The US government is the largest employer of physician assistants (PAs) and one-fifth of all PAs in the United States have served in uniform at some point.1 The US Army has the greatest proportion of military PAs (about 65%) compared with the Navy, Air Force, and Coast Guard.2,3 According to the PA assignment officer at Human Resources Command, the Army has about 850 active-duty PAs, with more than 120 in the active Reserves and National Guard (Written communication from Maj. Lauris Trimble, MPAS, PA-C, April 2016).
The roots of the military PA connect with the founding of the PA profession. Army medics and Navy corpsmen serving in the Vietnam War obtained battlefield medical skills but their training failed to translate into civilian healthcare professions. Two of the early developers of the PA profession felt that veterans with healthcare experience could be trained to fill physician shortages.4 As PAs emerged as well-trained healthcare professionals in civilian roles, the Army looked to use them. Initially, PAs were projected to provide general medical care to soldiers in their respective field units, replacing general medical officers. The experience was considered successful, and in 1971, the Army began its own PA training program.5
In an effort to document the growth, training, and use of Army PAs a historical study was undertaken. A secondary purpose was to evaluate the use of female PAs.
Journal articles in public bibliographies and documents in the Army's research collection at its medical department Center of History and Heritage in San Antonio were searched. Historical events were researched and facts were verified via personal communication with Army PAs at Human Resources Command and throughout leadership positions.
The Army began a PA training program in 1971; the first class of 120 PAs was graduated in 1973 from the medical field services school PA program and awarded associate degrees from Baylor University.5,6 In 1975, the Army determined that enough PAs were on active duty and terminated its training program. However, within 3 years, a PA shortage followed and the Army Surgeon General ordered the program restarted. The program resumed in September 1979 at Fort Sam Houston in Texas, granting college credit through Creighton University.7,8 The Army program was converted to a baccalaureate program through the University of Oklahoma in 1983 and to a master's level program through the University of Nebraska in 2003.7
Before 2001, only enlisted applicants could enroll in the Army PA training program. In 2001, the program was opened to all Army personnel and by 2013, half of the students were commissioned officers.8,9
By the mid 1990s, all the uniformed services had a PA program. The US Interservice Physician Assistant Program (IPAP) began in 1996 to reduce government expense by combining the four uniformed service education activities into one housed at Fort Sam Houston in San Antonio, where the Army had its program. IPAP is the largest PA training program in the world, graduating about 170 students per year. It has a 96% pass rate of the national certification examination.8
Initially, Army PAs replaced physician general medical officers assigned to individual battalions. Upon initial assignment, graduates were designated as battalion surgeons, becoming first-line medical officers. In a letter to all Army physicians in 1971, Brig. Gen. Thomas J. Whelan, Jr., MD, explained that PAs were intended to fill the general medicine positions in field units so that general medical officers could be pulled back into the hospitals and specialists could remain focused in their specialty roles.10 The goal at the time was to pull 400 general medical officers from frontline units and replace them with PAs. Gen. Whelan further projected that the source of these PAs would be noncommissioned officer medics who went through the Army PA training program.10 As Army PAs filled the general medical officer role, their initial duties involved taking medical histories, completing physical examinations, running a preventive medicine program, diagnosing and treating basic conditions, and referring patients when appropriate.5 At the time of this directive in 1971, there was no intention for the Army PA to be employed in a hospital setting.6
Beginning in the 1980s, the duties of Army PAs, in addition to their clinical duties, included training medics and soldiers, specialty medicine, administration and planning, and unit leadership.9 According to Army Techniques Publication 4-02.3, PAs provide medical treatment within their scope of practice, referring patients to the supervising physician or higher level of care when necessary; provide advanced trauma management. In addition to the medical roles Army PAs assume they are also multitasked to conduct training for personnel in first-aid procedures (self-aid, buddy aid, and combat lifesaver), field sanitation, evacuation, and injury prevention; provide soldier and leader training on prevention and recognition of combat stress; support training to maintain medic certification; and ensure that medical records are maintained.11 A 2003 study of how deployed Army PAs spent their time found that 35% was spent in clinic care, 16% in administrative duties, 12% each in medic and soldier education and covering unit missions away from clinic, and 5% in treating combat-related trauma.12 In 2008, 80% of Army PAs were still used in maneuver battalions or in acute care in deployed environments.3
In order to support newly graduated PAs, the Army initiated the Professional Filler System (PROFIS) in 1980, which paired a physician assigned to a clinic or hospital with a battalion if that unit was used for combat or humanitarian missions.13 These physicians were intended to augment the medical unit and could be from any specialty. In a 2011 survey of deployed PAs and their PROFIS physicians, respondents voiced the opinion that PAs were appropriate and at least equivalent to the specialist physicians for prehospital care during combat operations.14
In the 1990s, Army PAs were integrated into the first two levels of care on the battlefield—the medical platoon that serves every combat battalion and the medical company that serves every brigade. At the battalion aid station, PAs were equipped to provide advanced trauma management to combat casualties and to conduct routine sick call when the operational situation allows.15 This evolution of Army medical care by PAs has not gone unnoticed. Robert Mabry, MD, then director of the US Army's prehospital research center, noted in a 2011 book that “it has long been a paradox of military [medicine] that the most junior and least experienced providers are the ones challenged to manage complex cases such as multiple combat trauma in a setting far from mentors or specialists.”9
Although Army PAs were developed for general medicine in line units, they started working in specialty clinics almost immediately. In 1980, the Army began training programs in several medical and surgical specialties; orthopedics, cardiovascular perfusion, emergency medicine, occupational medicine, and aviation medicine.7,16,17 In 1980, the Army Surgeon General converted a number of physician positions in aviation medicine, orthopedics, and emergency medicine to PA positions. These assignments were for PAs who had completed specialty training through the Army.16 In the 1990s, the Army specialty PA programs were converted to master's degree programs in collaboration with St. Francis University.7
A doctoral-level specialty training began in 2006. The intent was to prepare specialized PAs with a substantially higher level of clinical competency who could then be deployed on the battlefield.18,19 After an 18-month residency, the first class was graduated in 2007 from the US Army-Baylor University doctor of science program in emergency medicine.18 These PAs became the first in the nation to earn clinical doctorates. Since this first graduation, the Army has developed similar doctoral programs in clinical orthopedics and general surgery.19 As of 2015, 29 PAs on active duty have completed the doctorate in orthopedics and 36 have completed the doctorate in emergency medicine (Written communication with Maj. Lauris Trimble, MPAS, PA-C, April 2016).
Administration and policy
In 1973, graduating Army PA students were commissioned as warrant officers (technical experts ranked between commissioned officers, whose primary role is leadership, and enlisted soldiers).5 PA program graduates were fully commissioned as officers in the Air Force starting in 1978 and in the Navy starting in 1989. The Army commissioned PAs the first graduates in 1992. That year, the Army also commissioned 257 previous graduates, promoting them to the ranks of second lieutenant through major based on service time.7
After the initiation of the Army PA profession, PAs began filling advisory roles within the Army. In 1976, a PA consultant to the Army Surgeon General was assigned to assist the Army medical community in defining the purpose and use of PAs. This position was formalized in 1992 when PAs were assigned their own section chief. The need for a similar advisor in the combat commands was recognized; PAs became managers and administrators in division headquarters in 1983. A PA consultant to the Army Forces Commander at the Division level was initiated in 1987. In the Human Resources Command, an Army PA career planner was first developed in 1982.20
Initially, the instructors at the Academy of Health Sciences PA program (now IPAP) were all physicians; the first PA instructors were introduced in 1979 and a PA became director of the training program in 1994.20
Because PAs largely were assigned to deployable units, their focus stayed on combat medicine. Thus, in the early 2000s, Army PAs organized programs, including tactical combat medical care training focused on the techniques required to treat preventable causes of battlefield death, tactical combat casualty care training, and a combat lifesaver course.20,21 Army PAs also contributed to development of a hemorrhage control kit now attached to every soldier's uniform.21 This kit became today's improved first aid kit, issued to every soldier during the global war on terror.21
Upon incorporation into medical units, PAs took on leadership and administrative duties in addition to their clinical responsibilities. Once PAs became commissioned officers, leadership roles expanded and some became commanders of larger and more specialized medical units. For example, a PA commanded a medical company in 2004, a combat support hospital in 2008, a forward surgical team in 2009, and a warrior in transition battalion in 2010. In addition, in the early 2010s, many PAs served as officers in charge of troop medical clinics. Both of the Army's major combat training centers have had PAs as the top medical advisor and a senior PA has served as the deputy chief of clinical services in Germany.20
Advisory and leadership positions are generally filled by higher-ranking PAs and are administrative roles with little to no clinical time. To accommodate these increased leadership roles, the Army has expanded the rank structure and authorization of PAs. (Authorizations are the cap or quota of rank for a specialty group in the military, for example, the number of Army PAs authorized for any rank level.) In 2016, there were authorizations for 48 lieutenants, 486 captains, 146 majors, 28 lieutenant colonels, and 4 colonels (Written communication with Maj. Lauris Trimble, MPAS, PA-C, April 2016).
As the Army transformed how it organizes itself on the battlefield, one notable way was the rising role and number of female PAs. Because most PAs were former medics, most Army PAs were men. Beginning in the mid-1980s, the Army has added more female PAs. As of this writing the ratio of male to female PAs is 5:1.3
The first female PAs to be deployed in combat roles were part of the operation in Grenada in 1983. In 1990, as part of Operation Desert Storm, the Army deployed 230 PAs, including 12 women.7 In more recent operations, female PAs were deployed to larger, more centralized bases with little limitations on their location on the battlefield. Starting in early 2012, the Army permitted limited numbers of female PAs to be assigned to combat units.22 In 2015, the Army officially removed all limitations on assignment of female PAs to combat units.22
The Army and military PA education have kept pace with the civilian standards for training and degrees awarded. Backgrounds and rank have changed along with evolution of PA education. In 2001, IPAP was opened to officers; half of the students are commissioned officers compared with applicants only from the enlisted ranks.8
In addition to some of the typical duties described by the American Academy of PAs (AAPA), Army PAs have additional roles as officers, leaders, administrators, and managers of health personnel (see Profiles of two Army PAs). These tasks may be in addition to or in lieu of clinic time depending on the unit to which the PA is assigned.
Civilian specialty certificate programs began with the profession but the Army did not initiate certificate programs until the early 1980s. From certificate to bachelor's degree to master's degree, the evolution of PA education in the Army has been steady and now includes an optional doctorate for specialty training. These Army educational achievements are among the few doctoral-level PA programs in the nation.23
Like civilian PAs, most Army PAs practice in family medicine. A 1978 study comparing military and civilian PAs found that 93% of military PAs worked in general or specialty primary care compared with 69% of civilian PAs.24 The study found that only 2% of military PAs worked in a surgical specialty compared with 21% of their civilian peers.24 In early 2016, about 4% of Army PAs were specialized in orthopedics and 4% in emergency medicine (Written communication with Maj. Lauris Trimble, MPAS, PA-C, April 2016). According to the 2015 AAPA salary report and the National Commission on the Certification of Physician Assistants, about one-fifth of civilian PAs worked in family medicine, with slightly smaller percentages working in orthopedics and in emergency medicine.25,26
Administration and policy
PA supervision in the military differs from the civilian sector. Being part of the federal government, Army PAs are required to hold a state license but may not be obligated to comply with state scope of practice laws, regulations, or credentialing bodies that direct the supervisory duties of physicians for PAs.2,24 This federal policy introduces some unique practices, such as aviation PAs, for which there is no civilian equivalent.17 In 1978, military PAs indicated that only 22.9% of their patient care time was in the presence of a supervising physician, compared with 42.1% for civilian PAs.24 In the early 1990s, the ratio of PAs to physicians across the military was 1:10.2 This continues to be the case as physician general medical officers are not as prevalent and PAs work in more numerous, decentralized clinics.14 Because of this ratio, physician supervision, direct or indirect, is limited.
As PAs progress in rank, they are afforded more leadership responsibilities that progressively take them away from clinical tasks. PAs serve in advisory roles in every level of Army command and as these roles grow, they further the PA visibility in the Army. These leadership roles give PAs input into military medical policymaking at the highest levels, something uncommon in the civilian sector. Additionally, PAs have begun to have smaller unit commands. These command positions are not required, although this could change.
As civilian ratios of male to female PAs gradually shifted from a 2:1 ratio in the 1970s to a 1:2 ratio in the 2000s, the Army continued to be dominated by men.1 In the military as a whole, the ratio of male to female PAs remains at 5:1.3 In the last decade, about 72% of applicants to civilian PA programs were women, compared with 72% male applicants to IPAP.8
Women have deployed with Army units since 1983 and continue to move further forward on the battlefield. In 2012, the Army began the process that permitted female PAs to be assigned to combat units and they can be assigned to any combat unit.22 This translates to female PAs providing frontline medical care that was limited to only male PAs just a few years ago.
Although PA duties are defined by Army regulation, no repeated or comparative studies have focused on what Army PAs do on a regular basis. The last study of what deployed PAs do daily was conducted in 2004 by Tozier and colleagues and the last study that compared Army PAs with their civilian counterparts was conducted in 1978 by Perry.12,24 Data on specific numbers of deployed PAs, especially by sex, and career progression are not documented. This lack of information makes historical analysis from the institution of the Army PA to today difficult. The observations mentioned in this review may not embody the full history of Army PAs.
Career progression, annual productivity, adverse events both in stateside and deployed settings, regular nonmedical duty requirements, and team relationships (such as with supervising physicians) are areas that require additional study. Inclusion of NPs is critical as on the civilian side, PAs and NPs share similar roles. To date, most Army NPs do not serve in forward medical units.
The Army PA is a story of parallel evolution with its civilian counterpart but diverges and converges depending on role and responsibilities. By drawing on their broad experiences, Army PAs lead in both tactical and clinical settings, filling command roles, senior clinical positions, and administrative leadership. This study offers some insight into Army PA use with a focus on PA training, PA use in general medicine and specialty medicine, their participation in administrative and policymaking roles, and how female PAs are included. PA use in the Army is wide, diverse, and changing. Their role draws on a wide range of skills and their contribution to the military medical team appears to be critical.
Profiles of two Army PAs
Col. Gross has served in the US Army for more than 4 decades. She has seen Army medicine through a number of conflicts and changes, including the initial use of PAs. Col. Gross now works to advise major commands on ways to preserve the fighting force.
After 9 years of enlisted service as a medic and OR technician, Col. Gross became a PA. As a warrant officer, for 9 years she saw patients in various locations. Becoming a commissioned officer opened other doors. She became an instructor in IPAP, then chief of a clinic, then deputy chief of the Army Medical Specialist Corps Branch at Human Resources Command. As a staff officer at the Office of the Army Surgeon General, she worked on policy for treating Army Reserve and National Guard soldiers closer to home. While branch chief of the PA program, she also deployed to Iraq for a year as a medical adviser to the Iraqi police.
Col. Gross is now command surgeon (medical advisor) for Army Installation Management Command, where she advises on varied topics from the Zika virus, to ambulance coverage on Army posts, to healthy eating programs, to the Army Substance Abuse Program, and to the Sexual Harassment/Assault Response Program.
On October 3, 2009, Army PA Christopher Cordova, then a captain, was at Combat Outpost Keating, in an Afghan valley overlooked by Taliban positions. At 0600, a heavy enemy attack began, with rifle and machine-gun fire, rocket-propelled grenades, mortars, and other heavy rounds hitting every few seconds in the perimeter. Within seconds, several Afghan National Army and US Army troops had been killed, and within half an hour, Capt. Cordova pronounced two soldiers dead while continuing to treat seven patients and supervise his medics. Five more patients arrived and Taliban fighters penetrated the outpost, so Capt. Cordova had to detail guards for the doors. The aid station almost caught on fire, and new patients continued to arrive. A critically wounded soldier required a fresh whole-blood transfusion, for which Capt. Cordova gave a unit of his own blood. After 12 hours of fighting, and treating 43 US and Afghan wounded, helicopters finally arrived to evacuate the wounded. For his actions as a leader and a clinician, Capt. Cordova received the Silver Star.
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