Throughout the second millennium, physician assistant (PA) prototypes, who could provide care in areas where physicians were scarce, were a vital part of urban and rural medicine. In the past century, many of these practitioners have disappeared, unable to compete with expanding numbers of physicians. Such personnel include the officier de santé in 19th-century France, the practicante in Puerto Rico in the late 19th and early 20th centuries, the barefoot doctor in China during the mid-20th century, the assistant medical officer (AMO) in Sri Lanka during the late 20th century, and PAs in Taiwan during the early 21st century.1-6
In well-resourced countries, PAs play an ever-greater role working alongside physicians in hospitals, generally relieving them of tasks that do not require a physician's extensive preparation.7 Many serve as sole providers and perform a wide variety of procedures unassisted. In remote areas and developing countries such as those in sub-Saharan Africa, AMOs play an independent role in providing medical care to isolated populations.8-10 Less familiar is the experience and changing role of the first described PA prototype, the Russian feldsher.
Feldshers, a title taken from the German description of military medics as feldschere or field barbers, emerged in Russia in the late 18th century to serve as army medics or provide medical services where physicians were scarce (Figure 1). At times in the 20th century, the title feldsher has been compared with that of PAs.11 In Russia at the beginning of the 20th century, feldsher societies changed their title from feldsher to physician's assistant (sic.), hoping that the title of PA would enhance their professional status. But the title feldsher proved resilient and survives to the present day. A different but analogous shift from feldsher to PA occurred in Bulgaria when health authorities judged that feldshers were no longer needed but contemporary trained PAs were.12 The identity and role of the classic PA prototype—the Russian feldsher—continues to evolve.
To students of Russian medicine, the parallels between feldshers in Russia and PAs in other parts of the world are immediately apparent. This author, a historian of Russian medicine, kept these similarities in mind while studying the historical experience of feldshers in Russia. This article draws upon published literature in Russian and English, the author's work in Russian archives and libraries, as well as meetings with Russian feldshers and physicians. The literature on PA prototypes is drawn from a wide range of secondary sources, colleagues, and contacts.
During the first part of the 19th century, military authorities in Russia established schools to train feldshers. The early students were recruited in their mid-teens from the sons of men enlisted in the army as well as from orphans at foundling homes in Moscow and St. Petersburg. Upon completing a 3-year course at state expense, graduates entered military service. These early students had next to no general education, and their grasp of medical subjects following graduation remained equally superficial before the 1870s. Some proved capable as assistants to military physicians, but the tsarist officials who evaluated these early schools found their graduates to be manifestly unqualified as medical practitioners.13
During the second half of the 19th century, responding to the need for a larger and better-trained corps of feldshers for civilian practice, new provincial and district administrations known as zemstvos began establishing more sophisticated feldsher schools with a 4-year curriculum. Zemstvo self-governments, introduced into European Russian provinces after 1864, were charged with developing rural healthcare programs. They did so from their inception until the Russian revolution in 1917. The zemstvos moved to expand the training of feldshers, who played a key role in delivering medical care in rural areas. The quality of feldsher training gradually improved, so that by the early 20th century, many feldshers were quite capable practitioners.
Initially, zemstvo feldsher schools preferred to recruit students from the peasant population. Physicians and zemstvo administrators reasoned that feldshers of peasant origin would find it easier to serve a predominantly peasant population. In this view, feldshers from peasant communities enjoyed important advantages in a rural practice: they understood the problems of the communities they served, they would be more content to live in remote areas, and, most important, they spoke a language that peasants could easily understand. In short, they saw feldshers as providing a “link between science and the village.”14
Formal schooling did not come easily to the teenage peasant recruits, and the initial results of their training were mixed, but physicians generally agreed that these “schooled” feldshers had greater knowledge and therapeutic ability than “company” feldshers who had acquired their skills in the army. As their numbers increased, the graduates of zemstvo feldsher schools became an ever-larger proportion of practicing feldshers and assumed increasing numbers of positions in urban hospitals and rural outposts. Russian legislation provided that feldshers could only practice under the direct supervision of a physician. Despite this, many feldshers of all types continued to be assigned to remote rural outposts where they practiced more or less independently, visited only occasionally by a physician. Such independent practice, or feldsherism, remained a contentious issue in Russian medical circles throughout the tsarist period.15,16
Leading Russian physicians may have acquiesced to assigning feldshers to independent rural clinics but they were adamantly opposed to granting legal sanction to such feldsherism. They insisted that even the best feldshers, however valuable as assistants, lacked sufficient training and diagnostic skills to treat patients on their own. They were also troubled by the very diversity of feldshers' overall qualifications, which meant that the title feldsher did not guarantee any fixed and predictable degree of knowledge or skill. As a result, the popular image of a feldsher was predominantly negative, ascribing the worst traits of older “company” feldshers to the entire feldsher community. Clearly many early feldshers were not always responsible in their duties; some were alcoholics and had a reputation as such. The trust that peasants often had for their local feldsher did nothing to alter the generally negative image of feldshers that was widespread in educated society.
The shortage of rural physicians in prerevolutionary Russia and the enormous territories for which they were responsible made feldsherism inevitable: without such independent feldsher outposts, most peasants would have no access to medical treatment.16 Although rural physicians disputed local officials' claims that peasants suffered from simpler diseases, country-dwellers did suffer from many conditions and accidents that an experienced feldsher could treat successfully. Defenders of independent feldsher practice argued that such postings were better than having no modern medical care at all. To many Russian physicians, however, such feldsherism was little more than licensed quackery, no better than the practice of older traditional healers. For most of the period between the 1870s and the end of the tsarist regime in 1917, the number of independent feldsher outposts in rural areas equaled or exceeded the number of physicians' rural clinics. As a consequence, feldsherism remained an integral part of rural medical practice in Russia well into the 20th century.16
Not all feldshers worked in rural areas. Many worked in urban hospitals; factories, railroads, and other institutions hired others. In the popular mind, however, the term feldsher suggested primarily a rural practitioner. Whether working alongside a physician or at an independent clinic, feldshers performed a variety of tasks. For feldshers throughout history, many public health measures, such as immunizing the rural population, were vital. Sometimes these activities were not successful because of peasants' suspicion and fears of vaccination. Feldshers were important in treating wounds, fractures, and other injuries requiring emergency attention. The chief cause of mortality in peasant villages was infectious diseases, so feldshers—like physicians—were called upon to treat a wide range of diseases and disorders. Their limited medical training as well as the limits of late 19th-century medicine meant that there was little they could actually do in the face of such widespread sources of mortality as cholera and typhus. Confronted with epidemic diseases, they tried to isolate patients from their fellow villagers and keep them comfortable. Given the nature of peasant dwellings, such isolation was difficult to achieve. Confining the sick in special barracks, often done during cholera epidemics, bred popular suspicion that the physicians and feldshers who mandated such isolation were in fact murdering peasants' loved ones. Thus feldshers, like physicians, endured exposure not only to serious disease but also to retribution at the hands of the very people they were helping.
In the 1870s, the tsarist regime opened feldsher practice to women; almost immediately large numbers streamed into feldsher schools. Most were from urban families of modest means instead of the peasantry; others were drawn from a variety of social groups, including some from the aristocracy. Many of these female entrants had completed either part or all of a gymnasium education (the equivalent of an elite high school) that provided a broader and more sophisticated general education than that of their male counterparts. Their gymnasium training had better prepared them for formal instruction than the elementary schools that male peasant candidates had attended. Feldsher schools for women commonly added an extra year of training in obstetrics, and their graduates emerged with the title of feldsher-midwife (feldsheritsa-akusherka). Physicians and hiring agencies gradually began to see feldsher-midwives as preferable to their male colleagues. Generally, they were closer to physicians in their overall culture and tended to be free of the less-attractive behavioral traits common to male feldshers, particularly excessive drinking.
Beginning in the 1890s, feldshers in a number of cities began to form professional associations. Ostensibly created for the purpose of mutual aid, these societies contributed to the emergence of a shared professional consciousness among practicing feldshers. The most important spark for this movement was the appearance in 1891 of a newspaper titled Feldsher that was specifically devoted to feldshers' professional needs.17 Feldshers, who often worked in relative isolation, quickly began to share their everyday burdens and experiences in the pages of Feldsher. In doing so, they elaborated a litany of shared complaints and aspirations and forged a professional movement that would seek change. Equally important, sustained dialogue in Feldsher gradually enhanced feldshers' consciousness of their own social identity. In short, the newspaper enabled feldshers to feel that they were part of a larger and awakening professional community.
In articles and letters, feldshers portrayed themselves as “invisible men” whose contributions were ignored by physicians and the broader society alike. They were a classic semiprofession whose medical role would always remain under the authority of physicians.18 But the arbitrary nature of physicians' authority in the workplace could subject them to abuse, and feldshers understandably sought clearer definitions of what that authority included. Between 1891 and 1917, the feldsher movement sought to achieve professional rights and recognition that would establish them not simply as visible participants in Russia's medical world but as part of the Russian intelligentsia. At the same time, feldshers became common figures in Russian belles-lettres of the late 19th century (Table 1).
Feldshers forcefully advocated their professional goals in a variety of specialized publications. In addition to standard bread-and-butter issues such as improved pay and working conditions, they sought access to periodic refresher courses, regular meetings of zemstvo feldshers at the district level, and feldsher representation on disciplinary review boards. They also urged that their representatives be included in broader zemstvo medical bodies such as sanitary councils. Feldshers were particularly anxious to acquire opportunities for upward social mobility, something the image of rural and limited training made virtually impossible. They urged that feldshers with demonstrated abilities should be allowed to enter the medical faculties, which were open only to candidates who had graduated from a classical gymnasium. Physicians and tsarist medical authorities insisted upon this, arguing that physicians should be persons with a broad education, not simply technicians. For their part, feldshers regarded this requirement as an unjustified social barrier to their own advancement.
Although men were the most numerous participants in feldsher professional societies, women were by no means excluded. Although there was some professional rivalry between men and women, the source of this rivalry was not sex alone. The superior general education that most women had received together with their obstetric training gave them an advantage over the predominantly peasant males in the labor market. Physicians regarded feldsher-midwives as more cultured and reliable assistants than males and tended to prefer them in hiring, something that male feldshers resented. The advantages that feldsher-midwives enjoyed in obtaining the best jobs meant that some women saw less need to take part in the professional movement that had originated among men. Others, however, played an active role in this movement, and male feldshers welcomed their participation.
By the end of the tsarist era in 1917, the best Russian feldshers (including feldsher-midwives) had medical training and skills that were equal if not superior to those of many American physicians before the Flexner Report of 1910.19,20 Feldshers also became active participants in the emerging public sphere in Russia after 1905, and feldsher leaders were able to lobby high-ranking tsarist officials on behalf of their goals. Even if they were not always successful, such efforts testify to a broader social recognition of the feldsher's professional role.
In the years before World War I, feldshers continued to occupy a central place in the overall Russian healthcare system. By 1913, there were 30,000 feldshers in the Russian Empire as a whole, compared with only 24,000 physicians. Despite physicians' sustained and passionate opposition to independent practice by feldshers, there were still 2,620 independent feldsher stations in Russia's zemstvo provinces alone, which was virtually equivalent to the 2,688 rural physicians' clinics in the same provinces. By 1910, there were 8,000 students training to be feldshers or feldsher-midwives, of which 70% were female. Despite the large numbers of women training to be feldshers, men remained the overwhelming majority of feldshers in actual practice, particularly at rural postings, until the 1920s.
The outbreak of World War I fundamentally transformed everyday life in Russia, including the world that feldshers inhabited. Fifteen million men were eventually mobilized, including practicing feldshers as well as physicians, which radically diminished the medical personnel in the interior of the country, particularly in rural areas. A host of draftees underwent accelerated albeit limited feldsher training in order to serve as medics. The war also gave rise to a growing contingent of nurses, figures who had been much less prominent in prerevolutionary Russian medicine.21
During the war, the feldsher professional movement entered a period of relative stagnation, but its leaders sought to achieve two professional goals. They continued to argue for legislation that would recognize and sanction independent practice by feldshers assigned by their superiors to isolated outposts. Civilian feldshers also feared that the mass of military “company” feldshers, with limited wartime training, would enter the civilian labor market once the war was over. They insisted that the state should prohibit this because the truncated training that wartime feldshers had received was not sufficient for civilian practice.22
Following the February revolution that toppled the tsarist regime in 1917, feldshers joined in celebrating the country's newfound freedom. For most in society, one's profession or workplace was the most readily available entry into revolutionary politics. The feldsher professional movement instantly acquired a new vitality. New feldsher societies sprang up across the country, espousing some version of socialism. In October 1917, the Bolshevik revolution transformed the medical landscape in Russia. Anxious to expand the number of practicing physicians in the country as quickly as possible, the Bolsheviks opened the medical faculties to all who could do the work, setting aside older restrictions that required a gymnasium diploma.
In addition to opening new medical courses and democratizing admissions, the Bolsheviks shortened the course of physician training to accelerate candidates' graduation. Although the door had opened for feldshers to enter the medical faculty, few were able to do so for practical reasons, particularly the need to work and support their families. But young persons who might earlier have become feldshers instead now entered the medical faculty. The Bolshevik democratization of medical training produced increasing numbers of physicians, but the accelerated and somewhat truncated requirements for the physicians' title somewhat diluted the average physician's overall medical knowledge and skills.
The Bolshevik revolution also brought the independent feldsher professional movement to an end. All medical personnel—from cooks to feldshers, midwives, nurses, and hospital workers—were amalgamated into one large medical union, the Vsemediksantrud. Once incorporated into this broader medical union, the feldsher professional movement as it had existed before the revolution ceased to exist. For their part, physicians vigorously resisted inclusion in this union, arguing that their training and professional expertise entitled them to a special status and exclusive medical authority. In order to diminish their opposition, early Soviet healthcare authorities let physicians have a separate voice on any questions involving purely scientific expertise.
In 1924, Bolshevik medical authorities decided to cease training feldshers, replacing them with nurses and midwives. The decree sought to eliminate feldshers from the ranks of the young Soviet Union's medical professionals through attrition; thus feldshers already in practice were allowed to continue. The Soviet authorities believed that given an expanded corps of physicians, feldshers trained as quasi-physicians would no longer be essential. In part this decision grew out of medical authorities' sense that feldshers' training exceeded what was necessary for PAs. Here they judged that nurses and midwives would be equally qualified to serve as PA-like personnel but would be considerably less expensive to train. By the 1930s, the notion that feldshers would no longer be necessary had proved untrue, and feldsher training was resumed. Like Soviet physicians, most feldshers during and after the 1930s were women. Feldshers (women as well as men) played a major role in providing medical care during World War II, and remained prominent medical practitioners right up to the 21st century.
Before the establishment of Soviet power in 1917, the overwhelming majority of medical personnel in Russia were either physicians or feldshers (including feldsher-midwives). During the Soviet period, following the resurrection of feldsher training, this configuration of “middle medical personnel” combined feldshers, nurses, midwives, laboratory and technical personnel, and dentists. By the 21st century, nurses had become the most numerous of these practitioners by far, with feldshers a distant second. Although feldshers continue to play a role in the overall Russian healthcare system both as emergency medical personnel and rural practitioners, nurses are increasingly replacing them. A move to transform Russian feldshers into practitioners more like Western PAs has not occurred. In some former Soviet countries such as Bulgaria, a shift from feldshers to PAs is underway.12
In recent decades, the once prominent role of feldshers in Russia has been in decline. In 1970, for example, the Soviet Union had 591,800 nurses and 291,300 feldshers. By 2015, the Russian republic had 1,069,000 nurses but only 129,900 feldshers. The number of feldshers in the Russian republic in 2015 was thus only 12% the number of nurses and had undergone a comparative decrease of more than 50%. The absolute as well as comparative decline of trained feldshers is similarly evident by comparing the numbers of nurses and feldshers per capita (10,000 populations). In 1970, for example, there were 45,300 nurses per 10,000 population in the Soviet Union compared with 22,300 feldshers. By 2015, there were 73,000 nurses per capita and only 8,900 feldshers. The urban/rural breakdown is less clear but nurses are replacing feldshers primarily in Russian cities; feldshers continue to serve in more remote rural areas.23
However, recent events in Russia have suggested just how important feldshers and midwives remain in the country's healthcare. In April 2018, in a missive to the Russian State Duma, President Vladimir Putin and Duma Chairman Vyacheslav Volodin emphasized the need for more feldsher-midwife stations in rural areas, and for recruiting and training healthcare providers.24 The vitality of the feldsher's position and role as a PA is being recognized at the highest levels of the Russian government.
The history of the Russian feldsher is in remarkable parallel with that of some Western countries. Born out of a strong need to fill areas of physician scarcity, feldshers have been both welcomed and decried. Physicians' ambivalence toward feldshers' medical role was not unlike that in the United States, Australia, and Canada.25
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