PHYSICIAN ASSISTANTS

The Physician Assistant concept of providing health care delivery began in 1967 in North Carolina.  (*)

The medallion to the right is from the Society of Army Physician Assistants.
The motto "Primum Non Nocere" translates to " First Do No Harm"
The reverse shows a combat medic providing care for an injured soldier similar to the photo below with the caption "To conserve the fighting strength"
It can be enlarged.

ORIGINS  

The original concept of the Physician Assistant (PA) profession was created by Dr Eugene Stead in Durham, North Carolina in 1967. 
Dr stead was an ex Navy physician who was walking down the hallway of a hospital in North Carolina when he noticed a janitor cleaning the hallway whom he had worked with while in the Navy. 
He was appalled to see such a well trained, skilled and knowledgable Navy Corpsman doing such menial labor. 
Upon investigating he learned that there was no process by which ex-military medical personel could be employed in the civilian health care field without starting from scratch and obtaining civilian related training. 
Their expensive military training and valuable experience was useless.
The photo to the right is of a monument located at the Eugene Stead Center for Physician Assistants located in Durham, N.C. (North Carolina Physician Assistants Association)
It is entitled "Life Savers Then, Caregivers Now".

Click on the photo to enlarge it for better details.

EDUCATION


He determined to change this and he did. 
Working with Duke University, he developed a program that built on ex-military corpsman's (Navy) and medic's (Army) training and experience, polishing and enhancing their skills and knowledge. 
He designed a two year program that provided a college degree in Health Sciences that would be recognised everywhere.
He determined that the public would best be served and would be more receptive to this new health care provider if they were intimately associated with physicians.  It was  decided to identify them as Physician Assistants. Actually the very first PAs were identified as Physician's Assistant, using the posessive apostrophe, however this was later dropped. 

SUPERVISION

PAs are legally subordinate to a supervising physician and in some states, their license are bound to that physician.  The supervising physician is responsible for the actions for 'their' Pas. 

CREDENTIALING

The National Commision on the Certification of Physician Assistants (NCCPA) was created to test and credential PAs, providing a process by which their comptency was assured.  This was an essential part of getting the individual states to license PAs.
Unlike physicians, (except Family Practioners) Physician Assistants are required to update their certification every 2 years by proving they have obtained 100 approved hours of continuing medical education to assure their competence.
They also have to retake the national certification examination every 6 years in addition to the prerequisite 100 hours of CME.

DIFFICULT BEGINNINGS  

The original concept as imagined by Dr Stead, would be that PAs would be used in medically underserved rural areas of the country where physicians could no longer be economically viable. However, this proved to be an elusive goal, as Medicare would not reimburse for PAs office visits and most insurance companies would only provide minimal  reimbursement for their services.  

Another problem was that the various states were slow to legalize PAs and each state was a separate battle for recognition through their individual legislative bodies. To further complicate the process, many physicians perceived the new providers as competition to their well being, and fought tooth and nail to keep them OUT! 
Additionally, many nurses also considered the PAs to be a threat to them, and originally many state nursing organizations refused to recognise PAs as legal providers and instructed their members (Rns and LVNs) to refuse to honor PA orders. 

Each state was a complex and separate battle.

However the source of the new PA students proved to be the entity that valued the new providers the most. The military. 
With the loss of the draft and the Barry Plan (an old federal program that payed for medical students training in return for 2 years of military service for each year of training) the military was hurting for physicians, and this new mid-level health care provider was a perfect answer to their problem. 
PAs would be used at the 'front line'  or 'primary care' level to replace the disappearing physicians.  Military physicians rapidly recognized the competence and value of the new providers and as they got out of the military and entered the civilian milieu, they were powerful allies in establishing a demand for our services. This demand carried over to the Veteran's Administration who became an early supporter and user of PA services.  

THE BIG BREAK THROUGH 

In 1991 the US Congress passed the Rural Health Care Act, finally authorizing Medicare (and Medicaid) to reimburse hospital and clinics fully for mid-level practioners (Physician Assistants and Nurse Pratitioners) service. 
Not only that, but in certain underserved areas, certified Rural Health Clinics would be reimbursed at an even higher rate, to encourage the placement of clinics in areas that had until this time been economically unreasonable to have a health clinic. This act not only authorized the enhanced reimbursement, but mandated  that these clinics be staffed by mid-level practioners.
Consequently the demand for PAs exploded.

Most people who seek health care probably have came in contact with a Physician Assistant, as they are employeed in all 50 states
They have proven themselves to be excellent health care providers.
Patients like them, not only for their competence, but also because they  make an effort to spend more time with each patient visit and tend to speak to their patients in a language the patient can understand.
PAs also take the time to  explain what is going on and to provide more education.

PAs are now utilized in every field of health care delivery.
The work in Emergency Rooms, assist in surgery, and in every specialty field in medicine.
Many PAs who work in isolated areas and in Rural Health Clinics are the sole provider for entire towns and counties.
They are still supervised by a physician, but this frequently is from a distant location and supervision is by telephone or radio.

The present (2007) median salary for PAs in the US is around $77,000. However, in Texas that figure is closer to $87,000

Becoming a PA usually requires a BS degree to enter a training program, preferably but not mandatory that it be in the health care field.
Most programs also prefer that applicants have at least some experience in the health care field, even if it is only voluntary.
However, the actual training as a PA is only two years, and does not require an internship or residency period following graduation.

A couple of excellent web pages which describes the concept in some detail are located at:

http://www.colby.edu/health.serv/pa.html

http://www.princetonreview.com/cte/profiles/dayInLife.asp?careerID=181

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* The Russians have utilized extended care providers (Feldshers, literally, 'barber') in rural areas for many years (since the 1600s) before the concept was started here in the US.
They are not as well trained as PAs, but in many areas of Russia, that is all they have, with no opportunity for the patient to seek a higher level of care.


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