Wasn't that a time! PAs in Alaska in the early 1980s

FigureFigureThe 1980s were an exciting time to be a physician in the Indian Health Service (IHS) in Alaska. Brian McMahon, MD, at the Alaska Native Medical Center in Anchorage had through brilliant research worked out the epidemiology of hepatitis B in Alaska. This had been a poorly understood but spreading disease in rural Alaska, showing completely different routes of transmission than did hepatitis B in the lower 48 states. By 1982, a vaccine had been developed and was pressed into service. Similarly, another highly infectious disease, the encapsulated bacteria Haemophilus influenzae type B, had been a major cause of morbidity and mortality among Alaska Native infants and children younger than age 2 years. We had seen many of these tragic cases in our clinic and hospital, and we were among the first to test new vaccines when they became available and incorporate them into our vaccination schedule. Thus in less than half a decade, two of the last remaining infectious diseases of special susceptibility for Alaska Natives had been brought under control. I became a part of this healthcare system in 1980, joining during a time of dramatic transition for our Interior Alaska Service Unit. Our group of three physicians was centered in Fairbanks, and we served the primary care needs of about 30,000 Alaska Natives, more than half of whom lived off the road system. These remote villages were by tradition located along the major rivers that served as routes of transportation and sources of food. Our service unit extended from the Canadian border to the lower Yukon River and from the Brooks Range to the Alaska Range—an area the size of Texas. To meet the healthcare needs of this farflung population, the Alaska Region of the IHS had evolved a very effective system of community-based village health aides, local people held in high esteem and trust by their neighbors, who were specially trained for this role at Alaska Native Medical Center in Anchorage. They were supported by a robust presence of State of Alaska itinerant public health nurses and by daily satellite radio communication with and twice-yearly visits by our physicians from Fairbanks. Because of the great distances that separated us from many of our patients, it made sense for our health service to decentralize its operations. Two of the largest villages, Galena and Ft. Yukon, were well positioned geographically to become subregional health centers. With help from the Tanana Chiefs Conference, the native organization that represented our beneficiaries, we obtained funding to upgrade and build new clinic facilities. But who would staff these new subregional clinics? The answer was a new category of certified and licensed clinicians who were starting to emerge from training at that time—PAs and NPs. By the summer of 1981, we had hired two PAs for Ft. Yukon and an NP for Galena. I believe that the proximity, accessibility, and engaging personalities of these first clinicians inspired our community health aides in the surrounding villages to consider PA training, a career path in healthcare that was much more accessible and more compatible with rural Alaskan lifestyles than physician training could have been. It also was a pathway to a career in medicine that would build on the thousands of hours of experience that many of the health aides had logged in their service to their communities. If this route to a certifiable medical career was appropriate for military corpsmen, surely it could be appropriate for our village health aides. Throughout Alaska's history, recruiting and retaining medical professionals, especially for rural service, has been very difficult. Isolation, adverse climate, and distance from family and friends are reasons often cited. We three physicians (William James, MD; Floyd Elterman, MD; and myself), seeing an opportunity to “grow our own,” each began encouraging outstanding health aides who were open to considering PA training. This turned out to be an embarrassment of riches, as three of our rural health aides applied and were accepted to the MEDEX program for the entering class of 1983. One problem remained: how to support our future PAs financially during their 2 years of training. The PA profession was new, and there was no provision in Alaska law for scholarships or loans to support the cost of this training, let alone the costs of living in Seattle for a year. Ironically, national politics provided the answer. During the early 1980s, the IHS, as part of the federal government, had been on a prolonged hiring freeze. This led to a small budget surplus at the end of the fiscal year, and at a meeting of the medical directors of all the Alaska service units, I proposed and it was agreed that the IHS would continue to pay these three students their health aide salary for the duration of their training. After their didactic year in Seattle, all three returned to our clinic for parts of their clinical training; and in May 1985, all proudly graduated from MEDEX Northwest as certified PAs. In the decades that followed, many more Alaskans entered PA training. Most have remained in Alaska to practice, many in rural settings. In fact, Alaska has the highest number of PAs per capita of any state. Most have come to the program from nonacademic backgrounds but with thousands of hours of practical clinical experience. An emphasis on academics tends to favor applicants from large cities and universities but requisite clinical experience can be obtained in many different settings. I for one view with alarm the pending changes in PA training and certification that attempt to gentrify the profession by making the academic prerequisites more rigorous and require a master's degree to be certified. This will clearly discourage applicants from rural Alaska, and I believe it will fundamentally change the focus and career choices of future PAs.

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