1957 to 1970
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.
US Surgeon General, Leroy E. Burney, identifies a national shortage of medically trained personnel to provide basic medical services.
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.
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, EdD, RN, 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 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.
The first class of three PAs, Victor H. Germino, Kenneth F. Ferrell and Richard J. Scheele, graduates from Duke University on October 6th.
Henry K. Silver, MD, establishes the Child Health Associate (CHA) Program at the University of Colorado (a PA program with emphasis on pediatrics).
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 on May 20th, 1968. 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.
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. The University of Washington School of Nursing develops the PRIMEX (short for Primary Care Extender) programs. The program was developed by Madeleine Leininger. It’s focus was to expand the role of nurse practitioners involved in primary care and preventative services.
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.
The term “physician associate” starts to be used for the university-trained “Type A” PAs. At this time, the Duke University PA program, along with six other PA programs, change their program names to the “physician associate program”.
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.
Joyce Nichols graduates from the Duke PA program, becoming the first female PA in the United States.
Estimated Number of PA programs: 12
Estimated Number of PAs: 150
