Oral History Interview: APAP Panel Discussion

Participants: Donald Fisher, Suzanne Greenberg and Thomas Piemme
Moderators: J. Jeffrey Heinrich and Reginald Carter
Place and Date: APAP Education Forum, 30th Anniversary, Miami FL — November 2002

Summary: In celebration of the 30th Anniversary of the founding of the Association of Physician Assistant Programs (APAP now PAEA), a panel of distinguished PA leaders were invited to reminisce about the establishment of the PA concept in the early 1970s. Dr. Thomas Piemme served as the Association’s second president and participated in the establishment of the National Commission on Certification of Physician Assistants (NCCPA). Mrs. Suzanne Greenberg served as the Association’s first secretary and treasurer. Dr. Donald Fisher served as the Academy’s (AAPA) and Associations (APAP) first executive director and was also involved in the formation of the NCCPA. At the time, Dr. J. Jeffrey Heinrich was president of the Society for the Preservation of PA History and Dr. Reginald Carter was the Society’s executive director and historian. The session was a huge success with the audience, many of whom where hearing about the early days of the profession for the first time.

Piemme remembers the formation of the American Registry of Physicians’ Associates (ARPA) in 1970, the 4th Duke Conference and the establishment of the Association of Phyician Assistant Programs in 1972:

APAP Panel – Piemme 1 from PA History Society Vimeo

Note: Transcripts are edited for clarity, punctuation and grammar or to fill in gaps of missing information. So the transcript may deviate from the actual audio recording.

TP: Well, the Registry was an organization formed in 1968 {sic 1970} for the purpose of keeping track of all the people graduating from physician assistant programs. But its {PA Program} membership was concerned with a number of issues that inevitably would have to be addressed for a new health occupation. There was the issue of accreditation of the emerging programs, the need for an association that would allow training programs to exchange information and a need to create a body in the public interest that would certify graduates of the programs and assure their competence to practice.

In 1972 in Durham, a few people decided to carve off the first piece of that, and said this Registry is too diffused and too unfocused, let us create an association of physician assistant programs. Those of us who were a part of this will then concern ourselves with the other issues, but let’s get this one underway. And that happen in September of 1972. The other organizations followed in the next year.

RC: Do you remember how Fred became president {of the Association}?

TP: Oh yes! Well, his recollection is clearer than mind. There were eight people around the table; at that time I think there were twelve PA programs and only eight were represented. Fred came back from the bathroom, to where he had excused himself, and was told by Bob Howard, “Congratulations, you have just been elected president.” {Laughter}

RC: Fred said, “I guess whoever would have gone to the bathroom would have been the president of the Association. So a lot of our history started out in the bathroom, and hopefully gone [better since].

Greenberg speaks about her role as the Associations first secretary and treasurer and the types of questions being asked in the early days:

APAP Panel – Fisher from PA History Society on Vimeo

RC: Sue you were secretary and treasurer for two or three years and actually the Association’s box office was your box office {in Boston}. What did the secretary and treasurer do and how glad were you when the national office opened and Don and staff took over some of that responsibility? What are your memories of those first two or three years?

SG: They were not hard; it was fun. But the questions — you never knew what kind of questions; the phone would ring and you would never know what kind of questions you would be asked and where you were going to dredge up an answer; because there were not a lot of answers. We were just starting and there were things that we had to think about. When the national office opened it was wonderful to have someone to refer inquires to for response; to think things through. But there were other members of the Board so if things came up that I could not deal with — it was very easy to call one of them. But most of the questions were about who are PAs? What are they? What do they do? We still had issues of the Registry that was still part of us — which was the graduate group in essence. At that time, there was a rival organization that wanted to take over {the registry} but its standards were somewhat different from that of the Registry. More time was spent dealing with issues like that then they were — and the politics of how to handle this particular group; can’t remember his name or that of his organization out of New York?

TP and RC: Paul Palace and the American Association of Physician’s Assistants.

SG: Some time was spent discussing the differences between the two organizations. Another thing we spent a lot of time on was what was the difference between a nurse practitioner and a PA? That was the constant question coming up and ….

DF: It still is!

SG: And it still is… but one had to listen carefully to who was asking the question and what kind of answer they were looking for. You just couldn’t give a rote answer. So there were challenges but it was fun and exciting. What we saw over a period of time was growing interest and that was really the most important thing. People were beginning to hear about the concept and were interested in knowing more about it and we thought we were on the right track.

Fisher talks about the formation of the National Commission on Certification of Physician Assistants; the deals made and why he remembers vividly the date the “papers” were signed:

APAP Panel – Piemme 3 from PA History Society on Vimeo

JH: Dr. Fisher and Dr. Piemme, you were both involved in the development of the NCCPA. Can you tell us about that Chicago meeting?

DF: I’ll start and Tom can fill in the details. A lot of work led up to the meeting in Chicago on August 8th 1974. What I would say is that it was one of the most incredible pieces of work ever done for the PA profession because back in 1972, 3, and 4 — most professions certified themselves. You would get together, set the bar, the competencies and standards to sit for the examination and in essence the profession would determine who would practice in that profession. It was done like this in almost all the allied health professions. But when the PA profession came along, there was a different vision. It was partially brought on because the National Board of Medical Examiners had been engaged to produce the examination for PAs, which by the way was the first time the National Board of Medical Examiners had ever tested any profession other than physicians. This was a huge step forward for the PA profession. Secondarily, the AMA feared that this profession could be a run-away, renegade who could go out and practice independently, become like nurse practitioners, independent practitioner who therefore would ultimately be in competition with physicians — and they did not want that either. So what they wanted was the creation of a body, which today you know very well is five PAs with the rest of the Board made up of physicians and non-physician representatives of organizations who ultimately employ PAs and are representative of the public at large. Just think about going back to 1973-74. Who ever thought about putting public members on boards of certifying organizations? And this was done by this group at that time.

We got all the work done as Tom will remember, as with most organizations as they are forming, a lot of the decisions were not made in the board room but were made in meetings prior to the board room meeting because we needed to make sure the right people got elected and to make sure that the right make-up of the Commission was in place. Once we had decided that in a small meeting that took place with Tom Piemme, myself, Frank Whittick (sp?) and Rhodes Haverty. I think I got all of them, right Tom?

TP: That’s right.

DF: Off in a side room, probably the bar actually, we decided that we needed five PAs on the Commission so that we could make sure that there were enough of them there that they never could change the bylaws without approval by the PAs. The certifying body could make their own decisions about past/fail, standards for sitting for the examination but as far as changing the bylaws, to change the direction of the organization, the PAs would have to go along with that. Once that was decided and agreed upon by these people that represented the National Board, AMA and the PA Profession — the only thing left to do on the 8th of August was to sign the papers, which we did.

The interesting thing about that meeting is that we elected officers and Tom was elected president of the NCCPA. We had a nice agenda that would carry us through most of the day, but I got slipped a note that morning that the president of the USA {Richard Nixon} was going to resign that evening or the next morning. I slipped that note to Tom and we decided this meeting had to be adjourned because we couldn’t be in Chicago when the president of the United States was going to resign in Washington where we both lived. So we got the meeting over, we signed all the papers and got on airplanes and went back to Washington. We spent the night on the lawn at the White House with our wives watching all this history unfold knowing that we had just established a national certifying body the day the president was resigning.

Piemme elaborates on the development of the national certifying examination for PAs by the National Board of Medical Examiners and what brought about the formation of the National Commission on Certification of Physician Assistants:

APAP Panel – Piemme 4 from PA History Society on Vimeo

TP: The National Board promptly appointed Barbara Andrews who did something quiet unique in test development. Instead of going to the programs to ask the question, what should the content of this examination be, she assembled a group of experts who had done research work in the field of new health practitioners, physician extenders, and number of other titles at the time. And a dozen of them met for a year to conduct a role delineation study to determine what physician’s assistants actually do. What is it that their employers have them do? What are their days like, what are the components of their activities? Out of that a test committee was appointed and an examination was drafted and in December of 1973 the examination was administered for the first time. Quiet successfully, with universal acclaim from not only the Academy but by the Association of PA Programs and the professional organizations that made up the constellation of people who would be utilizing PAs and the state regulatory boards.

But the National Board of Medical Examiners was uncomfortable with being the arbiter of who should sit for the examination. They had identified the thirty-two or three programs that the federal government was funding in 1972, the same number of programs that had been accredited during 1973 by the AMA’s Accreditation Council, and the eight MEDEX programs that existed at the time and being quiet attuned to the political winds, identified fifty-six nurse practitioner programs who had produced graduates who were often being used in the same capacity who might wish to sit for the examination. But they did not want to do this any further. They wanted to defer to a national body so Fred Sadler sat in at the invitation of the AMA on a preliminary meeting to identify those organizations that might usefully make a contribution. As Don said, there were seventeen organizations that assembled in Chicago in August 1974 and came to an agreement relatively quickly on all issues, the sticky issue being to what extent the physician assistants themselves would be represented. Once that compromise was reached we were ready to put this to bed.

Oral History Interview: APAP Panel Discussion