The Formative Years
As specialization in medical practice grew following World War II, a growing shortage in primary care health manpower has become clear. At Duke University in 1957, the nation’s foremost chair of medicine, and a visionary nurse begin a program to train nurses to provide direct assistance to physicians with emphasis on primary care. Having failed accreditation by the National League for Nursing (NLN), the program was discontinued, but the experience was not forgotten. In an address to the House of Delegates in 1960, an emerging leader of the AMA proposes the training of former military corpsmen as assistants to physicians. In 1965, Duke University establishes such a program with four ex-Navy corpsmen, creating a sensation in the national press. Within four years four other prototypes emerge. The Duke PA and University of Washington MEDEX programs are quickly emulated by other academic medical colleges. Meanwhile, the shortage of generalist physicians is compounded by the creation of Medicare and Medicaid, opening access to health services by millions of new patients. Two national commissions address the issue, promoting expansion of all efforts to support generalist physicians. By the end of the 1960s, the AMA formally endorses the concept of the “physician’s assistant,” and begins to explore accreditation of programs in order to achieve a common standard of training. The existing academic programs form a “registry” to assure the public of the qualifications of their graduates. Formalization of these processes will require compromise and cooperation, and is to be achieved in the next decade.
Thelma Ingles, RN, begins a clinical sabbatical year with Dr. Stead, at Duke University, which leads to the establishment of a master's degree program for nurse clinicians at the School of Nursing. The Program, funded by the Rockefeller Foundation, produces highly trained nurses who are taught primarily by physicians at Duke. Although highly successful, the program is denied accreditation by the National League for Nursing (NLN) because of the heavy reliance on physicians in the training program, and because Ms. Ingles lacked a degree in nursing. (She had a baccalaureate degree in English from UCLA and had graduated from the prestigious nursing program at the Massachusetts General Hospital.) It is generally conceded that, had this innovative program been accredited, Stead would not have initiated the Duke University PA program with former military corpsmen eight years later. The PA profession might never have existed.
US Surgeon General, Leroy E. Burney, identifies a national shortage of medically trained personnel to provide basic medical services.
An address to the House of Delegates of the AMA by newly elected Trustee, Charles Hudson, MD, is published in the Journal of the American Medical Association. Entitled, "Expansion of Medical Professional Services with Nonprofessional Personnel," it calls for a "mid-level" provider from the ranks of former military corpsmen. Movement toward the concept of the physician assistant is set in motion.
The World Health Organization (WHO) begins introducing and promoting new categories of health care workers in developing countries (e.g., Me'decin Africain, Dresser, Assistant Medical Officer, and Rural Health Technician).
Hu Myers, MD, approaches the Alderson-Broaddus College Board of Trustees in Philippi, WV, about starting a four year degree-granting program to educate physician assistants similar to the degree granting nursing program that he had helped establish at the College in 1945. The Board turns him down.
The Civil Rights Act is enacted as a landmark piece of legislation in the United States. The Act outlaws major forms of discrimination against African Americans, including racial segregation. It removes socioeconomic barriers to voter registration and ends racial segregation in schools, at the workplace and by facilities that serve the general public such as restaurants, bathrooms, hospitals and clinics.
Eugene A. Stead, Jr., MD, disillusioned by organized nursing’s rejection of the advanced nurse clinician program that he and nurse educator, Thelma Ingles, had developed, announces in a letter to Duke Hospital Administrator, Charles H. Frenzel, his intention to develop a program for the “physician’s assistant”, using former military corpsmen, modeled after the relationship between Amos N. Johnson, MD, and Henry Lee “Buddy” Treadwell, his assistant, that was well known in the North Carolina community.
As announced by Stead, the nation’s first “physician assistant” educational program is inaugurated at Duke University. The Program accepts four former Navy medical corpsmen.
A Reader's Digest article about jobs in the health care industry mentions the development of the PA program at Duke University, causing a flood of inquiries from ex-military corpsmen.
A White House Conference on Health discusses the use of former military corpsmen/medics as "assistant medical officers."
Henry K. Silver, MD, and nurse educator Loretta Ford establish a four month Pediatric Nurse Practitioner program at the University of Colorado.
Medicare and Medicaid are passed by the United States Congress, expanding the need for basic medical services – already in short supply. The legislation stipulates that no reimbursement will be provided to segregated hospitals. The reorganization of US hospitals sets the stage for the development of new roles within hospital systems.
Richard Smith, MD, who later becomes the founder of the MEDEX Programs, is appointed by President Lyndon Johnson to lead the federal effort to desegregate the US hospital system.
Mao Zedong, Premier of China, calls for the training of Barefoot Doctors to provide basic medical services to rural Chinese populations. By 1968, the barefoot doctors program becomes integrated into national policy to establish “rural cooperative medical systems” (RCMS) throughout China. (The barefoot doctor system ends in 1981, when the agricultural communes are abolished.)
The Willard Commission, appointed by the AMA, recommends that the "general practice" of medicine be transformed into the specialty of "family medicine," that a three-year residency be required, and that a board be established to oversee formal certification.
The Millis Commission (Citizens Commission on Graduate Medical Education) reinforces creation of family medicine as a specialty, and defines the term “primary care” to mean first contact, management of common illness and health maintenance. Such care is expected to be provided by general internists, general pediatricians, and family physicians. It is identified as the Nation's most critical health manpower issue.
A Look Magazine article entitled "More Than a Nurse; Less Than a Doctor" creates a sensation when it catapults the PA concept to national attention but undermines attempts to foster nurses' acceptance of PAs.
Former military corpsmen are increasingly being informally trained to assist physicians in a variety of specialties and practice settings. National attention is brought to the issue in People v Whittaker, a case in which the State of California charged ex-Navy operating room technician, Roger Whittaker, as assistant to neurosurgeon, Dr. George Stevenson, with "engaging in the unlicensed practice of medicine." While found guilty, both men were assessed only a small fine. Whittaker was invited by Eugene Stead to join the incoming class of students at Duke University. The case underscores a need for legislation to permit physicians to delegate tasks to qualified non-physicians.
Duke University hosts the first of four national conferences on physician assistants to explore the issues of development and standardization of educational program curricula, study and promotion of the PA concept to professional, private and Federal organizations, and the development of model legislation for PAs.
The American Association of Physician's Assistants (AAPA) is established by Duke University PA students and alumni, and is incorporated in NC. Its stated purposes are to encourage its members to render honest, loyal and efficient service to the medical profession and quality care to the public whom they serve. William (Bill) Stanhope, PA, is elected as the first president.
Richard Smith, MD, launches the MEDEX program at the University of Washington, Seattle, WA, in partnership with the Washington State Medical Association. It is designed to rapidly deploy ex-military corpsmen to rural primary care practices throughout the Northwest.
The American Hospital Association and the Joint Commission on Accreditation of Hospitals release a report on the "Utilization of Physician's Assistants in the Hospital."
At the request of the Assistant Secretary of Health, Roger O. Egeberg, Alfred M. Sadler, Jr., MD, and Blair L. Sadler, JD, of the National Institutes of Health (NIH) complete an intensive nationwide survey of all licensed allied health occupations. Their report recommends that State Medical Practice Acts be amended to permit the practice of physician assistants under the supervision of a physician as long as both the PA and MD are responsible for these activities.
Kaiser Permanente becomes the first HMO to employ PAs.
A consortium of PA programs establishes the American Registry of Physicians’ Associates (ARPA). It is incorporated in NC to grant and issue certificates to graduates of approved programs or others who can "demonstrate by examination" that they possess the knowledge and skills of a graduate of an approved program.
The American Medical Association (AMA) Council on Health Manpower endorses the PA concept. The House of Delegates adopts "Guidelines for the Development of New Health Occupations."
With the recognition that more than 100 programs throughout the country have arisen to train what are termed "physician's assistants," and that they vary widely in length and depth of training and in quality of instruction, the Board of Medicine of the National Academy of Sciences releases a report classifying physician's assistants as Type A, B, or C. Type A assistants are broadly trained in an academic institution across the full range of specialties in a program of at least two years in length. Type B assistants are narrowly, but intensively, trained in a particular specialty. Type C assistants are broadly trained, but in less depth over a shorter length of time. National medical organizations respond by making it clear that their focus will be on the "Type A" assistant to the primary care physician.
Martha Ballinger releases a report of a project, conducted at Duke University, on "model legislation" for physician assistant practice. In California, Governor Ronald Reagan signs Assembly Bill 2109 into law on September 17, 1970. It directs the Board of Medical Examiners to establish this new category of health professional. Thus, California becomes the first state to enact enabling legislation for physician assistants.