In 1968, my twin brother, Blair (a lawyer), and I were asked to explore the credentialing alternatives for the new types of healthcare professionals being produced at Duke University, the University of Colorado, and the University of Washington. We had an opportunity to visit these pilot programs from our US Public Health Services (USPHS) base at the National Institutes of Health. At the time, focus was on the shortage of primary care physicians to care for recently enfranchised older (Medicare) and poor (Medicaid) patients, although there also was interest among surgeons in producing well-trained surgical assistants.
Military corpsmen in the Korean and Vietnam wars had performed with great success, and they clearly could make a significant contribution to civilian medicine, if given the opportunity and additional training. Standing in the way, however, was a moratorium on licensure for new health occupations declared by the American Medical Association, American Hospital Association, and US Department of Health, Education, and Welfare (now the Department of Health and Human Services). Our recommendation and that of our Duke colleagues (E. Harvey Estes, MD, and Martha D. Ballenger, JD) was to simply amend each state's medical practice act to allow a physician to delegate tasks to specially trained personnel, as long those tasks were within said physician's scope of practice and both practitioners were responsible. This became national and state policy throughout the 1970s and beyond and was highly successful. The delegation amendment, as it was called at the time, allowed the physician and physician assistant (PA) team to have considerable latitude in how they functioned together.
The central premise was that a highly trained clinician could carry out many of the tasks that a primary care physician could perform if the trained clinician was part of a medical care team and supervised by a physician. By extending the reach of the physician, more services could be provided for the many Americans who were without medical care.
When Blair and I moved on to the Yale School of Medicine in 1970, we founded a PA program based in the Department of Surgery (under a Commonwealth Fund grant) and supported by the faculty of the entire medical school. Aided by Duke PA graduate Paul Moson, I served as the program's director (all of the earliest programs were directed by physicians). Together, our team developed a curriculum and clinical rotations to prepare our first class of five students in a 24-month program. Even during our experience with the first class, we saw clearly that these very capable students would be performing traditional physician-only functions such as taking a complete history and performing a physical examination. All of us engaged in PA education, starting with Eugene Stead, MD, at Duke, observed the same phenomena. This view was codified as we program directors worked together (as members of the Association of Physician Assistant Programs) with the AMA and supporting physician organizations to develop accreditation standards for programs and certification criteria for graduates. By the second National Board of Medical Examiners' examination in 1974, the certification criteria included a physical examination.
In 1981, I began a primary care internal medicine practice in Monterey, Calif., and soon thereafter opened a primary care clinic with a PA in the nearby underserved town of Marina. I split my time between the two practices over the next 7 years, and much of the supervision was done over the phone or by record review. Subsequently, on assuming the medical directorship of an urgent care center in nearby Salinas, I hired an outstanding colleague, Stephen Panattoni, PA-C, to work side-by-side with one of the generalist physicians to help staff the center 7 days a week. Mr. Panattoni had become a substitute for a second physician and was so well trained and experienced that we learned from him even as we “supervised” him. Our team also precepted students from the Stanford PA program, providing a clinical education much like we would for medical students.
When I referred patients to the neighboring hospital EDs, I often would present the case to a PA who was working as part of the ED team. When I went to have my screening colonoscopy recently, a PA performed the preoperative history and physical examination. I experienced a PA in a new way—from the point of view of a patient.
Recently, as I have served on the board of trustees of the Physician Assistant History Society, I have had the opportunity to witness the extraordinary growth and the development of the PA profession. The PA role has expanded to include virtually every medical specialty—far beyond what we could have imagined in the early days. PAs have become vital components of surgical and other physician specialty training programs. I know that the next 50 years of PA education will continue to evolve and continue to effect the training of physicians as well. The greatest beneficiaries of this collaborative care model are patients. It has been said that the most important healthcare innovation to come out of the Korean and Vietnam wars has been the development of the PA profession. I agree.Copyright © 2017 American Academy of Physician Assistants