This Timeline contains important milestones and events in the development of the physician assistant (PA) profession. It provides the reader with an introduction to the people, events and activities that have shaped the growth of the profession from concept to reality. With the exception of the precedent years that date back to 1650, the Timeline presents a decade by decade progression in the use of non-physicians to provide health care in the United States and other countries. Imbedded in the Timeline are links to other relevant sites, illustrations and references to enrich the reader’s depth of knowledge about our professional history and how it is intertwined with that of other health professions.
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Historic Precedents Providing medical care to remote populations where none existed, and meeting military and public health needs, have been concerns of nations for centuries. The use of non-physicians to provide health care services has an extensive history. Among the more noteworthy experiments were efforts to deliver services to the Russian wilderness, to the communes of rural China, to the frontiers of the American West, and to native-American villages in Alaska. Military necessity, especially in times of war, led to the use of non-physicians to provide acute care at army bases, and on warships in France, England, and post-revolutionary America. The United States Public Health Service found a need to use former military corpsmen in prisons. Advanced, highly technical surgical procedures, developed in mid-20th century, led innovators to train technicians to assist in urology and cardiovascular surgery. In the 1940s a unique event took place. A highly respected general practitioner in rural North Carolina trained his own "doctor's assistant" to care for his patients, even while he was away to further his medical education. Remarkably, that partnership received great praise from organized medicine. A road had been mapped; it was soon to be paved by pioneer educators.
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.
Establishing a Profession The structure of a profession rests upon four pillars: A society of practitioners; an association of educational programs training those practitioners; a nationally recognized body charged with accreditation of the programs; and a process of certification of graduates in the public interest. By the middle of the decade of the 1970s all four of these entities are in place, and functioning with paid executive management. AAPA, established in 1968 by students and alumni of the Duke program, extends membership to graduates from programs around the country, and becomes the legitimate voice for the profession. APAP is formed in 1972 in order to share information among programs regarding curriculum and admission policy. Foundation funding in 1973 permits the establishment of a National Office to manage the affairs of both organizations. The several program models converge as the AMA, together with four medical specialty societies, begins the process of accreditation in 1972. The NBME administers an examination in 1973, followed by the formation, a year later, of the NCCPA, a consortium of societies and agencies, charged with oversight of the certification process. Federal funding, authorized under the 1971 Health Manpower Act, stimulates an explosion of training, tripling the number of programs in a single year, 1972. Begun as a Federal study, a foundation-funded book is published in 1972, tracing the origins of the PA concept, and suggesting policy direction for a new profession. Following four successful conferences, Duke University passes the baton of leadership to the new organizations to create, in 1973, the first nation-wide conference on "New Health Practitioners." States begin to adopt amendments to their medical practice acts which allow delegation of tasks by physicians to trained assistants. Multiple published studies conclude that PAs function at a level at least comparable to a control group of medical house officers. The AAPA establishes a House of Delegates to govern policy.
Nationwide Adoption The decade of the 1980s represents nationwide dissemination of an established profession. There is growing recognition of PA contributions to the medical workforce. With a single exception, all states now authorize the delegation of responsibility by the physician to the physician assistant, provided that tasks assigned are within the scope of practice of the physician. Revision of statutes allows prescriptive privileges in most states. There is a clear trend toward specialization with PAs employed by physicians practicing all specialties. By the end of the decade, branches of the military service begin to grant commissioned officer status to PAs. In 1981 the NCCPA introduces the process of recertification by examination. In 1986, reimbursement of PA services under Medicare, Part B, is authorized under the Omnibus Budget Reconciliation Act. The profession is poised for another period of rapid growth.
Maturation and Growth During the decade of the 1990s, there is sharp growth in the number of accredited programs from 45 to 114. Most of the new programs appear in smaller colleges affiliated with community hospitals. As applications soar, the vast majority of students admitted already possess a baccalaureate degree. The result is a trend toward the award of the Master's degree to graduating PAs. In a reversal from past experience, the majority of applicants are now women. Employment opportunities far exceed the number of graduates. VA medical centers, the Military, and other state and Federally-sponsored health institutions rely heavily on PAs to bolster medical staffs. Published studies lead to greater HMO reliance on PAs to reduce cost. States continue to revise legislation, rules and regulations in order to enhance the effectiveness of PAs. The Balanced Budget Act of 1997 recognizes PAs as covered providers in all settings at a uniform rate of payment. The last of the branches of the military service grant commissioned status to PAs. Mississippi becomes the last of the states to authorize physicians to delegate the practice of medicine to PAs. Administrative responsibility for ARC-PA is transferred from the AMA to AAPA; the corporate office moves to Marshfield, WI. The NCCPA examination is administered by computer in a move toward administration throughout the calendar year.
Going International As the new programs developed in the last decade grow and expand, record numbers of PAs take the certifying examination. As the profession celebrates its 40th anniversary, international interest in the PA model of health care delivery grows with the establishment of PA educational programs in seven countries. In 2001, ARC-PA becomes a freestanding accreditation agency. APAP launches a Central Application Service for Physician Assistants. The Physician Assistant History Society is established in Durham, NC in 2002. Increasing numbers of PAs are appointed to positions in Federal agencies, and in 2004, two PAs are elected to state legislatures. In 2005, APAP changes its name to the Physician Assistant Education Association; a year later the organization holds its first meeting outside the United States in Quebec, CAN. ARC-PA awards accreditation to two postgraduate programs, and the US Army and Baylor University create the first doctoral degree program. New regulations limiting the number of hours that medical residents may work without relief opens the door to expanding opportunities for PAs in hospital settings. In 2010 President Obama signs the Patient Protection and Affordable Care Act, potentially adding 20-30 million patients to the ranks of the insured population.
Into the Future The Affordable Care Act doubles the projected need for PAs. PAs are seen as essential components of new health care delivery structures such as "accountable care organizations" and "medical homes." Forbes and Money magazines rate the physician assistant Master's degree as the most desirable advanced degree in terms of employment opportunity, income potential, and job satisfaction. NCCPA develops the concept of a "Certificate of Added Qualifications" to meet the need of PAs for a credential in a specialty. The Physician Assistant History Society affiliates with the NCCPA, and moves their office and archive to Johns Creek, GA. PAEA celebrates its 40th anniversary at their annual meeting in Seattle in November 2012. Most significantly, the NCCPA issues its 100,000th certificate. The number of accredited programs exceeds 170 with as many as 50 more currently seeking provisional status. The profession is healthy and growing.