the introduction of PAs into Alaska were state and federal in origin. The National Health Service Corps (NHSC) had been placing health professionals in Alaska since 1972. With its massive boroughs and distant villages, Alaska remains a designated health professions shortage area. The NHSC and the Alaska Native Regional Corporations recruited PAs for Alaska beginning in the late 1970s. One early role for PAs deployed to Alaskan native villages was to support and provide additional training for CHAs, perhaps to prepare them to enter formal MEDEX training.
The development in the mid-1960s of federally qualified health centers, a designation from the Bureau of Primary Health Care, permitted Alaska natives and tribal groups governance of healthcare services. At least 25 are in existence as of 2012. Some have been staffed by PAs since the 1970s.
William De'ak writes, in July 2013: “I returned [to Alaska] during the summer of 1973. I do not recall how I came to get the new position with the Alaska Health Manpower Corp., a project funded through Region X of the Department of Health, (now DHHS). It was probably through the network of people training this new breed of providers, that is, PAs and NPs. In association with the newly formed National Health Services Corp. (consisting of two people in an office in Bethesda, MD), our job was to place these providers in Alaska villages and towns not served by the Alaska Native Health Service. Thus, this took me as far afield as Unalaska, Cordova, and Deadhorse. I believe it was the question of physician supervision versus independent practice that got me involved in the various communications with the Medical Society and officials and legislators in Juneau. However, unfortunately I do not recall any of the machinations that followed.”
At the end of the 1970s, Alaska had a contingent of PAs widely deployed, and more were arriving. Demand was high for all health professionals as the state had a new lease on life. More industry was arriving and more people were interested in being part of a frontier state.
The 1970s were transformative for PAs throughout America and Alaska played an important role in their development. From the pivotal work of Richard Smith and colleagues who developed and promulgated the MEDEX concept, to the Alaska Health Manpower Corp., to the pioneering spirit of the first students, the remoteness of the state seemed a last frontier to many. The introduction of PAs began in 1971 and was propelled by various influences including influential physicians, legislators, PA leadership, the pipeline construction, and federal influences. Other influences followed this 1970s story and so we leave the stage set for the next chapter of PA development in Alaska.
© 2013 American Academy of Physician Assistants.