History Of Physicians Assistant Essay

This essay has a total of 4703 words and 26 pages.

History Of Physicians Assistant

(this paper is very precise with several pages explaining the books that I read and even
the list of pages of every piece that I had cited. I recieved a A for this paper and it is
15 pages long



History of the Physicians Assistant Occupation
Jayme K. Hansen
13 December 1999
Course: LC 393
Professor: Ettinger, Laura












The year is 1959, and Mr. Scott has had a migraine headache for the past few weeks and so
he drives to the local Potsdam Hospital. The poignant antiseptic smell fills his nostrils
as he steps unto the polished hospital floor but what catches his eye is the large number
of people waiting in the lounge. Mr. Scott patiently stands behind the long line of people
to sign the needed forms to be seen by the physician. An hour and a half passes, and it is
finally his turn to see the receptionist. He looks at the woman behind the counter in the
bright white uniform and asks, "Is it always like this?" The woman replies in a weary but
irritated tone "It was not this hectic until Dr. Johnson and Dr. Smith left to specialize
in Syracuse." As Mr. Jones fills out the questionnaire about his insurance, he mutters to
him self, "Boy, they need to do something about this. They should hire more doctors or
something." The medical community did do something to off set the projected decline of
physicians. About thirty years ago, a new health care profession was integrated into the
medical field to assist physicians to prescreen and handle the routine patient loads. At
first, Physician Assistants (PA's) met some opposition, but later they were accepted as a
need and an asset to society. The following history of the physician assistant will show
how a crisis caused the development of this profession, and the conditions which created
the profession and how the struggles of the PA profession during the 1960's through the
1970's ended with the maturity phase of the 1980's and 1990's.

A crisis caused the development of the PA profession. This problem was the widely held
belief that there was a shortage of medically trained personnel , which originated from
the 1959 Report of the Surgeon General's Consultant Group of Medical Education. This
report gave three main reasons why an expansion of health care was needed in the United
States:

1. There was fear of rapid population growth projections with disproportionate increases
of the young and elderly. These two populations statistically and historically utilize
more health care than the average populace.

2. There was an increased per capita use of health care facilities. This was spurred by
numerous factors. The first was improved living standards that brought higher life
expectancy and lower infant mortality. An increase in health care facilities and
transportation systems, both private and public, increased the number of patients to the
hospitals. The public educated themselves; thus they knew the signs and symptoms of when
they needed to seek medical help. This knowledge spawned more frequent visits. Finally,
the wider use of medical insurance (private, as well as Medicare and Medicaid) gave
greater numbers of patient's access to healthcare.

3. There were large numbers of general practitioners that shifted into research,
specialization, industry, and other fields. One report concluded:

Although the physician rate per 100,000 had remained fairly constant for the 30 years
proceeding the report and was 141 per 100,000 in 1959, the percentage of physicians
serving as primary care physicians, even including the new specialties of internal
medicine and pediatrics, had decreased. Primary care physicians furthermore decreased in
absolute numbers, making the ratio per 100,000 physicians much smaller.


Ettinger's lecture on historical trends of physician placement further supported the
belief that general practitioners shifted into specialization. She stated that hospitals
developed and pushed training programs for specialization during World War II, and
hospitals made it easier for specialists to see more patients with the aide of
pre-screeners who in turn made specialists more productive and profitable than general
practitioners. Because of these incentives, many general practitioners became specialized.
In the 1960s, their utilization sharply declined. It was predicted they would become
extinct.

To summarize points one through three, this government report was inaccurate in its
projections. The population growth was over estimated and what really occurred was a shift
of growth to the young and elderly populations. Second, there was not an overall shortage
of physicians, but rather a decline in number per capita due to specialization . There
were numerous published documents, including the above-mentioned 1959 Surgeon General's
report, which theorized there could be a shortage of physicians. Actually, the total
number of physicians stayed the same; there was just a change of in the number of general
practitioners. Evidence that this belief still remained until the early 1970's can be seen
with a book that was published by Rashi Fein entitled The Doctor Shortage: An Economic
Diagnosis. The shortage concept was a snowball of popular writings that ended up as
beliefs. These small misconceptions helped develop a new medical profession called the
physician's assistant.

During the 1960's a new social consciousness emerged in the United States. This was that
everyone had a right, not a privilege, to access quality heath care. The three conditions
that made the physicians assistant profession to be conceived were: government was willing
to support measures to increase health care benefits, the public showed more support for
equity propositions , and there was a pool of trained medical personnel that could be
tapped into for use.

The demand for more health providers was partly due to the expansion of Medicare and
Medicaid in the 1960's. This allowed many of the nation's poor, rural, and elderly to
receive medical care. Politicians took a more active role. For example, Lyndon Johnson
went before Congress in 1965 and said:

Our first concern must be to assure that the advances of medical knowledge leave none
behind. We can and we must strive now to assure the availability of and accessibility to
the best health care for all Americans, regardless of age or geography or economic status
.


Ford an author about the PA profession was so optimistic about government's concern for
health care that she theorized that "(there is the) real possibility of some type of
national health insurance becoming operational in the mid to late 1970's."

The politicians became more involved with health care due to the pressures and demands of
the public. Rising incomes allowed more people to demand access to a better quality and
quantity of health care services. The increased level of education helped the public
become more aware of their need for health care services. Overall Americans began placing
higher value on health care, thus increasing demand for services.

The third condition that made the physician assistant to be conceived was the pool of
trained medical personnel that could be tapped into for use. There were three main
recruitment sources for the PA Program.

1. The first pool of potential recruits would have been individuals who were not
admitted into medical schools, or other college graduates with outstanding records and
interests in a medical specialty career. According to the Association of American Medical
Colleges, in 1970, 24,987 individuals applied to U.S. medical schools with room for only
11,348 students. This left a remaining 13,639 students, many of whom could become PA's.

2. The second pool consisted of the 700,000 employed registered nurses (500,000 full time
and 200,000 part time), …and more than 650,000 registered nurses in retirement. The
incentives for nurses to become PA's would be dually beneficial for themselves. The first
incentive would be increased knowledge and the ability to expand their role in the medical
field. The second would be increased financial reward. The nurses were specifically
invited by the American Medical Association (AMA) in 1969 to fill the newly developed PA
program.

3. The last major source of recruits would come from the military,
especially noted were the veterans of the Vietnam War. Ford wrote, (It is) estimated that
each year approximately 30,000 medics are discharged from the service; of these, about
one-third find their way into civilian health care employment . She further supported the
idea of recruiting medics because $25,000 of the taxpayers' money was already invested to
train each medic, giving them a medical background. However, she cautioned that each
branch of service had different levels of training in their medic's programs and that some
of these recruits (corpsmen) may not be interested in a medical career because some
individuals' jobs were picked for them. Schneller the author of a book titled The
Physicians Assistant claimed that the original design of the PA occupation emphasized the
male ex-medical corpsman as the ideal type of recruit to the PA occupation. He also stated
that there was a list of priorities for entrance into the PA program. The following list
is arranged from greatest to least: corpsmen, therapists and technicians (PT, OT, etc),
registered nurses, practical nurses, orderlies and aides, other health workers (dentistry,
and pharmacy), premedical students, students (high school or non medical), and lastly
individuals in a non health related occupation.

The PA concept was envisioned in 1961 by Dr. Charles Hudson as he addressed the American
Medical Association (AMA) for a need to develop a new health practitioner that could take
over routine cases to free up physicians for more complex tasks. Hudson's proposal lay
dormant until 1965 when Dr. Henry Silver and Loretta Ford, a registered nurse, developed a
midlevel practitioner as a physician extender for under served areas. When looking at the
history of nurse practitioners and physician assistants, it is hard to distinguish between
the two professions. It is not uncommon to find both the PA and NP occupations written
together, and this makes the tracking of the PA history confusing. Some authors mix the
history of physician assistants and nurse practitioners because they are confused about
the two similar professions. Actually, the professions are the same except for the names.
For example, some authors say Dr. Henry Silver and Loretta Ford founded the NP occupation
and others feel Silver and Ford is part of the PA history. The NP did not have much
influence on the structure of the PA profession. The birth of the PA program started when
Duke University started a pilot PA program in 1965 . The 2-year program at Duke trained 4
ex-Navy corpsmen to fill health care shortage positions within the hospital. It was
believed that the training period for the new professionals could be much shorter than for
medical students because of the previous experience that the physician assistant trainees
had gained in their military experience. Duke University studied the four students as they
progressed through the program as a basis for continuing curriculum development and
evaluation . A certificate was awarded at the completion of the program .

The infancy of the PA program during the 60's and 70's was filled with many struggles over
issues. The first of which was the opposition from the nursing community . As mentioned
earlier, the pool of nurses was considered as one of the main sources of recruitment. When
the AMA announced this idea, they were answered with a harsh rebuttal. The president of
American Nursing Association (ANA), Dorothy Cornelius replied with:

The ANA board of directors deplores this kind of unilateral decision made by the AMA,
since it is not the prerogative of the AMA to speak for any other profession . We strongly
object to this action-that AMA should attempt to meet the physician shortage by
compounding the shortages of nurses.


National League of Nurses (NLN) was another professional nursing organization that
advocated nursing concerns. The NLN replied responded similarly to the AMA's announcement.
Among her points was that:

1) neither the NLN nor the ANA had been consulted on the proposal;
2) in spite of the innovation in expanded use of health personnel, it is unreasonable to
rob one profession already depleted to meet the needs of another;

3) interdisciplinary cooperation and collaboration are necessary if common problems
between medicine and nursing are to be solved.

Not all nurses agreed with these two national nurses' organizations. A month after the
ANA's rebuttal, Dorothy Mereness, Dean of Nursing at the University of Pennsylvania,
spanned the breach with her mediating address to the Council of Baccalaureate and Higher
Degree Programs in Nursing of the NLN in Kansas City, Missouri. Mereness argued that the
professional nursing organization had not taken a position on the issue of nurses becoming
PA's. She then concluded: In spite of the misgivings of their colleagues, many graduate
nurses will most certainly be interested in relating themselves to a physician and
accepting whatever extra training he may deem necessary… Holt a physician assistant
historian, explained why the separation existed between the AMA and professional nursing
organizations by saying:

The nursing profession was in the process of shaping a major transition in the image of
the nurse that was necessary as the societal transformation that was improving the
position and opportunities open to women in general. In addition, professional nursing
organizations were struggling with their hatred of a history of authoritarian medicine,
which the AMA's persistent disregard for the problems of the nursing profession
exacerbated. Thus, while the extent on which the AMA misrepresented the physician
assistant concept is evident in retrospect, at the ANA had little choice but to respond to
the physician assistant by renouncing any desire for nurses to receive physician assistant
training.


Another immediate problem the PA occupation faced were the legal issues of a new health
occupation. There was significant disagreement among the PA programs regarding the most
likely and most legal problems faced by the PA. Of the initial 16 programs the most
important legal issue was about the issues of civil suits. Ford stated: Employers might
not be willing to assume responsibility for negligent acts committed by their PA-employee
particularly since common custom and usage might not be fully applicable to this new
health provider. She focused on negligence where PA's are not covered under a state
medical practice act and could be sued for practicing medicine without a license. The
physician could also be sued for aiding and abetting the PA. There were also problems with
the wording of the existing documents that spoke of PA roles and functions. An example
that was given was a passage cited from the 1970 National Academy of Science's report on
the PA. The document suggested that the PA could exercise a small degree of independent
medical judgement. There were no concrete examples or stipulations given, and the language
was too ambiguous for PA's to work without fear of legal ramifications. There was a
solution mentioned in the report, and this was to pass appropriate legislation to permit
PA's to act legitimately in full accordance with their capabilities and will full
responsibility for their actions.

The last major struggle the physician assistant occupation faced was internal between the
AMA, government and the institutions with PA programs. The PA was a new career without a
prior licensure or accreditation status. The book: Physician's Assistant Today and
Tomorrow defined licensure as:

The process by which an agency of government grants permission to persons meeting
predetermined qualifications to engage in a given occupation and/or use a particular title
or grants permission to institutions to perform specified functions (and) accreditation
(as) the process by which an agency or organization evaluates and recognizes a program of
study or an institution as meeting certain predetermined qualifications or standards. It
shall apply only to institutions and their programs of study or their services.


The question of which came first, the chicken or the egg comes up. Without licensure from
the government, accreditation becomes a mere thumbs up approval. Without accreditation
from the AMA in conjunction with the particular occupation's professional association,
schools have a hard time establishing curriculum standards for the PA programs.
Accreditation of the PA profession was done by the Committee on Allied Health Education
and Accreditation (CAHEA) through the AMA in 1971 but has been revised and updated
numerous times since its conception. Then in 1974, the National Commission on the
Certification of Physician Assistants (NCCPA) was established to certify and recertify
PA's and assure the public that the quality of the practitioner met a national standard.

The 80s and 90s were the maturity phase of PA development. This period brought stability
and structure to the PA occupation. The ambiguous language of the PA's roles and
responsibilities were eliminated. There were laws that required PA's to review patient's
treatment and diagnosis with physician's two days each week. Legislation was passed to
give PA's prescriptive authority in 46 states as of April 1999. The laws were passed by
each state, and vary in the restriction and liberal powers given to the PA.

By the early 1980s, PA's became established and recognized by legislation and the medical
community. PA's now were protected for reimbursement for their work. Cawley and Schafft
claimed that recent legislative measures have clarified and established in statute
policies whereby employing hospitals can by reimbursed for services provided by Physicians
Assistants. Such an example of this is when Congress passed a law in 1986 that allowed
Medicare Part B to cover PA services in nursing homes, hospitals and even their assistance
in surgery. This was not always the case. Ford noted during the early 70's that the issue
of third-party reimbursement for the PA's services... (was an) issue of major concern for
them at this time. PA's have established themselves both within the medical and general
public. Several things indicate this pattern of acceptance. First, there is an increased
number of PA graduates and even a greater number of jobs available. Also recent military
hospital polls indicate that its general populous is satisfied with the level of care
provided by the physician assistant.

The PA curriculum has become more structured since the 70's when it was constantly
Continues for 13 more pages >>




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