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Sunday, June 10, 2012

A history of physician assistants

As the delivery of health care becomes more team based and collaborative, we are experiencing a shuffling of roles and responsibilities. I did a literature review and found an interesting draft manuscript
http://medicine.utah.edu/upap/HistoryArchives/articles/PA_History_2011.pdf

This manuscript referenced a paper published almost 15 years ago in the Bulletin of the History of Medicine. This paper is behind the pay wall, but I was able to access it thorough my access to Project Muse.
http://muse.jhu.edu/login?auth=0&type=summary&url=/journals/bulletin_of_the_history_of_medicine/v072/72.2holt.html

The focus of these papers is on the history of the physician assistant training in the United States. It is both fascinating and timely. It is timely because the same thorny turf issues which are raised now had their origins in the past. Dr. Gene Stead, the famous Chair of Medicine at Duke University was a driver of the PA concept. It apparently developed as a consequence of a number of influences on Dr. Stead's career with a share of serendipity. Natalie Holt describes this her "Confusion Masterpiece" article from 1998:
Stead's first effort toward this goal began fortuitously in 1957 and was shared with the supervisor of medical and surgical nursing at the Duke Nursing School, Thelma Ingles. As Stead tells it, the setting of an administrative meeting brought the two together. They had assumed their places before the meeting, and in the style of a "Southern gentleman," Stead 
had to make conversation of some kind, so I said, "What are you going to do next year? Are you going to continue doing what you are doing?" She said, "No, I'm going to have a sabbatical year." And I said, "Well, I think you're going to waste that year." She perked up a little and said what did I know about it. I said, "Well, I've been watching people take sabbatical years and they will take psychology or they will take sociology or they will take administration, but [when] they would come back to the nursing school, they wouldn't be any better as far as what nurses do than they were if they'd never done it. I think you're just going to waste that particular year." 27
Ingles agreed that she wanted a program that would enhance her capabilities as a nurse, yet few such opportunities existed. In 1957, the "nurse-clinician" or "nurse practitioner" role had not developed. (In 1970, for that matter, there were few organized clinical nursing programs in the country, and the ANA had not expended much effort to publicize those that existed.) 28 Small barriers, however, did not usually stop Stead--particularly when he had the authority to eliminate them. "Well," he proposed to Ingles, "why don't we break the mold and you take a sabbatical year in the medical school? I don't think any nurse has ever done that." 29
Thelma Ingles became the first (at least at Duke Medical Center) to do just that. She operated much as a medical student in a clinical clerkship, using patients as the springboards for seminars on specific topics in clinical care. She selected patients in the hospital in whom she had taken an interest, investigated their conditions, and met with Stead daily to determine what instruction she needed. If Stead was not prepared to provide her with instruction in a particular area of biology or pathology, he "would collect some green stamps from somebody" who owed him a favor, and Ingles would receive instruction with the willing or begrudging assistance of other Duke medical professors. 30
 When Ingles attempted to deploy similar training within the nursing education establishment, she was stymied: Holt went on to describe:
After her sabbatical year, Thelma Ingles returned to the Duke Nursing School to create a Master of Science in Nursing program modeled on her experience with Stead. The program included clinical rotations for the nurses, taught with the assistance of the Department of Medicine staff. The University approved the program and, in the words of Stead, trained "some extraordinarily competent nurses." 33 But administrators at the National League for Nursing (NLN), the accrediting body for nurse training programs, did not approve of Duke's clinical nursing specialization program and withheld their accreditation. They complained that the program lacked structure. In addition, they criticized the use of physicians as instructors. 34 While the master's degree program continued to exist without accreditation, in Stead's mind the NLN's action squelched the excitement and opportunity offered by a nursing program jointly run by both medical and nursing professionals.
 Fear of change on the part of nursing administrators stifled more than one attempt to expand nursing responsibilities at Duke. The next major incident occurred in the Class of 1961 of Duke's baccalaureate nursing program. Shortly before graduation, the classmates approached the supervisor of the senior year nursing program, Ruby Wilson. The students wanted more authority and responsibility than they saw possible in the typical nursing role. As Wilson recalls, they said: "We don't want to become like all the rest, . . . and in talking about it, Thelma [Ingles] came up with the idea that maybe this group of graduating seniors might become the staff for a particular unit." 35
Only after development of an expanded nurse clinician role was stymied by organized nursing did the PA program develop as a separate entity under the direction of  physicians. There was substantial contention within the house of medicine, but the PA concept garnered sufficient support of major physicians groups early on which ultimately ensured its survival.

The turf battles still persist and in some respects are more complex. The parties involved, physicians and nurses, are perhaps even more interdependent. There are more parties added to the mix; NP's,Doctors of Nursing, Physical therapists, clinical psychologists, optometrists,  to name but a few. Each may have clinical responsibilities associated with complex reporting authority. At this point in time, leaders of teams which deliver care tend to be physicians. However, that may change.

Is training to be a physician any more or less preparatory to lead teams of people all involved in health care delivery? Is the curriculum of medical school essential or even relevant to leading health care teams? Is so,  how many physicians who are leaders now could muster a passing grade on the USMLE? One could argue that it is their broad experience which equips them for such a role but if it is experience that counts, what about the experience of others who have taken a different pathway and have also garnered experience?

It has been 100 years since the Flexner Report was published. This report revolutionized the training of physicians and put in place a model of training that remains in place today. It made allopathic medical training preeminent. In the big picture, 100 years is not such a long time. For physicians to continue to claim the leadership role in health care, we need to be more than point of service clinicians. The Flexner Report was innovative and disruptive and it, along with scientific based medicine, permitted the dominance of  physicians in health care for the next 100 years.

The next sets of disruptive innovations will be like Dr. Stead's creation of PA's, creation of other non-physician clinicians who can provide value to patients, likely at lower costs. Where physicians end up in this mix is an open question.

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