Physician Assistants
A Young Profession Celebrates the 35
th
Anniversary
of Its Birth in North Carolina
Reginald D. Carter, PhD, PA, and Justine Strand, MPH, PA-C
The physician assistant (PA) profession began at DukeUniversity Medical Center. It celebrates its 35th birthday on
October 6, 2000. The national success of PA programs canbe traced to North Carolina’s leadership in developing andusing this new kind of health care professional. The NorthCarolina Medical Society, North Carolina Medical Board,state legislators, and state agencies like the Office of RuralHealth and Area Health Education Centers (AHECs) workedtogether to make the program a reality. The evolution of the
Dr. Carter is Director of the Physician Assistant Program and Ms. Strand is Chief of the Physician Assistant Division in Duke’sDepartment of Community and Family Medicine, Box 3848, DUMC, Durham 27710.
In the late 1950s and early 1960s, Dr. Stead and ThelmaIngles, RN, proposed a program to train nurse clinicians atDuke Hospital. Three times the National League of Nursingdenied accreditation to the program, asserting that it was atleast inappropriate and perhaps dangerous for nurses toassume medical tasks. Dr. Stead considered recruiting Durhamfiremen to his fledgling program, but then decided thatveterans of the military medical corps were more suitablecandidates.
profession has been described in severalarticles in the North Carolina Medical
Jour-nal.1-5 We review here the development of
the PA concept, the establishment of theprofession, the expansion of the Dukecurriculum from certificate to master’sdegree, and trends in practice characteris-tics of Duke PA alumni.
History and Background
In the 1950s Duke hospital faced an in-creased demand for services and a shortageof all types of nursing and allied health
personnel. Dr. Eugene A. Stead, Jr., then chairman of theDepartment of Medicine, envisioned a physician’s assistant asa way to provide clinical support6-10 and to allow rural
physi-cians to leave their practices to pursue continuing educationopportunities. His experience at Emory University duringWorld War II had convinced Dr. Stead that after two years oftraining individuals would be prepared to help doctors inpatient care. In the 1940s, he had seen medical students helprun Grady Hospital, while doctors were educated and de-ployed to the military in three years.
On February 1, 1966, Dr. WilliamAnlyan (Dean of the School of Medicineat Duke) appointed a committee to ex-plore the potential roles for a PA, includ-ing education and experience requirements,and the scope of responsibilities. In Sep-tember 1967, Dr. E. Harvey Estes, Jr., inthe Department of Community HealthSciences, assumed administrative respon-sibility for the new program. Dr. Estesmoved quickly to establish the concept inNorth Carolina and the nation. The firstthree PA students graduated at Duke onOctober 6, 1967.
A series of conferences held betweenMarch 1968 and April 1972 promoted the PA concept. Thefirst two focused on curriculum development and ways toestablish PA programs. The third solicited the leadership oforganized medicine to set accreditation standards for PAeducation and to develop national certification throughstandardized examinations and continuing medical educa-tion requirements. Third party reimbursem*nt, public andprofessional acceptance of PAs, hospital credentials, produc-tivity and cost-benefits of using PAs, and professional liabil-ity issues were also discussed. The fourth conference drafted
Figure 1. Dr. Eugene A. Stead, Jr.,founder of the Duke PA program.
model state laws to enable physicians to use PAs in theirpractices. These conferences helped solidify leaders of the“PA movement” into a highly organized and effective teamof health policy innovators.
Initial funding for the PA program at Duke came froman unlikely source. As a member of a study section of theNational Heart Institute, Dr. Stead had been discussinginformally the idea of training former military corpsmen asPAs. In 1965, Dr. Herbert Saltzman from Duke asked theInstitute for funds to train hyperbaric chamber operators, aswell as a more general type of assistant for physicians. Therequest was approved, launching the first formal trainingprogram of this type in the US. Until then, the Institute hadsupported the training of only MD and PhD candidates.
In December 1966, Dr. Stead received a three-yeargrant from the Josiah Macy, Jr., Foundation. Other grantsfollowed from organizations like the Carnegie and RockefellerFoundations and the Commonwealth Fund. In May 1970,on the second attempt, a national review board approved theNorth Carolina Regional Medical Program’s request forpartial funding of the Duke program (the board had beenreluctant to fund an educational program that did not offerits graduates an academic degree). These funds were ex-tended for another year in July 1970.
Dr. Estes, then chair of the Department of CommunityHealth Science, and Dr. Robert Howard, the PA program’sfirst full-time director, had been soliciting funds from variousfederal agencies since 1967. All attempts failed until congresspassed the Comprehensive Health Manpower Act in 1972.This bill authorized support for PA training, and the DukePA program received its first Bureau of Health Manpowergrant in July 1972. The program relied primarily on federalfunding until 1982. Today it is financially self-sufficient,using federal funds only to support minority recruitment andto place students in community-based clinical learning siteslocated in medically underserved AHEC regions of NorthCarolina and southern Virginia.
Legal Issues and Legislation
From the beginning, it was recognized that a new type ofhealth care provider might face legal difficulties, given thecomplexity of laws licensing medical personnel.11 The initial
question was whether graduates’ activities would lie outsidethe scope of work allowed for persons operating undermandatory licenses. In 1966, the North Carolina AttorneyGeneral issued an advisory opinion that the performance ofphysician-supervised activities would not contravene thelicensure laws of the state. The program relied on thisopinion until 1971, when North Carolina wrote an exceptionfor physician assistants into its Medical Practice Act.
In 1969, a year-long project sponsored by the Depart-ment of Health, Education and Welfare and conducted by
Duke’s Department of Community Health Sciences deter-mined the most desirable and feasible means of accommo-dating PAs into the legal framework of medical practice. Theultimate objective was to develop model legislation that, ifenacted, would further establish the position of physicianassistants. Two ideas dominated the discussion: (1) Since thePA role was ill-defined and the concept still evolving,legislation should preserve maximum role flexibility conso-nant with patient safety. ( 2) Because doctors are liable for theactions of their assistants, the doctor should determine thescope of a PA’s practice. A final recommendation aboutexceptions to state medical practice acts made it clear thatdoctors may delegate tasks to assistants as long as they exertresponsible supervision. Quality of care would be safe-guarded by continuing vigilance of the supervising doctor.
On May 9, 1975, the North Carolina General Assemblypassed “an act to limit the prescribing, compounding, anddispensing of drugs by certain persons approved by the NorthCarolina Board of Medical Examiners and the North Caro-lina Board of Pharmacy.” This bill enabled PAs and nursepractitioners working in semi-autonomous settings (such asrural health centers) to prescribe certain drugs, waiving therequirement of a medical doctor’s signature on all prescrip-tions. In February 1977 a deputy attorney general ruled that“North Carolina statutes proscribe registered nurses andlicensed practical nurses from carrying out orders given byphysician’s assistants.” In June 1977, the General Assemblyamended the North Carolina Nurse Practice Act to correctthis oversight and allow nurses to carry out patient care ordersfrom a PA. Since the 1980s, North Carolina has been a leaderin amending its laws and administrative rules to improve theeffective use of PAs in the delivery of health care services. In1993, the Legislature passed a bill enabling PAs or nursepractitioners to serve on the North Carolina Medical Board(formerly the Board of Medical Examiners). The first suchperson appointed by the governor was Wayne Von Seggen,a PA who now serves as the Board’s president.
Program Accreditation
In December 1971, the House of Delegates of the AMAadopted “Essentials for an Educational Program for theAssistant to the Primary Care Physician,” which establishedstandards for the education of physician assistants. The Dukeprogram was one of the first to be approved in 1972. TheDuke PA program was re-accredited for the maximumperiod of 7 years in October 1996.
Evolution of the PA Curriculum
Dr. Stead saw the ideal candidate for an intensive two-yearcurriculum as someone with prior health care experience, as
in the military medical corps. He was not overly concernedabout formal education nor about what type of certificatewould be conferred at graduation. Stead believed that “aperson with a high school education, a reasonable rate oflearning, and a tolerance of the unavoidably irrational de-mands often made by sick people can learn to do well thosethings a doctor does each day. Under the wing of the doctor,such a physician’s assistant can collect clinical data, includingthe history and physical examination, organize the materialin a way which allows its use in diagnosis, and carry out anyrequired therapeutic procedure which the doctor commonlyuses.”12 Guided by this principle and with the approval of an
ad hoc committee appointed by Dr. Barnes Woodhall, thenVice-Provost for Medical Affairs at Duke University, Dr.Stead launched his program in October 1965. The first fourstudents, Victor Germino, Donald Guffey, Richard Scheele,and Kenneth Ferrell, were all former Navy hospital corps-men, dedicated to providing health care services (Figure 2).Stead recruited a clinically trained nurse educator,Kathleen Andreoli, RN, to organize the first nine-monthdidactic phase of the curriculum. Andreoli had been instru-mental in setting up the nursing component of the cardiac
care unit in 1965 under the direction of Dr. Andrew Wallace.Wallace was named medical director of the PA program and,with Stead, Andreoli, and Mr. James Mau, an administratorin the Department of Medicine, formed the program’sacademic and administrative team. Hospital conference roomswere used for lectures, and the adjoining wards were used toteach physical diagnosis and history-taking skills. Studentslearned laboratory, surgical, and clinical skills in the worksetting. Formal instruction consisted of 140 hours of clinicalmedicine and nursing, 60 hours of anatomy and physiology,60 hours of pharmacology, 100 hours of animal surgery, and90 hours of electronics instrument theory and troubleshoot-ing. Hospital doctors, nurses, and support staff gave lecturesand taught students clinical, nursing, and technical skills.Student feedback was immediate, and schedules and contentwere changed as needed. The students were opportunisticlearners. They shared with each other the skills and knowl-edge learned in the Navy and didn’t hesitate to ask house staffto let them see interesting cases in return for doing routineclinical tasks. During the second year, students were assignedto various teaching services and clinical laboratories at DukeHospital, Durham Veteran’s Administration Hospital, Lin
Figure 2. Nursing instructor Kathleen Andreoli teaches EKG interpretations to the first four physician assistant students enrolled atDuke (l. to r., Don Guffey, Vic Germino, Dick Scheele, Ken Ferrell). Photo reproduced from Look, September 6, 1966; produced byRoland H. Berg; photographed by Phillip Harrington.
coln Hospital in Durham, and the North Carolina StatePrison clinical facilities in Raleigh.
There had been little publicity about the program beforethe first class was selected. This changed dramatically afterarticles in the Reader’s Digest13 and Look Magazine14
an-nouncing the new Duke program to the public. The first fourstudents had been hand-picked from a small pool of appli-cants; 200 people applied for the second class and over 1000for the third class in 1967. Class size quickly expanded; therewere four part-time and nine full-time students in the classof 1968 and 12 students in 1969. More students meant newchallenges—to secure adequate classroom space and labora-tory facilities, and to redefine the content of the curriculumand teaching methods.
In 1967, Stead stepped down as chairman of the Depart-ment of Medicine, and the PA program moved its base ofoperation to the newly created Department of CommunityHealth Sciences. Dr. Harvey Estes, Jr. appointed Dr. RobertHoward as the program’s first full-time medical/programdirector. A family doctor, Howard had just left the Air Forceand was used to working with corpsmen. Howard recruitedMr. David Lewis, whose background was in public educa-tion, as assistant director. A classroom trailer was purchasedto house students, and the curriculum was expanded andformalized. Based on student feedback and criticism, basicscience instruction was expanded, and PA students weretreated more like medical students than technicians onclinical rotations. The medical instruments course was re-placed by courses in microbiology, human growth and devel-opment, and clinical laboratory procedures. Clinical learningopportunities increased, and community physicians beganaccepting PA students into their practices. Other academicmedical centers began requesting Duke PA students to testthe feasibility of undertaking similar programs, or to test theconcept of using PAs to bolster the practices of their clinicalstaff.
The core curriculum was designed to educate generalistPAs, but in 1968 the program experimented with specialisttraining in surgery, radiology, and psychiatry. Dr. David C.Sabiston, Jr., chairman of the Department of Surgery, Dr.Thomas T. Thompson, chief of Radiology at the DurhamVeteran’s Administration Hospital, and Dr. Marvin J. Short,a psychiatrist based at Broughton Hospital in Morganton,NC, were instrumental in establishing specialty rotations for
PA students.15,16 The radiology and psychiatry modules
required students to spend an additional four months intraining, after which they were issued certificates as “Physician’sAssistants in [Psychiatry or Radiology].” This inscriptioncaused some PAs problems when they later sought employ-ment as generalist PAs, because most medical boards viewedthe special designation as a limitation, not an expansion, ofscope of practice. Specialist certificates were abandoned in1972 shortly after the University approved awarding bachelor’sdegrees to PA graduates. The accreditation standards for the
education of primary care PAs adopted by the AMA in 1971and the Federal Government’s 1972 requirement that grantsbe awarded only to PA programs educating PAs for primarycare practice also contributed to their abandonment. Re-maining innovative, Duke began educating PAs for the USCoast Guard in 1971 and joined the School of Pharmacy atthe University of North Carolina at Chapel Hill to trainpharmacist PAs–a forerunner of today’s clinical pharmacist.The UNC collaboration lasted two years, but the training ofPAs for the Coast Guard continued until 1990 when Dukedecided to award the master’s degree to its graduating PAs.In 1968, Dr. Howard explored awarding academiccredit for courses offered by the PA program. He felt thecaliber of the curriculum was “at or above the level of generalcollege course work.” He was also aware that five monthsearlier the Commonwealth Foundation had funded Dr. HuC. Meyers at Alderson-Broaddus College in West Virginiato prepare “college-trained” PAs. On September 19, 1969,Estes and Howard proposed to Dr. Thomas D. Kinney,Dean of Medical Education, and Dr. William Anlyan, VicePresident for Health Affairs, that a bachelor’s degree bemade optional for PA students who met general undergradu-ate requirements. The university provost held a series ofmeetings to resolve whether the undergraduate college or themedical school should grant the degree. Estes, Howard, andKinney wanted it in the medical school since the program’sfaculty was based there and other baccalaureate programswere being considered (for pathology assistants and nucleartherapists). All parties finally agreed that the medical schoolshould establish requirements for a Bachelor of HealthSciences (BHS) degree for allied health programs. Themedical center’s administration granted permission to offerthe degree on September 1, 1971—and entering studentslearned that they would have to pay tuition for the first time.The bachelor’s degree required the basic science departmentsto teach courses to allied health students, and the chairmenof several departments balked at the idea of teaching studentswho did not have proper college prerequisites. Estes andHoward felt that demanding prerequisites of all studentswould destroy the original intent of providing career entry tocorpsmen, licensed practical nurses, and other clinical per-sonnel with “non-academic” health care education and expe-rience. They resisted attempts to divide students into twogroups to be taught basic sciences by different faculty accord-ing to degree eligibility. Stead waded into the conflict,reiterating his position that PAs needed a more applied basicscience course than that taught to medical students. Heargued that in most cases such a course could be taught betterby practicing physicians than by basic scientists. Compro-mises were reached, and on May 16, 1972, the MedicalSchool Advisory Committee agreed to go ahead. Twelvestudents were awarded the BHS degree on May 4, 1973.
Howard and Lewis left the program in 1972 and movedto Florida to establish a family medicine residency and PA
Table 1. Demographic profile of PA classes at 5-year intervals
Men Women MinoritiesClass Total Number (%) Number (%) Number (%)67-71 71 67 (94) 4 (6) 5 (7)72-76 203 166 (82) 37 (18) 15 ( 7)77-81 198 116 (59) 82 ( 41) 13 (7)82-86 192 92 (48) 100 (52) 10 (5)87-91 196 55(28) 140 (72) 20 (10)92-96 203 56 (28) 148 (73) 26 (13)97-00 174 47 (27) 127 (73) 37(21)Total 1237 599 (48) 638 (52) 126(10)
Data do not include 60 students (42 men and 18 women) who withdrewbefore graduating. This group includes 18 minorities. Perc entages maynot be exact because of rounding.
program there. At the time of their departure, studentenrollment had risen to 40 students per year, and classroomand laboratory space were made available in a newly con-structed allied health building on the Durham Veteran’sAdministration Hospital campus. Reginald Carter, PhD, aphysiologist, was recruited to replace Lewis, and Estes servedas program director until Dr. Michael Hamilton, a generalpediatrician working at Lincoln Hospital in Durham, wasrecruited to fill this position in 1975. Carter was responsiblefor assuring that the curriculum conformed to Universitydegree and AMA accreditation standards. He completedcourse work as a part-time student and became a PA himselfin 1978.
Based upon his experience as a student and the recom-mendation of accreditation site visitors to teach more preven-tive medicine and behavioral science, Carter proposed acomplete overhaul of the first year curriculum. It wouldreduce the time devoted to basic science by integrating coursecontent and minimizing duplication of effort. The curricu-lum was streamlined so that content of one course built onthat of parallel courses. For example, students learned headand neck anatomy at the same time they were learning howto examine these regions in physical diagnosis. The clinicalmedicine course focused on the 100 most common clinicalproblems seen in primary care practices; radiology, ECGinterpretation, therapeutics, and preventive health measureswere integrated into the course where most appropriate. Thechairs of clinical and basic science departments were asked tosupport the new curriculum, and, with their approval, theAllied Health and Medical School Advisory Boards
imple-mented the integrated, competency-basedcurriculum in 1980.
While Carter worked on the first phaseof education, Hamilton worked to improveclinical training. The accreditation site visi-tors felt that students spent too much time inhospital-based inpatient and ambulatory clin-ics and not enough time in community-basedprimary care clinics. Hamilton used the newlycreated family medicine residency program toestablish a team practice clinic in southernDurham. This clinic, which opened in 1981,offered interdisciplinary education opportu-nities for family medicine residents and medi-cal, nursing, and PA students.
By 1980, the PA curriculum was in thehands of a small group of educators based inthe Department of Community and FamilyMedicine. The program was recognized forits innovative use of standardized patients toteach physical diagnosis and patient assess-ment skills, and for its developassess-ment of com-puter-based systems to manage and evaluatethe curriculum. Carter became program di-rector and chief of the PA Division in 1985 when Hamiltonmoved to a part-time role. Dr. Joyce Copeland assumed therole of medical director in 1990.
By 1985 most PA students already possessed bachelor’sdegrees, so several PA programs began offering their gradu-ates advanced degrees. In 1987, the Duke program asked themedical school to establish a Master of Health Sciencesdegree and award it to PA graduates. Associate ProgramDirector Patricia Dieter, MPA, PA-C, developed the pro-posal; it had the support of Dr. George Parkerson, Jr., chairof the Department of Community and Family Medicine, Dr.Doyle Graham, Dean of Medical Education, and Dr. RalphSnyderman, Chancellor for Health Affairs, and was quicklyendorsed. Courses in epidemiology, research, and healthsystems were added to the curriculum and, unlike the BHSproposal, the MHS proposal moved smoothly through allthe necessary committees. It was approved, with a few minormodifications, by the Academic Council in January 1989;students entering the program in 1990 were awarded theMHS degree. Because the BHS curriculum had already beentaught at an advanced level, the Provost allowed formergraduates who had a bachelor’s degree on matriculation toreturn to Duke to complete additional coursework andreceive an MHS degree. During the next five years, over 100alumni completed the work needed for the MHS degree.
In 1996, students moved into new educational facilitiesprovided by the medical school. The space consists of a state-of-the-art multimedia classroom, small conference rooms,and a clinical-skills laboratory. Each student workspaceprovides computer connection to the university’s Common
Table 2. Prior health care experience of students at matriculation, at5-year intervals
Medical Pt. care Clinical
Class Total corpsman assistant techician EMT Nursing Other
67-71 71 57 4 5 0 2 372-76 203 99 39 14 5 13 3377-81 198 62 58 21 6 19 3282-86 192 20 64 14 30 17 4787-91 196 9 14 15 27 12 8492-96 203 0 41 55 11 6 8897-00 130 1 76 36 19 6 36Total 1237 250 331 160 98 75 323
Clinical technician: medical technologist, clerical and research technicians. Other:social workers, counselors, pharmacists, health care administrators and other alliedhealth professionals.
Services Network and the Internet.Students lease laptop computersduring the two years they are en-rolled in the program. Course syl-labi, assignments, handouts, lec-ture notes, links to electronic jour-nals, and other learning resourcesare available by computer. Quizzes,examinations, and course evalua-tions are administered and ana-lyzed by computer.
The PA program now enrolls44 students annually. The curricu-lum runs for 25 months (a 12-month preclinical phase and a 13-month sequence of clinical rota-tions). The highly integrated pre-clinical curriculum presents con-tent in manageable units. Coursework consists of lectures, smallgroup and computer-assisted tuto-rials and patient case simulations,laboratory sessions, and standard-ized patients. After the first semes-ter, students perform weekly evalu-ations (history and physical
exami-nations) of hospitalized or ambulatory patients. The clinicalrotation year is divided into four- and eight-week blocks.There are eight core rotations—inpatient medicine, generalsurgery, emergency room/surgery outpatient, pediatrics, be-havioral medicine, obstetrics and gynecology, outpatientmedicine, and research—with the remaining time devoted toelectives. Two clinical rotations must be completed in medi-cally underserved settings. All students complete basic andadvanced life support instruction. They must pass computer-based examinations after each required rotation, as well as aseries of problem-oriented patient assessment examinationsobserved and evaluated directly by faculty. Students areawarded MHS degrees in May and PA certificates of comple-tion in August of their second year.
In 1998, Justine Strand, MPH, PA-C, became chief ofthe PA Division; Carter continues as program director. Thedivision is expanding postgraduate educational offerings forPAs in leadership management skills, faculty developmentand occupational and environmental medicine.
Student Trends
Tables 1 and 2 show trends in gender, ethnicity, and priorhealth care experience of entering students over 35 years.Former military corpsmen made up the initial pool of
Table 3. Practice characteristics of 610 Duke PAalumni
Practice setting
Hospitals and institutions 43%
Offices 33%Clinics 20%Other 4%Type of practicePrimary care 53%Surgery 23%Internal medicine 19%Other 5%
the program offered new career pathways for those in alliedhealth and nursing professions who wanted to expand theirroles in patient care. Prompted by federal funding aimed atincreasing the number of women and minorities, womenbegan replacing the dwindling number of military corpsmen.From 20% in 1975, the enrollment of women grew to 50%by 1985 and 72% by 1995. The ratio of women to men is now3:1. Since 1980, the number of students from medicallyunderrepresented groups and disadvantaged backgroundshas increased seven-fold from 5% to 34% of the class enteringin 2000. Students from minority or economically/education-ally disadvantaged groups now constitute 25-30% of theclass.
baccalau-enrolling students has evolved as well. In the first five yearsof the program, fewer than 10% of students entered as collegegraduates; this percentage gradually increased so that for thepast decade all students have college degrees when they enter.Today’s student is typically between 25 and 32 years old; theaverage age of entering students has increased from less than26 years old at the start of the program to nearly 29 years oldnow. On the other hand, the number of years of prior healthcare experience obtained by students before entering hasdeclined since 1967 (from almost 5 years to a steady averageof 3.5 years now). The average entering student has a gradepoint average of 3.2-3.6 (up from 2.6 during the first decadeof the program), has earned 40-70 natural science credits,and has Graduate Record Examination scores of between1680-1840.
Practice Trends
The 1237 graduates of Duke’s PA program are employed in48 states, mostly in the south, southeast and northeast; 417work in North Carolina. Their work settings reflect theprimary care emphasis of the program. Of the 610 alumniwho responded to our two last surveys, 53% practice inprimary care settings (family medicine, general internalmedicine, pediatrics, urgent care, and obstetrics/gynecology)(Table 3).
A gradual trend over the past 10 years finds more
Figure 3. Specialty choices of new PA graduates 1990-1999.
students working in primary care and far fewer in surgery(see Figure, page XXX). In 1990 and 1991, fewer than30% of students entered primary care practices; in 1999only 30% did not choose primary care careers. In 1992,funds from the Duke Endowment and the federalgovernment, allowed the program to renew its efforts toattract individuals interested in primary care ambulatorymedicine, especially in rural, medically underservedcommunities of North Carolina. Today, only 30 % ofDuke PA students’ clinical education takes place in theDuke University Health System, the rest is based incommunity and institutional practices in North Caro-lina and southern Virginia. The program works closelywith four AHECs—in Fayetteville, Wilmington, RockyMount, and Asheville—to place students in medicallyunderserved communities.
Over the past ten years, salaries paid to PAs haveincreased at an annual rate of 5% per year from anaverage of about $35,000 in 1990 to $55,000 in 1999.Over the past four years, the rate has slowed to 3.75%,because more students have chosen less lucrative pri-mary care positions. About 30% of Duke PA graduateswork in areas with a shortage of health professionals.Employment opportunities are generally good, and theaverage Duke graduate can expect to earn about $55,000upon completion of training. Mid-range salaries ofgraduates working for more than five years range from$48,000 and $70,000, not including fringe benefits.
Conclusion
The physician assistant profession went from concept toreality in only 35 years, thanks to the innovative thinking ofDr. Eugene Stead and the support and commitment ofcountless North Carolina physicians. There are now morethan 38,000 PAs in the United States, and more than 1,500practice in North Carolina. PAs have nationally standardizedaccreditation, board certification, and mandatory recertifica-tion.
A positive practice environment enables full use of PAsin North Carolina. In company with their supervising doc-tors they improve access to health care for the state’s citizens.PAs are eligible to join the North Carolina Medical Society,which has an active PA section, and to participate on its manycommittees.
Alumni of the Duke Physician Assistant Program haveprovided leadership for the profession since its inception.Duke University PAs formed the American Academy ofPhysician Assistants in 1968. They have held leadership rolesin national and state organizations, and they have foundedPA programs across the country. Perhaps most important,they have established a record of service in primary care,particularly in rural and medically underserved citizens inNorth Carolina and throughout the country.
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A word from Dr. Stead:
It’s great to be number one in national rankings.Most proponents of the Duke medical school areused to being ranked in the top 20, but the Duke PAprogram is the only component always ranked infirst place year after year.
Congratulations to its leader, Reginald Carter, tohis faculty, and to the student body, and to the NorthCarolina Medical Society, whose members have al-ways ably supported the PA program.
Eugene A. Stead, Jr., MD
A Word from Dr. Estes:
Few of us have the opportunity to participate inthe birth and rapid development of a new profession.I was very fortunate to be on Dr. Eugene Stead’s teamwhen the Physician Assistant program was conceived,and even more fortunate to be in a position to “takeover” the Duke program when Dr. Stead retired fromhis role as Chair of Medicine in 1967. I hope that I havehad a positive effect on the profession, but its re-markable success is clearly due to the PAs them-selves, the men and women who chose this path, andto their wise decisions.
PA education was patterned after medical cation, but there are important differences. PA edu-cation aims at producing a generalist, and all gradu-ates take a certification examination covering theknowledge and skills required in primary care. PAsmust be recertified every six years, and the generalistcontent of this exam is the same, no matter whatspecialty the examinee has pursued since the lastexam. A PA who has worked in orthopedics, orendocrinology, or pediatrics must demonstrateknowledge of generalist topics.
Recertification, and the requirement that all mustpass the same recertifying exam, has had a remark-able effect, which physicians should view with envy.This common experiential thread has, in my opinion,caused the PA profession to be a more unified andcohesive professional group than the medical pro-fession. They attend meetings in much higher num-bers, they attend a variety of clinically oriented lec-tures on general medical topics, and they share expe-riences and problems across their specialty bound-aries. Political and economic issues are discussed, asthey are in medical meetings, but the basic purposeof preventing disease and treating illness is alwaysthe dominant theme.
This is one of many lessons we can learn from ourPhysician Assistant colleagues. I invite all physiciansto learn from them as they rub shoulders with PAs intheir practices, and in interactions in the North Caro-lina Medical Society.
