Physician Assistants as Social Innovators in Healthcare

FigureFigureIn as much as the typical physician associate/assistant (PA) can be profiled in 2022, that PA likely would be female, in their mid-30s, White; college-educated with a master's degree; and able to diagnose, prescribe, and bill directly for professional services rendered in a clinical medicine setting—a stark contrast to the PA of 50 years ago. In those early years of the profession, most PAs were male, slightly older, many with a military service background, and possessing perhaps an associate's degree above and beyond a certificate of completion of PA studies; their services were billed incident to the supervising physician, hence much of their productivity remained hidden. That the PA profession has undergone such a profound metamorphosis since its inception is an understatement. These are just a few of a myriad of fascinating facts documented in what is surely destined to become the definitive tome of the history of the PA movement in modern medicine, Physician Assistants as Social Innovators in Healthcare. Sponsored and underwritten by the Physician Assistant History Society, Physician Assistants as Social Innovators in Healthcare tracks the development of the PA profession from its tenuous beginnings in the mid-1960s to its current state, if indeed its current state can be defined; for the evolution of the modern PA workforce is a work in progress. Under the apt leadership of Leslie Kole, PA-C (the founding editor of JAAPA), a committee of seasoned PAs, some of the best minds in the profession, formed the outline of a book that eventually took shape as the premier history of the profession. But more than that, in its pages, the authors have made an admirable attempt to examine the development of the profession as an experiment in creative innovation in the healthcare system. Referencing Murray's social innovation model, the book's authors trace the evolution of the PA profession from its inception to its current status in the healthcare arena. Short of a Ken Burns documentary, this engaging book is as good as it gets. Here we read of the roots of the profession. Early pioneers—Eugene Stead, MD, and Charles Hudson, MD, among them—proposed the creation of a new breed of practitioner, “the assistant to the primary care physician,” to meet the overwhelming need for primary care accessibility in the country. Candidates with clinical backgrounds, largely drawn from former military medics and hospital corpsman, were put through an accelerated program with hands-on training undergirded with a “need-to-know” skill set necessary for the delivery of quality medical care. These clinicians would practice under the supervision of the physician in the field, enabling the physician to dedicate time to the care of more complex patients. Here we learn that a series of political, legislative, and economic forces served to shape the evolution of PAs. After a tenuous start through the 1970s, the fledgling profession floundered in the 1980s when the Graduate Medical Education National Advisory Committee report predicted a surplus of 145,000 physicians in the workforce by the end of the century. That prediction proved to be erroneous; and subsequently, through the 1990s the PA profession flourished. Ongoing research documented the cost-effectiveness of healthcare delivery by PAs; PA programs mushroomed overnight; legislation supportive of PA practice was enacted; licensure and prescriptive privilege shortly followed. Meanwhile, PAs themselves were forging new pathways of professional development, not only in clinical practice but also in administrative roles in education, industry, and government. These developments are documented and discussed in individual chapters devoted to the evolution of the profession, as PAs relied on their clinical flexibility to transition from primary care to medical and surgical specialties and subspecialty practice. Being a Vietnam-era veteran myself, I came to appreciate the dissemination of PAs through the branches of the armed forces, Veterans Administration, the US Public Health Service, and other federal agencies. (I was astounded to learn that PAs have even clandestinely infiltrated the ranks of the CIA: who knew?) Much of this expansion of the use and acceptance of PAs would not have been possible without the undergirding of advocacy for the profession by the American Academy of Physician Associates, the National Commission on Certification of Physician Assistants, and various constituent organizations nationwide. The Accreditation Review Commission on Education for the Physician Assistant established the essentials for PA education; the Physician Assistant Education Association continues to support faculty and curriculum development. The evolution of these agencies, so necessary to the growth and flourishing of the profession, is aptly traced in these pages. I was pleased to read of the early efforts to foster diversity, equity, and inclusion in the ranks of the profession. These are issues that the profession still faces today, despite its best efforts to shape its constituency. Also documented here is the vital role that research played and continues to play in the evolution of PA acceptance and practice. The PA movement in this country has arguably traceable roots to antecedents in other regions of the globe: the 19th century Russian feldshers, the officiers de santé in France, the barefoot doctors in China. Through its collaborative model, competency-based curriculum, and need-based deployment, the PA profession in the United States has spurred offshoots in the healthcare systems of other countries: Canada, Great Britain, Germany, New Zealand, Australia, Africa, India, Israel, and Saudi Arabia, to name a few. Largely, these movements were modeled on the US PA. If what goes around comes around, globally, it appears as though we are coming full circle. History is made daily: today's current events become the history of tomorrow. Today's highly educated clinical PAs enjoy relative autonomy in collaborative relationships fostered through optimal team practice. Where will the PA movement find itself in 5 years? In 10 years? Largely this depends on the leadership and ongoing involvement of PAs themselves. One reason, perhaps the main reason that the PA profession has enjoyed widespread recognition and acceptance is because of its ability to innovate, to adapt to new paradigms in the healthcare system, be they market-driven or of medical necessity. A case in point here is the way in which PAs have responded to the COVID-19 pandemic, demonstrating their ability to segue quickly into areas of clinical need, such as primary care and telemedicine. When Charles Darwin embarked on what would become his 5-year voyage aboard the HMS Beagle, I doubt that he had fully formulated in his mind what would eventually become his theory of natural selection. It would take more than 3.5 years of observing wildlife in the natural setting, collecting and studying specimens from the field, and considerable thought to assimilate these data into his master treatise; and it would take an additional 23 years for The Origin of the Species to be published. If Physician Assistants as Social Innovators in Healthcare serves as the definitive documentation of the origin of our species, it will be up to those PAs now entering the workforce to craft the next volume in this fascinating series, a tome I look forward to reading.

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