Duke PA Program History and Philosophy

The Physician Assistant Profession

• The origin of the profession and supporting organizations

PA Profession Origins

• Feldshers in Russia
• Barefoot Doctors in China
• Military Corpsmen in the United States

Feldshers

• Originally German military medical assistants (field surgeon)
• Introduced into the Russian military system by Peter the Great in the 17th century
• Large numbers of Russian troops relied on feldshers for a majority of their medical care due to a physician shortage
• Feldshers who retired from the military settled in small rural communities, where they continued to provide access to health care
• Feldshers assigned to Russian communities provided much of the health care in remote areas of Alaska during the 1800s
• By the late 19th century, formal schools were created for feldsher training.
• By 1913, approximately 30,000 feldshers had been trained to provide medical care.
• Feldsher training programs required 2 years to complete, located in institutions similar to nursing schools.
• Unlike some PAs in the U.S., Feldshers did not work alongside physicians daily to improve physician efficiency; they were substitutes in rural areas for diagnosis, prescription, and emergency treatment.
• In urban settings, their role was more complementary than substitutional.

Barefoot Doctors in China

• Originated in the 1965 Cultural Revolution as a physician substitute
• Known as the "June 26th Directive," Chairman Mao called for a reorganization of the health care system.
• In response to Mao's directive, China trained 1.3 million barefoot doctors over the subsequent 10 years.
• Received 2–3 month training courses in regional hospitals and health centers that were linked to local hospitals for additional training.
• In the early 1980's, the use of feldshers and barefoot doctors was significantly greater than the use of PAs in the U.S.
• Currently, numbers of both have declined due to lack of governmental support and an increase in physicians.

Development of Physician Assistants in the United States

• Starting in the 1930s, former military corpsmen received on-the-job training from the Federal Prison System to expand prison physician services.
• In 1961, Charles Hudson, MD, proposed the concept of physician assistants at an AMA conference, recommending assistants to doctors, performing tasks like suturing, lumbar punctures, and intubation.
• Numerous physicians in private practice started using informally trained individuals to expand their services.
• In the late 1950s and early 1960s, Eugene Stead, MD, developed a program at Duke University hospitals to expand nurse capabilities. This was opposed and the format of the program moved from the ranks of nursing towards a "medical model."
• In October of 1965, the first four students started the Duke PA Program.
• The program focused on primary care and lifelong learning skills for professional growth.
• The program originally called for two categories of PAs: general practice and specialized inpatient care.
• Three students completed the program in 1967 (Ferrell, Germino, Scheele).

Challenges of Education and Practice

• The concept of medical education was first to learn basic sciences, then pathophysiology, and, finally, normal structure and function.
• PA education was different; some early PAs lacked formal college educations previously, physicians were the sole possessors of medical information.
• The "primary care" nature of PA training made PAs adaptable to various patient care settings, but not originally intended for specialty areas.

Military Corpsmen

• The decision to train military corpsmen as the first PAs was a key factor in the success.
• This capitalized on the U.S. military's prior investment in providing extensive medical training to these men, making the PA concept one of the "positive products" of the Vietnam War.

Name Controversy

• In 1970, the AMA-sponsored Congress on Health Manpower chose "associate" over "assistant" for a more collegial relationship between PAs and supervising physicians.

• The AMA's House of Delegates rejected "associate," applying it only to physicians working with other physicians.

• Some programs continued using "associate," and the debate resurfaced recently when the AAPA changed its name.

• The correct term is "Physician Assistant." Numerous programs now use "physician associate program," and states use "physician associate."

• The apostrophe was previously used, but is not correctly used.

Program Expansion

• 31 new PA programs were established between 1971 and 1973, due to federal funding.
• By 1975 (10 years after Duke's first PA program), there were 1,282 graduates of PA programs.
• 9 new programs were added between 1974 and 1985.
• 16,000 practicing PAs in the U.S. by 1985.
• 76 programs were accredited between 1965 and 1985, but 25 closed.
• In 2011, there were 159 accredited PA programs. There were approximately 80,019 certified PAs at the end of 2010
• As of December 2024, there were 311 accredited PA programs.
• The profession grew by 75.2% over the past 10 years, reaching 178,708 certified PAs at the end of 2023.
• 52 applicant programs are developing PA programs as of January 1, 2025.

Need for Physician Assistants

• Projected physician shortage of between 13,500 and 86,000 by 2036.
• Projected shortfall in primary care (20,200 to 40,400 physicians by 2036) and non-primary care specialties (19,500 to a surplus of 4,300 by 2036).

Accreditation

• Accreditation of formal PA programs became necessary because the term "physician assistant" had been applied to many types of trained health professionals.
• The AMA (with other medical organizations) approved "educational essentials" for PA training programs in 1971.
• Accreditation applications and site visits for programs began in 1972

Certification

• The first certifying examination was administered by the NBME in December 1973 to 880 candidates.
• The NCCPA was created in August 1974 by cooperating with the AMA and the NBME.
• Graduates of formally accredited PA programs have been eligible for the NCCPA examination since 1986.
• The first recertification examination was given in 1981.

Supporting Organizations

• American Academy of Physician Assistants (AAPA)
• Physician Assistant Education Association (PAEA)
• State PA Organizations (e.g., TN Academy of PAs)
• Specialty Organizations (e.g., Society of Dermatology PAs)

AAPA

• Started in 1968 as the American Association of Physician Assistants.
• Headquartered in Alexandria, Virginia.
• Other organizations aiming to represent PAs were formed; however, AAPA emerged as the single professional voice.
• The first AAPA House of Delegates meeting was convened in 1977.
• Governed by a 13-member Board of Directors. Includes 10 standing committees and 4 councils; and state and student representative.
• PA Student Academy of chartered student societies from each PA program.
• The annual conference for PAs draws 7,000–9,000 participants.
• Capital Connections is scheduled in March each year.
• Staff of AAPA

PAEA

• Started in 1972 as the Association of Physician Assistant Programs
• Network for programs to work on curriculum development
• Define the role of the physician assistant
• Represents educational programs, whereas AMA and AAPA represent individual practitioners.
• Governed by a twelve-member Board of Directors, which includes student representation.
• Ten standing committees and two institutes, along with special committees and task forces.
• Centralized application process (CASPA) introduced in 2001 to streamline program applications.
• Publishes a journal (Journal of Physician Assistant Education) and provides CME and professional development.
• Annual Forum is held in October of each year.

The Political Process

• PAs in states where their controlled medications are not recognized.
• The political process involved in addressing this and gaining prescriptive privileges.
• How a bill becomes a law. Stages of the process that a bill can be expected to follow through Congress and the appropriate agency.
• Individual responsibilities in the political process, to advance the interests of patients.

Practice Laws

• Occupational regulation is the responsibility of the state, not the federal government, and each state regulates various occupations, from plumbers to physicians.
• Protection is provided only to those who meet education and skill standards, abide by scope of practice, and adhere to professional standards.
• PAs must obtain permission from the state to practice and comply with conditions of practice.
• There is uniformity to state laws regarding PAs.
• The Board of Physician Assistants regulates PA practice. This board was transitioned from a committee to its own, independent board in 2021.
• The universal requirements for obtaining state credentials (licensure) as a Physician Assistant are:
  • Graduation from an accredited PA educational program
  • Passing the Physician Assistant National Certifying Examination (PANCE).

PA Laws and Regulations

• State licenses must be renewed (1–3 years depending on the state).
• PA laws include physician supervision criteria, and may have restrictions on medications.
• Good state law allows delegation within the PA's scope of practice.
• The scope of PA practice is limited by laws, regulations, or application lists of tasks delegable by physicians.

The Six Key Elements of a Modern PA Practice Act

• The regulatory term is “licensure.”
• Full prescriptive authority
• Scope of practice determined at practice level.
• Adaptable collaboration (proximity) requirements
• Cosignature determined at practice-level.
• Number of physician–PA collaborators determined at practice level.

AAPA Roles

• Advocacy and government relations
• Research and data collection
• Public education
• Publications
• Continuing medical education and professional development
• Employment
• Other member services

AAPA Advocacy and Government Relations

• Speaking for the profession before U.S. Congress and federal agencies.

• Difficulties for individuals to sway legislation.

• The Academy advocating for the PA profession to legislators, expressing the PA profession's views on federal legislation and regulations.

• Lobbying by AAPA professional staff.

• Legislative alerts and publications.

• Inviting members to attend government affairs conferences in Washington, D.C.

State PA Associations

• Chartered constituent chapters of AAPA
• Employ professional association management staff, lobbyists, and legal counsel

How a Bill Becomes a Law

• Legislative proposals may be introduced by senators or representatives.
• The bill is prefixed with HR (House) or S (Senate); it is numbered and referred to the relevant committee.
• The bill receives close scrutiny in committee. Hearings offer opportunities for executive branch, interest groups, and individuals to provide views.
• Committee meetings to “mark up” the bill establish its language and amendments.
• A report justifying committee actions accompanies the bill, often outlining changes to existing laws.
• Most bills do not pass committee and often never make it to the floor for vote.
• Bills are considered in the Senate and House, may be amended, and sent to the other chamber.
• Process repeats till both chambers approve the same version.
• The bill is sent to the White House.
• The president may sign the bill, veto it, or allow it to become law without signing (after approximately 10 days).
• Congress may override a veto with a two-thirds vote.

State Legislative Process

• State PA chapters work closely with legislative staff in drafting bills.
• Finding someone to sponsor the bill.
• The bill is printed and introduced by reading it to the entire chamber.
• The bill is referred to the relevant committee for review and action.
• State chapters can be helpful in the committee review process.
• Committee approval sends the bill to the full legislative chamber for vote.
• The same process (with the same supporting materials like visits and committee meetings) occurs in the other chamber.
• Governor signs or vetoes; Congress can override a veto.

Stakeholders to Work With Before Drafting Legislation

• State medical society
• State association of family physicians
• State association of emergency physicians
• Rural health association
• Primary care association
• Hospital association
• Other organizations with an interest

Federal and State Regulatory Process

• After a law is passed, an agency (or agencies) develops the necessary regulations for implementation.
• The staff of the bill's sponsor can identify the agency.

Procedures for State Rule Making

• There are processes to follow in drafting regulations after a law has been passed.
• Agencies draft and publish proposed regulations; the process involves public notice, public hearings, agency review, and possible legislative review, and publishing of finalized regulations.

Patient Safety

• Medical errors are often hidden in the past.
• The IOM (Institute of Medicine) reported that 98,000 people died yearly (now over 250,000 annually). Injuries occur frequently, too.
• The “blame and shame approach” is replaced with a systems approach by seeing medical errors as multiple failures, not one.
• The Swiss cheese model illustrates multiple layers (and potentially overlapping holes) and factors, that contribute to medical errors.
• The overwhelming majority of medical errors are not from lack of knowledge or training, but rather demanding or stressful jobs. Automatic tasks and interactions often lead to errors.
• The Joint Commission defines sentinel events as events (not due to the underlying illness), impacting patients with death, permanent, or severe harm.
• Common examples of sentinel events include infant abduction or to the wrong family, wrong site surgery, or severe jaundice.

Medication Errors

• Medication errors result in injury and death (approx. one per day, 1.3M injuries).
• EHR (Electronic Health Record) helps reduce some of these errors, in part by having a prescription checker to find possible conflicts between prescribed drugs.

Prevention of Medication Errors

• Recognize common medication errors and take preventive measures
• Pharmaceuticals should limit creating medications with similar names, or limiting medications with similar appearance or pronunciation.
• Ban on the use of certain words, abbreviations, or specific categories of drugs.

Surgical Errors

• Two sentinel events relating to surgical errors are: wrong site surgery; and unintended retention of a foreign object.
• The universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery involves: team members, verification process, site marking, time-out procedures.

Transition and Communication Errors

• Discontinuity of care is problematic.
• Patients may not establish ongoing relationships.
• Multiple provider visits or duplicate tests increase costs and decrease efficiency.
• Emergency departments and other high-volume settings can amplify these challenges.
• Discontinuity of care involves miscommunication between providers, contributing up to 80% of severe medical errors.
• Standardized approaches that include interactive communication, up-to-date and accurate documentation, avoiding interruptions, a verification plan, and reviewing relevant historical information, during transitions.

Health Information Technology

• EMR aids in reducing errors (medication interaction checker).
• Theoretically, better access to information exists but is hampered by different EMR systems failing to communicate.

Role of the Patient

• Patient rights and responsibilities in their medical care.
• Patients need to actively participate in health care; understanding their medical history, medications, and allergies.
• They need to know about their medication, how to take it, potential side effects, and interactions with other drugs.
• They need to research their medical condition using valid resources.
• Verify information with their physician/providers.

Medical Error Disclosure

• Three-step process for providing empathy and reestablishing trust including initial disclosure, investigation, and resolution to the patient/family.

• Steps 1-2 focus on learning the truth, being empathetic, and taking care of patient needs.

• Step 3 focuses on admitting fault if necessary, offering solutions, ensuring patient-family feel supported.