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Original Research

The PA profession in the 1990s

Cawley, James F. MPH, PA-C, DFAAPA; Hooker, Roderick S. PhD, MBA, PA

Author Information
doi: 10.1097/01.JAA.0000823176.02964.c4
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Abstract

The causes of events are ever more interesting than the events themselves.”—Cicero

The 1990s were a pivotal time in the development of the physician assistant/physician associate (PA) profession. That decade saw the profession advance and mature in US healthcare perhaps more than any other decade before or since. Following the previous decade, during which a perceived physician surplus had a depressive effect on PA growth, the profession entered the 1990s with an upbeat attitude and a growing list of accomplishments.1 The 1990s were a period of remarkable development and integration of PAs into US medicine.2 During this era, substantial PA program growth occurred across US colleges and universities. Reimbursement for PA services through Medicare was first passed in 1986 but affected the medical marketplace and PA growth in the 1990s. In the preceding decade, the acceptance of PAs by patients and other healthcare professionals was emerging, and a solid legal foundation for their inclusion in clinical practice became established in healthcare delivery systems.3 National workforce policies had endorsed PAs in medical practice by employment in the federal Departments of Defense, Veterans Affairs, and Health and Human Services. The government began reimbursing for professional services provided by PAs and continued subsidizing their education for clinical practice during this era.4

The decade of the 1990s was a punctuating moment in history where PAs came to the fore in US medicine and their development was propelled across the states. Healthcare reform had been a growing focus for many Americans throughout the 1990s and became a core initiative of the Clinton administration (1993-2001). During this final decade of the 20th century, an unprecedented acceleration of PA growth produced an image and set of accomplishments that changed the way society viewed these “new health professionals.”5

We engaged scholars, observers of healthcare professionals, and colleagues about this period and followed up with publications and reports. The salient developments of the PA profession in the 1990s are presented as themes: public perceptions, healthcare workforce policies in the federal government, state regulations, education, and research. A narrative review of the empirical evidence was selected as the best way to examine this historical period.

Topics of interest included federal workforce policy, shifts in the proportion of male and female PAs, state legislative progress, PA education, organizational development, and notable advancements of the profession. The authors were active during the 1990s in clinical practice, research, education, consulting, and executive leadership. Because of the familiarity of the events leading up to and following the 1990s, we adopted a pragmatist paradigm in research philosophy that adheres to the proposition that researchers should use the method approach that works best for the issue being investigated.6 Select qualitative and quantitative data bolstered our premise that the 1990s were unprecedented times that advanced PAs in US medicine.

The method of documentation involved conversations with observers of PA behavior and a review of the literature from 1975 to 2020, with a particular focus on the 1990s. Observers included scholars in medical sociology, medical anthropology, health economics, national leaders (leaders of PAs, nurses, physicians), officers in uniform (active and retired, military and public health), educators, and clinically active and retired PAs. The conversations took place formally, unofficially, verbally, and by written communication. At times questions were directly asked, and observations were offered informally and unsolicited or included as part of another topic. The authors undertook a scoping review of PA history and development on two occasions and presented the information to national and international audiences. More than 40 individuals influenced this undertaking. A few colleagues and informants served as open reviewers of earlier drafts.

Reviewed documents included those from the American Academy of Physician Associates (AAPA) (including the Association of PA Programs [APAP]), the National Commission on the Certification of the Physician Assistant (NCCPA), the PA History Society, and the National Library of Medicine. A wide range of PA association documents were reviewed. Literature searches were undertaken for select events, and publications were drawn from international biomedical bibliographies such as CINAHL, PubMed, Google Scholar, etc. Keywords used in searches included federal workforce policy, gender shifts, state legislative progress, PA education, organizational development, and notable advancements of the PA profession.

PUBLIC PERCEPTIONS

The image of the PA, as a recent entrant in US medicine, was consolidated early and quickly as a profession by the 1990s. This occurred over a decade, and the transformation was observed by Burgess and colleagues that physician perception of PAs and advanced practice RNs (APRNs) had shifted positively during this time.7 The power of marketing also came into play unexpectedly in the '90s and may have helped ensconce the title PA in American minds. One early influence was the award-winning television show ER. The program portrayed a PA as a bright, personable, knowledgeable, and sympathetic figure found in various hospital roles. In the comic strip Gasoline Alley, Chipper Wallet, a former Navy Corpsman and Vietnam veteran, returns home and becomes a PA, leading up to and continuing into the 1990s.

Although Wallet's story mirrors that of many pioneering PAs, the strip alerted Americans about the new profession and its Vietnam War-era roots. This endearing everyday character and other popular media depicted the PA during the 1990s as a well-liked clinician easy to portray.8

A SHIFT TOWARD WOMEN

The PA profile changed in the mid 1990s from majority male to majority female.9,10 Although the shift toward female graduates preceded the 1990s, it was by 1997 that parity was reached when the number of younger females began replacing older, retiring males (Table 1).

TABLE 1. - Sex transition of PAs in the United States9
1991 1996 1999
Female 42.4% 50.2% 54.3%
Male 57.6% 49.8% 45.7%

A sociologist noted that the influx of females, possibly influenced by the women's movements, brought about the attractiveness of a PA career. In the 1970s and 1980s, feminism led many women to seek medical careers. But the demands of prolonged training, including residency, created a difficult work/life balance. When the PA profession emerged with many of the changes and recognitions for women, the career choice was easier. Women who wanted a challenging career but valued a work/life balance saw this as a shorter and easier pathway. The shifting ratio started in the 1980s with female graduates inching up to match males, but by the 1990s the trend had accelerated.11 Sometime in the mid-1990s, the proportion of clinically active male and female PAs balanced.

Sociologist Sally Lindsay theorized that at this time, young women sought meaningful jobs in the health sciences that permitted a career-personal life balance, the PA profession being favored, but pay equity remained unbalanced.10,11 The first report of a substantial wage gap between men and women emerged in 1992, drawing attention that a female shift was underway.12 Although women became a majority in the profession by the late 1990s, the wage disparity has narrowed some but persists 3 decades later.13

FEDERAL WORKFORCE POLICY

Throughout the 1990s, the speculation was: “If the Clinton healthcare reform legislation passed, the demand for primary care providers needed to serve the uninsured population would be strong.”14,15 At this time, demand for medical services was growing, and in turn resulted in (or coincided with) a heightened market for PAs and APRNs. For the PA profession, the possibility of national healthcare reform was seen as a potential boon during which the number of programs and graduates would markedly expand.16 Although the Clinton Health Security Act did not become law, a significant expansion of the PA profession occurred either coincidentally or as the result of interest in the novelty of another cadre of medical professionals. From 1994 to 2001, PA education programs doubled, as did annual graduates.1,17 At no other time in 60 years was the program growth as significant as it was then. Published studies that arose during this spurt of activity assessed the PA and NP in managed care organizations, which may have stimulated employment elsewhere.18-20 The 1990s represented a timeline of history that has yet to be matched in terms of pivotal events and changes (Figure 1).

F1-8
FIGURE 1.:
A timeline of PA history in the 1990s

The Air Force was first to commission PAs (in 1978) but the other services maintained their PAs as warrant officers. By the late 1980s, the disparity between the services in rank and pay had become a policy issue in the Department of Defense. A decision was reached that PAs needed to be uniformly commissioned in all branches of the services.21 In 1992, the US Army and Coast Guard commissioned PAs as medical officers.22 Among the military PAs who were instrumental in this effort was US Army Maj. Jimmie Keller, MPH, PA-C, DFAAPA, who was posted in the Reagan White House as part of the president's medical team. For his next assignment, he was seconded as staff to the Army Surgeon General. This was in the early 1990s, and his assignment was to attain a commissioned status for the PA profession.23 In 1987, Chief Warrant Officer P. Eugene Jones, PhD, PA-C, was appointed PA Specialty Advisor to the Navy Surgeon General and championed commissioned officer status for Navy PAs—which occurred 5 years later (Personal communication with P. Eugene Jones, July 2021). Both were influential advisors about the need to fully commission PAs. By the mid 1990s, PAs were commissioned officers in the Army, Navy, Air Force, and Coast Guard, elevating their status and contributing to their retention.24 In 1997, the US Public Health Service (USPHS) expanded the clinical role of PAs, their deployment, and their administrative tracks. For the USPHS, this significant change produced an unprecedented milestone: two PAs promoted as admirals.25

In 1993, an estimated 23,000 PAs were clinically active in the United States.9 With PA numbers growing in managed care and the federal government, their presence was noted by medical workforce scholars during this era as significant partners in providing access to care.26,27 One reason for this observation was that PAs' economic benefit as revenue generators was viewed as valuable to employers.28,29

On the national level, PAs were considered relevant players in healthcare reform under various proposals that came to fruition. For example, the Balanced Budget Act of 1997 better clarified the Medicare policy of PA reimbursement.30 Significant achievements on the state level included the passage of enabling legislation and prescribing in most states.31 This broad change across the various states' practice acts enabled PAs to expand healthcare services with more visibility and fewer barriers.4,32 Alongside family physicians and APRNs, PAs emerged as essential members of the US primary care workforce. One reason was the expansion of physician graduate medical education had been capped by the Balanced Budget Act of 1997. With the number of residencies and fellowships for physicians restricted, the role of residents as house officers was constrained at a time of hospital expansion. PAs stepped in to fill a medical labor shortage.33

During this period, healthcare reform and universal access became a partisan issue. First Lady Hillary Rodham Clinton was the keynote speaker at the 1993 AAPA convention. This was significant because President Bill Clinton proposed the Health Security Act and pushed for healthcare reform, as did many in Congress. In 1992, Mrs. Clinton convened a working committee of healthcare experts to overhaul the federal healthcare system and extend health insurance to all citizens. To do so, she included PAs, NPs, and nurse-midwives in the mix and passed the findings on to subcommittees that assessed their role and responsibilities.34 The report described the traditional working relationship between PAs and physicians, and how the elements of this relationship (consultation, referral, review) form the basis of successful professional healthcare relationships in general.34

Following this assemblage of new information on PAs and APRNs, the Association of Academic Health Centers submitted their report in 1993, and in 1994 published a book on the health workforce that portrayed PAs as essential players in healthcare reform known as the Clawson report.35 The Clawson report was distributed to congressional representatives that year.

In the early 1990s, the US Bureau of Labor Statistics added PAs to their forecasted industries and projected PA jobs to increase by 36% from 1992 to 2005. In 1993, lobbying efforts by AAPA resulted in the Drug Enforcement Administration registering PAs as legal prescribers of controlled substances.36 Also in 1993, Stephen C. Crane, PhD, MPH, a respected health services researcher, was hired as AAPA executive vice president, improved AAPA-based research, and created a Masterfile database. In 1994, the Council on Graduate Medical Education (COGME) commissioned a task force to examine the PA profession's workforce contributions (Figure 2).37 Federal policy toward PAs had rapidly changed social views, and its influence was unprecedented.4

F2-8
FIGURE 2.:
Report of the Council on Graduate Medical Education on PAs, 1994

STATE LEGISLATIVE PROGRESS

The decade of the 1990s saw significant advances in state adoption of PA licensure and prescribing authority. In 1990, PAs were present in most states and had prescriptive authority in 30 states and the District of Columbia; in 1995, the number was 39, plus the District of Columbia and Guam. Mississippi became the 50th state to authorize PA practice in 2000, after a decade of intense lobbying.32 Federalism, the system of government that works both centrally and at the state level, had propelled the PA into the national spotlight.

PA EDUCATION AND ACCREDITATION

The 1990s were a period of rapid expansion of PA education with a doubling of programs. In 1993, there were 57 accredited PA programs, 104 in 1997, and 120 by 1999 (Figure 3). Most PA programs in the early 1990s awarded the bachelor's degree, but leading programs such as Emory University, George Washington University, and the University of Colorado had transitioned to the master's degree by the 1990s. By 2000, students in 43 of the 120 programs (36%) were awarded a master's degree.

F3-8
FIGURE 3.:
Growth of PA educational programs, 1990-2000Source: ARC-PA

PA education support under federal Title VII funding began to wane in the 1990s. In 1998, the amount awarded to 47 qualifying PA programs was $5.8 million. Analysis of the financing for PA programs between 1984 and 2003 revealed that the total mean budget for PA programs was $276,919 (in 2000 dollars), with 35% of the budget subsidized by federal funding.38 The Health Resources and Services Administration's message concerning overseeing PA education funding was that programs needed to institutionalize themselves into their sponsoring organizations and wean themselves from federal support. For the most part, this transpired during this time, although the pilot light of federal aid stayed lit for another decade with a series of small education grants.39

In the late 1990s, the Association of PA Programs (APAP) formed a PA Degree Task Force. The task force recommended the de facto standardization of PA education be set at the master's degree level. In 2000, APAP membership adopted the task force recommendations to standardize the entry-level degree for the PA profession at the graduate level (that is, the master's degree).40

In terms of accreditation, for 2 decades subagencies of the American Medical Association (AMA) provided oversight services for PA accreditation. In 1991, administrative responsibility for PA program accreditation became self-contained, and AAPA assumed staffing responsibilities. In 1994, the AMA Committee on Allied Health Accreditation and Education became the Commission on Accreditation of Allied Health Educational Programs. This AMA oversight devolution led the Accreditation Review Commission on PA Education (ARC-PA) to become a freestanding accreditation agency in 2000. This was seen as an essential indicator of professional self-actualization (www.arc-pa.org/about/arc-pa-history). In 2005, APAP was renamed the Physician Assistant Education Association (PAEA), consistent with the desire to be self-reliant and independent of AAPA. The profession was growing and maturing and the 1990s was the accelerant for this spurt.

SPECIALIZATION AND EMPLOYMENT

With specialization among physicians, it is not surprising that PAs also entered specialty practices. Although their deployment was across the diversity of medicine and surgery, the role of the PA as medical generalist was changing. The original intent of Eugene Stead, MD, in founding the first US PA program at Duke University was that PAs would work with physicians in all types of settings and specialties and provide medical services to underserved populations.41,42 None of the dozen or so founders of PA education programs used the term primary care at the time. However, several years later, in response to the influence of federal funding for primary care education, the profession took a marked turn toward primary care.43,44 By the late 1980s, half of PAs (51%) practiced general/family medicine (primary care). However, as a social innovation that grew in the 1980s and 1990s, it was within this era that PAs increasingly chose specialty practices.45 This shift away from primary care led to PA specialty societies, the growth of PA postgraduate programs, and created the impetus for PA specialty certification.46-48

The percentage of PAs in primary care fell from 43% in 1997 to 24% in 2018.37,49 In 1996, AAPA estimated that 32,600 PAs had graduated from an accredited program, and an estimated 29,000 were in active clinical practice.9 Of those, 39.8% were in family medicine, 8.3% in general internal medicine, and 2.7% in general pediatrics (all primary care specialties). About 11.4% were in surgery (general and specialty), 5.8% in medical subspecialties, 7% in emergency medicine, and 1% other.9

ECONOMICS OF PA EMPLOYMENT

One of the drivers of employment was the perceived economic value of employing a PA in a solo practice, group arrangement, rural medicine, or federal institution. Their cost-effectiveness was revealed early in their development, beginning with the seminal research of Jane Record and colleagues at Kaiser Permanente.50 This era was followed by papers on physician replacement and rural employment.27,51,52 Richard A. “Buz” Cooper, MD, stands out as the leading observer of PAs and NPs during the 1990s.26,53,54 Cooper's critical observations on supplementing physician shortages with PAs and NPs did not endear him to those with more elitist views that physicians were the nation's sole health policy drivers. The idea that PAs were physician substitutes instead of complements was shifting due to the work of Cooper and others.55,56 Some of the subjects during this time included predicting the effects of healthcare reform on physician workforce requirements; substituting PAs and NPs for physician residents; and the use of PAs and NPs in rural hospitals, which became an important topic in meeting smaller population needs.51,53,57-59

The public interest in health reform led JAMA to publish four papers by national medical workforce scholars on the potential effect of PAs on the appearances of US medicine—changing it from physician-only services to adding PAs and NPs during this decade.16,18,53,60 In a joint report by the Pew Health Profession Commission and the University of California at San Francisco, the future staffing of managed care was seen as contingent on the role and expansion of PAs.34

ADVANCING THE PROFESSION

A profession's growth and development can appear in many forms, but one that stands out is how a profession sees itself in print. After various journal types and names were premiered, the profession's periodical—JAAPA, begun in 1988—became firmly established as the official organ of AAPA. In the early 1990s, Leslie Kole, PA-C, became its first full-time editor. The education journal, Perspectives on Physician Assistant Education, evolved from newsletter to peer-reviewed journal in 1997 and served as the official journal of APAP from 1998 through 2007, when it was renamed the Journal of Physician Assistant Education. Perspective was founded, underwritten, and edited by Donald Pedersen, PhD, MS, PA, of the University of Utah.61

GLOBAL DEVELOPMENT

The 1990s saw the adoption of the PA concept by other countries, among them the Netherlands, in 1999.62 The MEDEX model of PA education, founded at the University of Washington, was introduced to 14 countries in the late 1970s, and four were operational in the 1990s (Personal communication from R.A. Smith, May 25, 2006).

Canada introduced the PA profession as a healthcare career in 1984 by establishing a military PA program in Ontario.63 By the 1990s, the Canadian PA became prominent as a critical Canadian Forces member.64,65 By 2018, 17 nations had formally introduced the PA concept: Australia, Canada, Bulgaria, Germany, Ghana, India, Ireland, Israel, Liberia, Netherlands, New Zealand, Poland, Saudi Arabia, South Africa, the United Kingdom (UK), Taiwan, and the United States.66 Although these countries differ in their healthcare system structures, workforce needs, and degrees of integration, they have, as a common denominator, formally trained PAs in their healthcare systems.67

IN PERSPECTIVE

Perhaps at no time in the history of the PA profession in the United States did so much happen in so concentrated a period as in the 1990s. Notable events that occurred during this time were that PA numbers doubled, programs doubled, and females reached census parity with males. The entertainment industry portrayed the PA as a sympathetic figure on the small screen, quality economic and sociological research emerged about the PA profession, and daily newspaper comic strips illustrated a Vietnam War veteran who had become a PA. During the '90s, PAs moved into medical and surgical specialties and grew in stature.49

LIMITATIONS

No history is ever complete, and omissions inevitably emerge after the latest version is disseminated. In this article, many topics were set aside due to word length and relative importance. Readers familiar with this era may argue what they believe are overlooked critical events. We may agree and hope such observers will offer their interpretations and assessments in letters to the editor, PA History Society Newsletter contributions, and as brief reports in this journal. History is in a constant state of revision, and such clarifications are welcomed.

CONCLUSIONS

During the final decade of the 20th century, an acceleration of growth in the PA profession coincided with an attractive healthcare professional image for society. This image was enhanced with a set of accomplishments that changed the way policymakers viewed new healthcare professionals. Various theories are at hand to explain this phenomenon, but the one that fulfills Occam's Razor is, simply stated, supply and demand in a capitalist system favors innovation. In summary, shortages of physicians were exacerbated by population growth, new technology, errant predictions, and changing policy. Circumstances demanded more skilled medical labor, and the PA emerged as readily available. Molded by physicians in their image, PAs were widely accepted. More programs emerged to meet the supply requirement—a surge of them in the 1990s. Along the way, the profession advanced as a sterling vocation for young people in general and women looking for career equity. Other influences of the '90s included the federal government underwriting PA education, the Balanced Budget Act of 1997, a proposed Health Securities Act, mistakes of COGME, PAs commissioned as medical officers, and the federal government becoming a significant employer. During this time, with each event layered on, what emerged was a new healthcare professional influenced by the principles of federalism—central and state-based governments embracing PAs—and the necessity of additional qualified healthcare professionals to match the growing demand for more and better care. In the end, the events of the 1990s were a multisource springboard that propelled the American PA movement well into the 21st century in ways unprecedented both domestically and globally.

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Keywords:

physician associate; history; military; health policy; PA education; sex

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