Essay/Term paper: History of physicians assistant

Essay, term paper, research paper:  Humanities

(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 changing. The PA curriculum also underwent many changes until 90"s when the majority of PA programs began to teach similar courses. Bliss, Sadler ,and Sadler suggested in the early 1970"s that priority should NOT [sic] be given to training programs utilizing rigid education requirements (e.g., baccalaureate degree). Ford noted in the early 1970s that PA programs had undergone a number of changes in philosophy and content.

Some curriculum changes were very specific; that is, they dealt with particular course additions and deletions to program content. For example, one program had added courses in general medicine, pathology, applied physiology, obstetrics, and psychiatry and had omitted courses in biomedical physics.



Finally, in the 90s, the curriculum became uniform throughout the nation. Writing about the PA program content in the middle-90s, Sacks said that most programs focus on didactic instruction during the first year and a clinical rotation during the second year. The first year is comprised of basic sciences such as anatomy, pharmacology, physiology, microbiology, and pathophysiology. In the clinical rotations PA"s in training learn about physical examinations, patient history taking, physical diagnosis, and several weeks in a specific field such as internal medicine, pediatrics and surgery. The 1998-99 Occupational Outlook Handbook had the same courses listed as Sacks for the PA curriculum. It claimed that the majority of PA programs requires a baccalaureate degree or higher , and another source claimed that 94% of all programs had a baccalaureate degree or higher . Today"s overall curriculum for a baccalaureate degree differs from the early history of PA"s.

In conclusion, there were projections in 50"s and 60"s of a population increase in the United States. More alarming was the news that the young and elderly were the sub-populations that would increase the most. These two populations statistically and historically utilized more health care than the average populace. What added to the perceived problem of providing health care was that the population was making more frequent visits to the hospital. This onset was due to higher life expectancies, the wider use of medical insurance, and a host of other reasons. What probably became the straw that broke the camel"s back was that general practitioners (GP"s) were disappearing at an alarming rate. The reason for this change was that GP"s were given may incentives to specialize. Some authors even went further and claimed that there was a physician shortage. These three main reasons became the crisis that caused the development of the physician assistant profession. Then in the 1960s the social belief that all individuals had the right to quality health care emerged. As incomes and education increased so did the public"s demand for access to better quantity and quality of health care services. Politicians felt this pressure of demands and were forced to take a more active role in health care. An example of this was the expansion of Medicare and Medicaid service. Then there were many huge pools of personnel that could be trained to fill the gaps in the health field. Tens of thousands of individuals could be recruited through the military, nurses, and a pool of non-selected medical students. These three conditions created the physician assistant profession. The beginning years during the 1960s through the 1970s were filled with struggles for the PA profession. The nurses deplored the idea of being recruited into the physician assistant profession. There were many heated arguments between the professional physician organization (AMA) and the professional nursing organizations (ANA and NLN). There was also newly created legal issues within this young profession. The wordings of the original documents that governed PA"s were too ambiguous, and this added to physicians" fears of taking responsibility for negligent acts committed by their PA employee. The PA"s, in fact, were not covered at all by state medical practice laws, and there was the possibility of being sued for practicing medicine without a license. Little structure or support existed for the physician assistant profession. It did not even have any licensure or accreditation status. During the 1980s and 1990s, the PA profession became more mature, stabilized, and structured. Laws were made that specified PA"s roles and responsibilities. An example was that legislation was passed to give PA"s prescriptive authority in 46 states. The PA curriculum that went through the refining process was now consistent. In fact, 94% of the PA programs offers a baccalaureate degree or higher. The PA profession is one of the newest medical professions around, and under went many changes. The profession however, is now entrenched and established throughout the medical community and will continue to provide excellent medical care for the future.

Works Cited





Books



Bliss, Ann, Sadler, Alfred, Sadler, Blair, The Physician"s Assistant Today and Tomorrow. Yale University Press, 1972.



Cawley, James, Gretchen Schafft, The Physician Assistant in a Changing Health Care Environment. Rockville, Maryland, Aspen Publishers, Inc., 1987.



Cavallaro, Ann, The Physician"s Associate a New Career in Health care. Nashville Tennessee, Thomas Nelson, Inc., Publishers, 1978.



Ford, Ann, The Physician"s Assistant a National and Local Analysis. New York, Praeger Publishers, Inc.



Frew, Ann, Frew, David, The comprhensive Medical Assisting Administrative and Clinical Procedures. Philidelphia, FA Davis Co., 1982



Sacks, Terence, Opportunities in Physician Assistant Careers. Lincolnwood, Illinois, VGM Career. Horizons, 1995.



Schneller, Eugene, The Physician"s Assistant. Lexington, Massachusetts: Lexington Books, 1978.



Health Technology Case Study 37/ Nurse practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis. Washington D.C., US Government printing office, 1986.







Journals



Holt, Natalie, "Confusion"s Masterpiece: Development of Physician Assistant Profession, Bulletin of the history of Medicine, Vol. 72, No. 2, Summer 1998.







Interviews/Lectures



Ettinger, Laura Phd, classroom lecture, Class LC 393, 17 November 1999.



Gagnet, Michael PA, interview by phone, Suwon, S. Korea, 9 November 1999.



Leach, Judy NP, personal interview, Student Health Center, 6 December 1999.







Internet



1998-99 Occupational Outlook Handbook. 13 October 1999, http://stats.bls.gov/oco/ocos081.htm



What is a Physician Assistant-Certified. December 1998, http://www.nova.edu/pa/pafact.html



Into the Future:Physician Assistants Look to the 21st Century. 1999, http://www.aapa.org/strategicplan.html



National Commission of Certification of Physician Assistants (NCCPA Connect). 1999, http://www.nccpa.net/.



Physician Assistant Programs Directory. 1999, http://www.apap.org/directory/index.html.



Student Academy of the American Academy of Physician Assistants. 29 November 1999, http://saaapa.aapa.org/.



The Role of Physician Assistants in Evaluation and Certify Health Status. 1999, http://www.aapa.org/gandp/physcls.html.



California Employment Development Department Labor Market Information. 1998, http://www.calmis.cahwnet.gov/file/occguide/physasst.html.



Office of Professional School Advising: Physician Assistant. 23 April 1996, http://honors.tamu.edu/opsa/faqs/phyasst.html.



Internet Journal of Academic Physician Assistants. July 1999, http://www.ispub.com/journals/ijapa.html.



What is a Physicians Assistant. http://ww.crytech.com/rockypa/htmls/whatis.html.



BCM Allied Health Programs. 1999, http://www.bcm.tmc.edu/bcm-alliedhealth.html.



Duke University Physicians Assistant program. 2 November 1999, http://dml.www.mc.duke.edu/cfm/pap/.



What is a Physicians Assistant. http://www.ampka.com/iapa/whatis.html.





















































Sources listed by page (References)



Page where article was found: foot note number





Books



Bliss, Ann, Sadler, Alfred, Sadler, Blair, The Physician"s Assistant Today and Tomorrow. Yale University Press, 1972. 17:13, 17-18:14, 69:15, 20:16, 70-71:31, 70:32, 69-73:33, 84:36, 82-97:37, 144:46.



Cawley, James, Gretchen Schafft, The Physician Assistant in a Changing Health Care Environment. Rockville, Maryland, Aspen Publishers, Inc., 1987. 3-4:1, 3-4:2, 3:3, 3-4:5, 3:6, 3:8, 1,4:9, 3-4:12, 4:17, 4:8, 4-5:22, 4:23, 5:25, 4:26, 30-33:38, 128:42, 40:43.



Cavallaro, Ann, The Physician"s Associate a New Career in Health care. Nashville Tennessee, Thomas Nelson, Inc., Publishers, 1978. 41:18, 41:17.



Ford, Ann, The Physician"s Assistant a National and Local Analysis. New York, Praeger Publishers, Inc.

4, 29-33:1, 48:7, 3:8, 3:10, 3:12, 51-53, 56-57:15, 53-54:17, 53-54:19, 53-54:20, 40:22, 41:25, 41-42:28, 7:30, 7:31, 113-116:35, 125:44, 127:47.



Frew, Ann, Frew, David, The comprhensive Medical Assisting Administrative and Clinical Procedures. Philidelphia, FA Davis Co., 1982. (Nothing)



Sacks, Terence, Opportunities in Physician Assistant Careers. Lincolnwood, Illinois, VGM Career. Horizons, 1995. 13-14:1, 13-14:2, 12:11, 13-14:12, 15:22, 15:23, 15:24, 15-16:25, 36-37:48.



Schneller, Eugene, The Physician"s Assistant. Lexington, Massachusetts: Lexington Books, 1978.

3:1, 47-48:21, 21,29:25.



Health Technology Case Study 37/ Nurse practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis. Washington D.C., US Government printing office, 1986. (Nothing)







Journal



Holt, Natalie, "Confusion"s Masterpiece: Development of Physician Assistant Profession, Bulletin of the history of Medicine, Vol. 72, No. 2, Summer 1998. 268:15, 248-250:16, 273:23, 247, 253, 258:27, 248, 250, 270:29, 267:30, 273-274:34.







Interviews/Lectures



Ettinger, Laura Phd, classroom lecture, Class LC 393, 17 November 1999.



Gagnet, Michael PA, interview by phone, Suwon, S. Korea, 9 November 1999.



Leach, Judy NP, personal interview, Student Health Center, 6 December 1999.







Internet



1998-99 Occupational Outlook Handbook. 13 October 1999, http://stats.bls.gov/oco/ocos081.htm



What is a Physician Assistant-Certified. December 1998, http://www.nova.edu/pa/pafact.html



Into the Future:Physician Assistants Look to the 21st Century. 1999, http://www.aapa.org/strategicplan.html



National Commission of Certification of Physician Assistants (NCCPA Connect). 1999, http://www.nccpa.net/.



Physician Assistant Programs Directory. 1999, http://www.apap.org/directory/index.html.



Student Academy of the American Academy of Physician Assistants. 29 November 1999, http://saaapa.aapa.org/.



The Role of Physician Assistants in Evaluation and Certify Health Status. 1999, http://www.aapa.org/gandp/physcls.html.



California Employment Development Department Labor Market Information. 1998, http://www.calmis.cahwnet.gov/file/occguide/physasst.html.



Office of Professional School Advising: Physician Assistant. 23 April 1996, http://honors.tamu.edu/opsa/faqs/phyasst.html.



Internet Journal of Academic Physician Assistants. July 1999, http://www.ispub.com/journals/ijapa.html.



What is a Physicians Assistant. http://ww.crytech.com/rockypa/htmls/whatis.html.



BCM Allied Health Programs. 1999, http://www.bcm.tmc.edu/bcm-alliedhealth.html.



Duke University Physicians Assistant program. 2 November 1999, http://dml.www.mc.duke.edu/cfm/pap/.



What is a Physicians Assistant. http://www.ampka.com/iapa/whatis.html.