Duke PA Program History and Philosophy

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What was the original focus of the Duke PA program, with regards to the type of care provided?

To focus solely on advanced surgical techniques, due to the experience of the first cohort.

To focus primarily on primary care, with a secondary focus on urgent care services.

To specialize in inpatient care, mirroring physician specialties.

To provide comprehensive training for both general practice and specialized inpatient care. (correct)

Why was the National League of Nursing opposed to the initial PA program concept?

They believed the program did not provide enough training for its graduates.

They were concerned that the program would cause nurses to transition to a medical model. (correct)

They were concerned that the program would not follow sufficient nursing guidelines within the medical model.

They believed the program would encourage the medical field to move away from the nursing model.

Which best describes the philosophy behind the training in the 2-year Duke program?

To give students a completely different focus than their physician colleagues for a broader range of skills.

To provide students with a basic understanding of nursing practices, with more advanced procedures.

To focus solely on the development of surgical techniques and advanced procedures.

To provide students with education & orientation like the physicians they would collaborate with. (correct)

What was a distinctive feature of the first cohort of students in the Duke PA program?

They were all ex-Navy corpsmen. (B) Signup and view all the answers

Besides the medical curriculum, what additional skill did the Duke PA program emphasize?

Lifelong learning and professional growth. (B) Signup and view all the answers

What was the primary factor contributing to the establishment of 31 new PA programs between 1971 and 1973?

The availability of federal funding. (B) Signup and view all the answers

Approximately how many practicing physician assistants were estimated to be in the U.S. by 1985?

16,000 (D) Signup and view all the answers

By the end of 2023, approximately what percentage growth did the certified PA profession experience over the previous 10 years?

75.2% (C) Signup and view all the answers

Which of these factors is NOT identified as a contributing cause to projected physician shortages by 2036?

Aging population and increased demand for non-primary care specialties. (A) Signup and view all the answers

Between 1965 and 1985, while 76 PA programs were accredited, why were some of these programs not still active by 1985?

Some programs closed for various reasons. (D) Signup and view all the answers

What was a key factor that made accreditation of PA programs necessary, according to the information?

The inconsistent use of the term "physician assistant" to designate varying levels of health personnel. (C) Signup and view all the answers

Which organizations collaborated with the AMA to approve the creation of "educational essentials" for PA training program accreditation in 1971?

The National Academy of Health Science’s Board of Medicine, American Academy of Pediatrics, American Society of Internal Medicine, American Academy of Family Physicians, and the American College of Physicians (A) Signup and view all the answers

As of January 1, 2025, how many applicant programs were listed on the ARC-PA's website as being in the process of developing PA programs?

52 (C) Signup and view all the answers

What is the primary focus that should guide advocacy efforts for healthcare professionals?

Prioritizing the positive impact on patient care. (D) Signup and view all the answers

What is a key shift in how medical errors should be viewed within healthcare organizations?

From individual blame to system improvement. (C) Signup and view all the answers

In the context of medical error reduction, what does the 'Swiss cheese model' illustrate?

How multiple layers of safeguards can fail to prevent errors. (B) Signup and view all the answers

What was the primary goal of the Institute of Medicine report 'To Err Is Human'?

To shift the focus towards systemic improvements to reduce injuries. (D) Signup and view all the answers

What strategy does the text suggest regarding legislative and regulatory changes for healthcare policies?

Collaborate with organizations and maintain persistence. (B) Signup and view all the answers

What is stated as the current estimated annual number of deaths due to medical errors in the US?

Over 250,000 deaths (A) Signup and view all the answers

How does the text describe the previous approach on handling medical errors that is now being replaced?

A culture of blame and shame. (C) Signup and view all the answers

Where does medical error rank as a cause of death, compared to other causes?

The third leading cause of death (C) Signup and view all the answers

What year did the American Academy of Physician Assistants (AAPA) transition from APAP to PAEA?

2004 (C) Signup and view all the answers

A PA in a state without prescriptive authority for controlled medications wants to advocate for change. What is the most effective way for this PA to be politically active?

Working with the state chapter to advocate for improved health care policies. (D) Signup and view all the answers

What is the primary goal of occupational regulation?

To protect the public health and safety. (A) Signup and view all the answers

After a bill passes the first chamber in a state legislature, what is the next step in the legislative process?

The bill is introduced in the second chamber and goes through a similar process. (C) Signup and view all the answers

What action can a governor take regarding a bill that has passed both chambers of a state legislature?

The governor can sign the bill into law or veto it. (A) Signup and view all the answers

Which entity is primarily responsible for regulating the practice of physician assistants?

Each individual state. (A) Signup and view all the answers

Who is primarily responsible for developing regulations to implement a newly passed law?

A designated agency or agencies (A) Signup and view all the answers

What are the two primary requirements to obtain state licensure as a PA?

Graduation from an accredited PA program and passing the PANCE. (B) Signup and view all the answers

How often must a PA license be renewed in most states, if it varies from state to state?

It varies; it is generally every 1, 2, or 3 years. (C) Signup and view all the answers

When is the most effective time to influence the specifics of a regulation related to a new law?

While the regulations are still being written (D) Signup and view all the answers

As a PA seeking prescriptive privileges for controlled medications, and in order to get involved, which is the most useful action to take?

Mobilize the chapter membership and encourage letter writing. (D) Signup and view all the answers

Which is the best practice for a physician to delegate tasks to a PA?

Any task or responsibility within their scope of practice provided the PA is competent. (D) Signup and view all the answers

Why is it important for a PA to understand the state legislative process if they want to advocate for their profession?

To understand how bills become laws and how to influence the process. (D) Signup and view all the answers

Which of the following is NOT a key element of a modern PA practice act, according to the text?

Mandatory state mandated collaboration requirements. (A) Signup and view all the answers

What primary types of organizations are described in the content as being considered stakeholders when drafting legislation?

State medical societies, physician associations, and other specialized organizations (C) Signup and view all the answers

What does the AAPA do in terms of government relations?

They represent the PA profession before the U.S. Government. (B) Signup and view all the answers

Besides serving it's members, what is one of the core functions of the AAPA?

Collecting research and advocating for the profession. (A) Signup and view all the answers

According to the provided text, what character trait is most valuable when delivering information to legislators?

Honesty and Enthusiasm (D) Signup and view all the answers

According to the Joint Commission, what percentage of serious medical errors are attributed to miscommunication during care transitions?

80% (B) Signup and view all the answers

Which of the following is NOT a component of the standardized approach to patient handoffs established by The Joint Commission?

Mandatory electronic health record documentation (B) Signup and view all the answers

What is the primary goal behind the patient safety movement's focus on teamwork and leveling of responsibility?

To ensure all team members are equally responsible for patient safety (C) Signup and view all the answers

Which of these is a potential benefit of using electronic prescriptions, according to the content?

Reduction in medication errors through interaction checks (B) Signup and view all the answers

What is considered a key responsibility of patients at the time of their medical appointment?

To be open and honest about symptoms, medications, and medical history (B) Signup and view all the answers

According to the American College of Physicians, which of the following is a patient's right at the appointment?

To receive instructions that are understandable and legible (C) Signup and view all the answers

What is a key responsibility of patients according to the American College of Physicians at the pharmacy?

To remind pharmacists about other drugs or allergies (D) Signup and view all the answers

According to the provided information, how should patients approach researching their conditions at home?

They have the right to research using reliable sources such as libraries and Internet resources (A) Signup and view all the answers

What does the text suggest about the current state of Electronic Medical Record (EMR) systems?

Different EMR systems do not communicate effectively with each other. (C) Signup and view all the answers

What is the described consequence of a steep authority gradient within medical teams?

It discourages communication by certain team members. (A) Signup and view all the answers

Study Notes

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.

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Description

This quiz explores the origins and key features of the Duke Physician Assistant program, including its initial focus on patient care and the philosophical approach behind the training. Additionally, it delves into the early challenges faced by the program, especially regarding opposition from the National League of Nursing. Test your knowledge on the distinctive aspects of this pioneering educational model for healthcare providers.