PA History - American Academy of Physician Assistants

w w w . a a p a . o r g The Leading News Resource for Physician Assistants s e p t e m b e r 2 0 1 0
Special issue
PA History

PRESIDENT’S LETTER
V O L 2 | N O 8 | s e p t e m b e r 2 0 1 0
W W W. A A PA . O R G
AAPA BOARD OF DIRECTORS
President
Patrick E. Killeen, MS, PA-C
Chair of the Board/secretary
Daniel T. Thibodeau, MHP, PA-C, DFAAPA
immediate past president
Stephen H. Hanson, MPA, PA-C
President-Elect
Robert L. Wooten, PA-C
Vice President/Speaker, House of Delegates
Alan Hull, PA-C
Treasurer
Bruce C. Fichandler, PA
First Vice Speaker, House of Delegates
James E. Delaney, PA-C
Second Vice Speaker, House of Delegates
L. Gail Curtis, MPAS, PA-C
Director at Large
Michelle O. DiBaise, MPAS, PA-C
Director at Large
Jeffrey Katz, PA-C
Director at Large
Michael C. Doll, MPAS, PA-C, DFAAPA
Director at Large
Lawrence M. Herman, MPA, RPA-C, DFAAPA
Student Representative
Mark M. Shepherd
magazine staff
executive vice president/chief executive officer
Bill Leinweber
Chief Operating Officer
Sabrina Smith, DrHA
Vice President, Communications
Howard Glassroth
Director, Publications
Christopher Doscher
PA Professional Staff
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Living History
Most of us associate our first exposure
to the term “history” with our elementary
school years. Back then, the term most
likely went along with images of Egyptian tombs,
dinosaurs, the Founding Fathers or wars fought long
before we were born. I think all of us have wondered
what it would be like if we could speak to the people
we read about in history books and find out how
their perspectives might differ from the authors’.
Our profession’s own history extends back only
45 years, but it is rich with intrigue, impact and
colorful characters. We’re lucky in that many of the
pioneers who were there at the beginning of the profession
are still around and enjoy talking to us about
the early days and how the profession has changed.
There aren’t many professions that have the same opportunity to hear firsthand, in-person
accounts of history so important to what they do. These opportunities don’t last forever, so it’s
important to take advantage of them.
This issue of PA Professional features stories of some of the most important aspects of our
profession’s history. Several of the individuals who have been around since the early days have
graciously donated their time to contribute articles to this issue. While all the details of a 45-year
history are far too numerous to fit into one magazine, we hope that what we have included will
drive you to learn more about the profession’s roots. The best resource for this is the web site of
the Society for the Preservation of PA History at www.pahx.org. Take a few minutes to browse
through the many documents, photographs and articles that have been written by PAs, physicians
and others who helped build the foundation for PAs.
I hope you enjoy learning more about our profession’s roots and that what you learn enriches
your experiences and strengthens your sense of purpose as a PA. Never forget that as far as we’ve
come, there is still more history to be made.
PA
Patrick Killeen, MS, PA-C
AAPA President, 2010–2011
950 N. Washington St.
Alexandria, VA 22314-1552
p: 703-836-2272 | f: 703-684-1924
e: aapa@aapa.org | w: www.aapa.org
To place a PA Career ad, call 800-983-7737
Copyright ©2010 by the American Academy of Physician Assistants,
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B y A s h l e y K e n t
Rear Adm. Michael Milner is one of the highest-ranking
federal service PAs in the country. In addition to serving as chief
health services officer in the United States Public Health Service,
he also serves as assistant U.S. surgeon general and as regional
health administrator for the six New England states. He led
public health efforts during three Florida hurricanes in 2004
and helped get the New Orleans health system up and running
after hurricanes Katrina and Rita.
Milner, a former president of the
AAPA Veterans Caucus, is an example of
PA military success in a profession that began with veterans
with vast medical experience. He credits the profession’s military
roots with shaping his own journey as a PA.
“I still feel the connection to those first PAs and the combat
medics and corpsmen of the Vietnam era,” said Milner, who
began his career in the Air Force, then transferred to the
Commissioned Corps of the U.S. Public Health Service in
1989. “They made a mark on me and I silently thank them
every day for helping me become a PA.”
Rear Adm. Michael Milner
Maj. Dennis Hays, one
of the first PAs to hold a PA-specific
clinical doctorate degree from the
Army PA doctoral program.
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Gene
Jones in
October
1974, the
day he
completed
phase one
PA training
at Sheppard
Air Force
Base, Texas.
The PA
Profession’s
Military
Roots
PA History
Timeline
PA William Tozier examines a Honduran patient
as part of an Army Medical Civilian Aid Project
in the mountains of Honduras in 1983.
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Military Roots of the
Duke PA Program
The three ex-Navy corpsmen who were
the first PA students at Duke University
certainly never knew how their decision
to take a chance on this new career would
impact the thousands who would follow
in their footsteps. But Duke physician
Eugene Stead Jr. saw the value in their
Vic Germino
military medical training, and knew
it could help alleviate the primary care shortage. And so, in 1965,
Vic Germino, Ken Ferrell, Dick Scheele and Don Guffey (who later
dropped out), began their training as the first PA students.
Ferrell, who at 21 was the youngest student, left active duty in the
Navy a month early in order to begin PA school. Right around that
same time, many of his fellow sailors were being sent to Vietnam. “I
might not be here today if I hadn’t been in that first PA class,” he noted.
Ferrell was intrigued by the prospect of receiving an education to
support his hands-on experience. “I felt like I didn’t have anything to
lose,” Ferrell said. “It was getting time for me to get out of the Navy, and
I had no idea what I was going to do or where I was going to work.”
In the 1960s, it was common for military medics or corpsmen to
return from years of combat medical experience, only to be rejected
by the civilian health sector. According to Ann Suter Ford’s 1975
book The Physician’s Assistant: A
National and Local Analysis, of
the 30,000 medics who were discharged
annually from the service
around 1970, only about a third
found their way into civilian
health employment positions.
(Editor’s note: In the early days
of the profession, “physician’s
assistants” was an acceptable
way to refer to PAs.)
Vic Germino at age 23, posing in
front of Gibraltar as a Merchant Marine.
“It was looked at as about all that we
were good for was to be an orderly or
something like that,” said Germino, who
was working in surgery and the OR at Duke
when he was selected for the program.
“That’s where Dr. Stead, seeing beyond that
in all the training that we had, made me feel
good about what he was trying to do.”
According to Germino, Stead treated his
Ken Ferrell
PA students a lot like medical residents, taking
them on rounds and even allowing them to see patients within the
first few months of their didactic training. The intense training paid off.
Twenty-year-old PA Gino Gianola in 1966, caring for orphans
in Vietnam during his time as an Army specialist.
1942
1959
1964
Eugene Stead, Jr., MD,
is forced to develop
a fast track, 3-year
applied medical
curriculum to educate
physicians at Emory
University for military
service during World
War II.
Surgeon General
identifies shortage
of medically trained
personnel.
1961
Charles Hudson, MD, in the
Journal of the American
Medical Association, calls
for a mid-level provider
from the ranks of former
military corpsmen.
Eugene Stead Jr.,
MD, decides that
ex-military corpsmen
with their previous
training and
experience would be
suitable candidates
for his two-year
experimental
program.
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“Toward the end of the first year we took our medical
skill test just like the Duke medical students, and we scored
just as high as they did,” Germino said.
“Working up a patient in a hospital and doing some basic
lab work was probably easier for us than it was for the medical
students because we had already seen so many patients
in the military,” said Ferrell, who had cared for fellow sailors
on his Navy ship without the support of a physician. “I
think they were surprised that so many of the tasks that
had previously only been done by the physician or medical
student could be done by someone with less time in the classroom.”
Germino noted that soon after the PA program began, Duke
changed its medical school curriculum to begin clinical training sooner.
Germino, Ferrell and Scheele graduated from the Duke PA program
on October 6, 1967. All three went to work at Duke after graduation.
Germino later ended up serving 10 years in the Coast Guard as a
PA, including three years in Alaska doing helicopter search and rescue
operations. Ferrell remained at Duke, working in clinical practice for
an allergist, then as a coding expert. Tragically, Dick Scheele died in
1970 at the age of 31, just three years after graduating from the Duke
program. Before his death he was able to help establish the American
Association of Physician’s Assistants, which eventually became the
American Academy of Physician Assistants.
Military Roots of the MEDEX program
Two years after Duke graduated the first three PAs, Richard Smith, MD
launched the MEDEX, or Medicine Extension, program at the University
of Washington with 15 former military corpsmen as a way to
lighten the workload of rural primary care physicians in the Northwest.
According to Gino Gianola, a graduate of the eighth MEDEX class
and lecturer in the MEDEX Northwest PA program, the first class
was made up of mostly special forces veterans who could successfully
promote the profession to the public.
Gianola had heard about the profession while he was serving in Vietnam
as an Army clinical specialist. When he came back to the United
Army 1st Lt. Jessica Larson, PA-C,
treats an Iraqi child during a one-day, combined
U.S.-Iraqi medical clinic in Kubaysah, Iraq, June 6, 2010. U.S.
Photo by Army Spc. Katie Summerhill
States two years later, he found it hard to find a civilian job with his military
training. He went to work as an orderly at a children’s orthopedic
hospital and later took the Washington state exam to become an LPN.
But it was this new physician assistant profession that really intrigued
him. He was admitted into the 4th MEDEX class, but was asked to leave
after a disagreement with Smith about PA placement in inner cities.
Gianola returned to MEDEX a few years later, graduating from
its eighth class and returning as faculty. Shortly after graduation he
worked with psychiatrist and Navy veteran Jim McDermott, then a
Washington state legislator and now a U.S. congressman.
“He knew what corpsmen and medics could do, and thought [the
PA profession] was a very good use of that experience. He helped
sponsor the legislation [for PAs to practice in Washington.]”
Early PAs in the Military: the Battle for Rank
But even as PAs were making progress in the civilian world, they were
facing roadblocks gaining rank in the military. PA Gene Jones, PhD,
PA program director at the University of Texas Southwestern Medical
Center, remembers the battles he and others faced during his early
days as a Navy PA in the mid 1970s.
1965
1966
1964
Richard A. Smith, MD,
develops the MEDEX
(Med-icine Ex-tension)
model with a strong
emphasis on the
deployment of students
and graduates into
medically underserved
communities.
Academic committee
chaired by Andrew
Wallace, MD, approves
Stead’s proposed PA
curriculum and the
National Heart Institute
funds physician Herbert
Saltzman’s grant to train
hyperbaric chamber
operators and physician
assistants. This clears
the way for the first four
PA students, all ex-Navy
hospital corpsmen, to
begin training at the Duke
University Medical Center
in Durham, NC.
Allied Health Professions
Personnel Act (PL-
751) promotes the
development of programs
to train new types of
primary care providers.
Look Magazine article
entitled “More than a
nurse, less than a doctor”
catapults the PA concept
to national attention.
1967
First class of three PAs, Kenneth F. Ferrell, Victor H. Germino, and Richard J.
Scheele, graduate from Duke University on October 6. The American Academy of
Physician Assistants adopts the date later as “National PA Day.”
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“We were in an in-between category of not being enlisted yet not
fully commissioned as officers, and we started off as PAs at the bottom
rank designation of W-1. Now that was an interesting uniform,”
said Jones, who reached the rank of W-4 and served as PA specialty
advisor to the Navy surgeon general. “Vice Admiral James A. Zimble
asked me to continue to be patient about full commissioning for
Navy PAs in the Medical Service Corps and I responded that we could
wait no longer. A number of us were eligible to retire and soon chose
to do so. A few months later the commissioning was authorized.”
That was in 1989. Jones was offered the option of returning to
active duty status as a lieutenant with time-in-grade toward lieutenant
commander, but declined because he was enrolled in a PhD
program at the time.
In 1992, Army and Coast Guard PAs were commissioned. Air
Force PAs were the first to be commissioned in 1978.
Members of the Naval Medical Command EMT Training Program
in June 1986 at the Marine Corps base in Camp Pendleton, Calif.
PA Gene Jones (third from left) and others trained Navy hospital
corpsmen and all west coast SEAL team members as EMTs.
PAs Today: Rising in the Ranks
It’s hard for some of the first PAs to imagine the freedom that PAs in
the military enjoy today. “It’s amazing to see what is out there now for
PAs to do,” Germino said. “There’s one that’s in charge of a medical
brigade. I would have given anything to have done that.”
He’s referring to Col. Michael Robertson, who will be the first PA
to command a medical brigade when he takes command of the Army’s
18th medical brigade in Hawaii next summer. He’ll be in charge of
active duty, reserve and National Guard units for the Pacific theater.
“I was really humbled when they picked me up for another command.
Because besides being a first for a PA, it’s also the first for an
Army medical specialist corps officer,” Robertson said. “It’s a pretty
big deal for the young PAs that I’m doing this because it opens up a
lot of opportunities for them down the road.”
PAs from all branches of military are trained at the Interservice
Physician Assistant Program at Fort Sam Houston in Texas. Graduates
receive a Master of Physician Assistant Studies degree from the
University of Nebraska. PA and Program Director Col. William
Tozier says Robertson and Lt. Col. John Balser, who recently took
over Robertson’s former post as assistant corps chief of the Army
Medical Specialist Corps, have set an important precedent for PAs
in the military.
“When I came into the Army, PAs thought of themselves only as
clinicians. In turn, this reflected how PAs were viewed by others. These
two PAs have shattered these old, constraining views and added a whole
new dimension to how PAs are respected by the military,” Tozier said.
Robertson, who joined the Army in 1972, noted that the war has
created an even greater demand for PAs in the military.
“This war changed things for PAs. When the war came around, the
Army decided that they needed to keep experienced PAs.” Robertson
did what he could to make sure that happened. “One of the things I
accomplished while I was a consultant was bonus pay for PAs—31 thousand
dollars a year—which keeps a lot more of them in the Army now.”
Robertson said the number of PAs in the Army has doubled since
the war began, and he expects that number to grow another 50 percent
in the next five to ten years. “There’s plenty of room for growth
and there’s plenty of leadership opportunities for them,” he said.
According to the AAPA Census combined with data from the National
Commission on Certification of Physician Assistants, there are
1968
1969
1969
1970
1968
Hu C. Myers, MD,
establishes first
baccalaureate degree
program for PAs at
Alderson-Broaddus
College in Philippi, W. Va.
Health Manpower Act
(PL-490) funds the
training of a variety of
health providers.
Duke University hosts
first of four national
conferences on physician
assistants on issues such
as education, promotion of
the profession, and model
legislation for PAs.
1968
AAPA is incorporated
in N.C.
Richard Smith, MD,
launches MEDEX program
at the University of
Washington.
The American Hospital
Association and the Joint
Commission release a
report on the “Utilization
of Physician’s Assistants in
the Hospital.”
American Medical
Association Council on
Health Manpower explores
PA concept and the
AMA House of Delegates
adopts “Guidelines for
the Development of New
Health Occupations.”
Board of Medicine of the
National Academy of
Sciences releases report
classifying PAs as Type
A, B, or C according to
degree of specialization
and level of judgment.
The American Registry
of Physician Associates is
incorporated in N.C. Later,
the registry is absorbed
into the Association
of Physician Assistant
Programs (now PAEA) and
its certification functions
are assumed by the
National Commission on
Certification of Physician
Assistants.
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William
Tozier as a warrant
officer in the Idaho National Guard, 1977
1,412 active duty PAs in the armed forces. These numbers are likely a
bit low since military PAs serving overseas are less likely to respond to
the census survey, but they track well with numbers provided by IPAP.
Training Veterans in Civilian PA Programs:
the Education Dilemma
But more than 40 years after the profession began with three exmilitary
corpsmen, there are still challenges when it comes to training
veterans to become PAs. For one thing, most civilian PA programs
require a bachelor’s degree as a prerequisite for entrance into a program.
And, as Robertson notes, “It’s hard to meet the prerequisites
when you’re in Iraq every other year.”
“Service members tend to have lower academic backgrounds and
qualifications,” said Tozier, who served two years in Iraq with the
Army’s Third Medical Command. “Our [IPAP] program has tailored
its program of instruction to meet the unique qualifications of our
applicant pool. It is difficult to say how they would fare in the admissions
process of many civilian programs. Yet our graduates continually
score in the top fourth of the PANCE.”
The IPAP program is accredited to graduate up to 233 students
per year. But some, including Tozier, believe civilian programs should
do more to recruit veterans.
“I would like to see more medics and corpsmen with medical
experience get into [civilian] PA programs. If you view this as a
diversity issue, I believe this group of individuals should get the
support necessary to assist them in further contributing to our
national health care needs.”
According to Gianola, only about seven percent of most PA
graduating classes are made up of veterans. He says most MEDEX
classes have a 30 percent veteran population.
“These folks go out and sacrifice their time and sometimes their
limbs and life, and I think there’s some societal responsibility to
use that skill set that taxpayers pay for and make it available to the
general public,” he said.
He suggests having a bridge program for veterans who are attending
community college that helps them get the credits they need, and
then transition to a nearby university’s PA program. “I think in a year
there may be at least one or two community colleges in the country
that might be willing to actually start up and do that,” he said.
Some of the first PAs see military recruitment within civilian programs
as a natural extension of the profession’s roots. “It would be prudent
and ethical for us to get back to our beginnings,” said Ferrell. PA
Capt. Sharon Rosser, one of the first graduates of the Army PA
Doctoral Program, repairs a laceration in Iraq.
1970
1971
1970
AMA House of Delegates passes resolution recognizing PAs.
PA Joyce Nichols,
the first woman
to be formally
educated as a
PA, graduates
from the Duke
University PA
Program
American Medical
Association begins work
on national certification
and codification of PA
practice characteristics.
Comprehensive Health
Manpower Training
Act (PL92-157)
contracts for physician
assistant education and
deployment.
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Breaking Down Barriers
to Help Build a New Profession
Joyce Nichols,
the First Female PA
B y Ja n e t t e R o d r i g u e s
oyc e C l ay to n N i c h o l s
grew up on her family’s farm in the gently rolling
hills of central North Carolina. There, they grew cash
crops, such as tobacco and wheat, and raised some livestock.
In the early 20th century, one out of every seven
farmers in the United States was African-American. But during
the same period, millions of African-Americans left the South for
new opportunities in cities in the North and West, such as New York,
Chicago and Los Angeles, and to escape oppressive Jim Crow laws.
Her parents, though, decided to stay in Person County and raise their
children on the land they fought to keep.
Today, there are fewer than 18,000 African-American-owned
farms in the country, and less than 3,000 in North Carolina. In an
“endangered” profession, the African-American farmer is quickly becoming
extinct. Yet, the Clayton family stuck it out. “We still own our
family farm,” she said recently, a note of pride in her voice. “We had a
1971
1972
1972
1973
1973
1971
Cartoonist Dick Moores
introduces the general
public to physician’s
assistants in his comic strip
“Gasoline Alley.”
Marvin Gliedman, MD,
and Richard Rosen,
MD, establish first
postgraduate residency
program for PAs in surgery
at the Montefiore Medical
Center in Bronx, N.Y.
The Association of
Physician Assistant
Programs is established
with sixteen charter
members. Alfred M. Sadler
Jr., MD is elected as its first
president.
Alderson-Broaddus
College graduates its
first class of PAs with
baccalaureate degrees.
Bureau of Health
Professions Health
Resources Administration
awards first contracts to
support the development
of primary care physician
assistant educational
programs.
Nine sponsoring
colleges of medicine
located throughout the
United States establish
consortium of MEDEX
training programs.
First AAPA Annual
Conference on New Health
Practitioners held at
Sheppard Air Force Base,
Wichita Falls, with 275
attendees.
Fourteen national health
professional organizations
voluntarily form a
National Commission on
Certification of Physician
Assistants with
offices located in
Atlanta, Ga.
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lot of fun there; I mean, we also worked hard
because we would get up early in the morning
to do whatever we had to do on the farm,
and then we went to school. When we came
home, we did whatever we had to get done.”
Determination is a way of life for Nichols.
It’s what got her through the long, back breaking
days that come with farming. It’s what got
her through high school. It’s what got her into,
and through, the licensed practical nursing program at Durham
Technical Community College. It’s what helped her earn a place on
staff of the Duke University Medical Center cardiac care unit. And it’s
what led her, an African-American woman, working in the raciallypolarized
South in late 1960s, to fiercely lobby the university to let
her into the then all-male PA program.
“I applied three times before I was accepted into the PA program,”
recalled Nichols, the first woman to be formally educated as
a PA. “It was a male program, and I wasn’t a military corpsman. The
PA program was not for females, and female ‘life expectancy’ in the
profession was low because the belief was that a female would start
having babies and it would not be productive.”
In 1968, she successfully argued her way into the program after
convincing PA profession luminaries to take a chance on her: Eugene
Stead Jr., MD, founder of the PA profession and Duke PA program
concept; Harvey Estes, MD, the first chairman of the department of
community health sciences at Duke; Robert Howard, MD, the Duke PA
program’s first full-time medical and program director; and Jim Mau,
chief administrator for the department of medicine at Duke. (Duke
medical school did not admit its first African-American until 1963.)
Rough Beginnings
The men overseeing the PA program didn’t make it easy on Nichols.
“Jim Mau came up to me on a Friday afternoon and told me that I
had been accepted and that I had to report to class at eight o’clock
that Monday morning in the trailer,” she said. “And I was scheduled to
do evenings as a nurse, but I wouldn’t have
gotten out of class until four o’clock in the
afternoon.”A sympathetic nursing supervisor
made sure that Nichols was able to
stay in class the required hours before she
started her evening shift in the CCU.
“I have a tendency to be just as alley
[cat] as anybody else, and I went off in
the classroom, and said that everybody there had an area of
expertise and we can work together to get through this,” Nichols
said. So every Wednesday, she and her classmates would meet for
a study group. First it was at a pub close to the Duke campus. The
study group eventually migrated to her house. “We made a pact that
everybody in our class would graduate on time.” They supported her,
and she supported them, and each did their fair share of tutoring the
others. Things were falling into place.
In December of 1969, in the middle of her first year, a fire swept
through her home. She and husband, Mike, and children, Will, 12, Le-
Von, 9, and Melita, 5, lost everything they owned, everything they had
worked for. While no one was injured– she was in class, her husband
at work and the children in school—it was devastating. She decided
to drop out of the program so she could pick up some overtime to
help her family get back on its feet.
But her classmates wouldn’t let her. “Those guys got together and
sold tickets for a dance. They made enough money for us to buy
furniture, clothing and toys for my children for Christmas. I still have
the tin box they put the money in and gave to me in 1969.”
The 12 members of Nichols’s class supported each other; they
were a cohesive unit, and she was one of them.
“The thing I’m most proud of accomplishing is developing a
camaraderie with my classmates, even though it started out rocky,
all of us were able to end up as a cohesive group,” Nichols said. “We
respected each other and we looked out for each other. There is no
way to explain what those first three months were like compared to
the rest of the 21 months I spent with those guys. It was just unreal.
1973
National Board of Medical
Examiners administers the
first certifying examination
to 880 candidates, 10%
of whom are not PAs
but graduates of nurse
practitioner programs.
1974
AAPA and APAP establish
a national office in
Washington, D.C. under
the directorship of Donald
Fisher, PhD.
1975
NCCPA is incorporated,
and sponsorship of the
profession’s certifying
examination is transferred
to the NCCPA. Timelimited
certification is
established, and the first
certificates are issued.
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And I don’t have words to express it. They were a group of good guys
after we got our differences taken care of.”
All the members of her class graduated and went on to practice
as PAs.
Cardiology vs. General Practice
When Nichols was going through the PA program, she planned to become
a PA in cardiology. She enjoyed being a cardiac care nurse, so it
made sense for her to specialize in cardiology. She even did one of her
clinical rotations in it. The other clinical rotation was in general practice
with a rural family doctor, and it changed her life. The time she spent
treating patients in Garland, N.C., brought home some truths for her.
“I realized then that I wanted to do internal medicine,” Nichols
said. “The general practitioner I worked for, Amos Johnson, his
medical records were lousy, but he knew every one of his patients by
name and their medical history. He had a young man, who he had
trained, who could do anything. He could set broken legs and suture
lacerations when they came in, and I fell in love with that and doing
health education. And, not only did Dr. Johnson own the clinic, but he
owned the pharmacy as well.” All of which appealed to the independent-minded
daughter of a farmer. She also had first-hand knowledge
of the difficulties of obtaining adequate health care in rural America.
During this time, AAPA was being organized. PA William Stanhope,
the Academy’s first president, gave Nichols, then a PA student,
the job of writing the first draft of the organization’s bylaws. She was
elected to serve as a director at large on the AAPA Board of Directors
in 1971. She and Prentiss Harrison, the first African-American
PA, worked closely with PAs Earl Echard, John Davis and Steve
Turnipseed to establish AAPA’s minority affairs committee in the
early 1970s. They also helped the profession gain acceptance among
African-American physicians.
Prior to graduation, she met with Estes to discuss her employment
plans. The PA profession was still finding its way, and it was
difficult enough to help find jobs for white male graduates, much less
an African-American female. Estes asked her what she wanted to do
if she had the choice. “I told him that I wanted to have a rural health
clinic. I told him about the difficulties people like my grandmother
and other family members had because there was no place for them
to go for preventive care.”
Nichols credits Estes with helping her secure the funding to open
what would become one of the first rural, satellite health clinics in
the nation. She was still a student when she met with clinic board
members and advisors to conduct a health survey of the patients the
facility would serve. When she graduated from the Duke PA program
in 1970, the clinic was set up in the basement of a Baptist church and
ready for her to start work in Rougemont, N.C.
Taking the Salty with the Sweet
Nichols friends and colleagues joke about her sometimes brusk, tellit-like-it-is
manner. “Joyce is the type of person who doesn’t care what
color you are, she will curse you out and she is the same when it comes
to helping you,” said PA Earl Echard, a longtime friend. “She thrives on
things that are difficult. She has taken on things through the years that
have been monumental that a lot of people have shied away from.”
Born and raised not far from Rougemont, Nichols was not naïve
about how to get the white community on her side in the racially
segregated area. “The thing that made me excited about going to
work every day was home visits,” she said, adding it helped her gain
acceptance as a clinician in the white community.
“I made friends with the mail man, and through him I learned about
one of the influential families in the area. This was a well-off family and
they were big land owners. The matriarch of the family had severe corns
and calluses on her feet. I would go to that lady’s home, and soak her feet
in water, and manually take a scalpel and remove the corns and calluses
off her feet. She was able to walk without a walker, and wear her pretty
shoes, and I was the best thing since sliced bread. And because of the
pull her family had, it was automatic that I was accepted.”
Another wealthy family donated land so the clinic could build a
proper facility because it had outgrown the church. By 1972, though,
the external funding for the clinic began to dry up. She and Estes ap-
1977
1977
1980
1976
Federal support of PA education continues under grants
from Health Professions Assistance Act (PL94-484).
AAPA Education and
Research Foundation
(later renamed the
Physician Assistant
Foundation) is
incorporated to obtain
public and private
funds to support
student scholarships
and research about
the PA profession.
Rural Health Clinic Services
Act (PL95-210) provides
Medicare reimbursement
of PA and nurse
practitioner services in
rural clinics.
1978
Air Force begins
appointing PAs as
commissioned officers.
The AAPA Political
Action Committee is
established to support
candidates for federal
office who support the
PA profession.
1981
NCCPA introduces
the recertification
examination. PAs
who failed the
exam are recertified for
two years and allowed to
take the exam again.
24 | PA PROFESSIONAL | SEPTEMBER 2010 | WWW.AAPA.ORG

PAs Reginald Carter, Joyce Nichols and the late Thomas Godkins.
proached Lincoln Hospital, now Lincoln Health Center, which primarily
served Durham’s African American community, to take over the
clinic. Lincoln agreed and Nichols began to split her time between the
rural clinic and one operated by Lincoln in Durham public housing.
“So I was working two jobs, teaching classes in physician diagnosis
at Duke Monday, Wednesday and Friday, and going out to the
clinic in Rougemont at 10:30 a.m. on Monday, Wednesday and Friday.
And Tuesdays and Thursdays I was at the [public housing] clinic
until the load got too heavy and I couldn’t do both.” Echard, who was
a student when he first met Nichols, took over the Durham clinic
after he graduated from the Duke PA program in 1973.
She took on more and more responsibilities as a PA educator and
leader. She helped found the North Carolina Academy of Physician
Assistants and served on its board of directors. She acted as a preceptor
and taught as an adjunct faculty member of Duke’s department
of community and family medicine. Yet, Nichols refused to give up
the rural clinic. “I loved my rural folk,” she said. “And I understood
their need for health care—preventive health care—so I would be
there and I would even do an evening clinic so they could leave the
field and come right on to the clinic.”
Looking Back
Four decades have passed since she convinced the founders of the
PA profession to let her through the door. (Some would say she
kicked it in.) She has taught and mentored generations of PAs from
all walks of life
“Joyce has done so much, and she is such a humble person,” said
PA Barbara Bennett, a longtime friend. “She has been a mentor to
so many people and been there for so many people. She encouraged
you to continue your education, look beyond the general expectations
and think outside the box. All the PAs who know Joyce respect
her and love her. Some may have feared her because if you are wrong,
she is going to let you know you are wrong, and she is not going to
support you, and she is going to let you know what to do to rectify it.”
Bennett added that her friend, mentor and “big sister” has never
been about the almighty dollar. “She has always wanted to help people
be the best they could. Did you know in the summertime she would
have this teaching program for middle school kids from Durham? She
would take them to the beach for good behavior and academics, and
being mediocre was not good enough to get to go on these trips.”
AAPA President-elect Robert Wooten believes Nichols had a vision
for the profession. “She understood the hard work that it took to get
into PA school and to successfully complete the program,” he said. “She
encouraged us to mentor other students along the way. She understood
the obstacles that were out there facing PAs and encouraged others to
overcome these obstacles. Joyce does not accept excuses or lack of effort.”
Nichols retired from Lincoln Health Center in 1995, but she will
never fully retire from the PA profession. “I’ve had a wonderful career,
where I enjoyed what I was doing. I was able to be a clinician, a PA
educator. When a college or university wanted to start a PA program,
I went with [former Duke PA Program Director Bob] Howard to the
sites to look at the programs.
And whatever task she took on, or was given, she had the determination
to see it through—whether it was rushing a patient to a clinic
in the back of a flat-bed truck on back country roads or becoming
the first female PA.
PA
1985
1986
AAPA membership
surpasses 10,000.
NCCPA introduced
the newly-designed
Physician Assistant
National Recertifying
Examination. The half-day,
proctored examination
was a comprehensive
examination of general
medicine.
AAPA succeeds in
legislative drive for
coverage of PA services
in hospitals and nursing
homes, and assisting in
surgery under Medicare
Part B (Omnibus Budget
Reconciliation Act PL
99-210).
1987
New AAPA national headquarters at 950 North
Washington St., Alexandria, Va. is built.
1987
National PA Day, October
6th, is established.
PA PROFESSIONAL | SEPTEMBER 2010 | WWW.AAPA.ORG | 25

A A P A
A
of
History
Service
Regulatory History of the Phy
B y T h o m a s E . P i e m m e , M D, P r e s i d e n t- e l e c t, PA H x
he emergence of a formally trained assistant to the physician in the late
1960s was accepted with astonishing enthusiasm by the medical profession. The American
Medical Association and the relevant specialty societies quickly approved the concept and
greatly assisted in its transition from an experimental new health occupation to a full profession,
recognized in nearly every state in less than a decade.
The prototypical program, founded by Eugene A. Stead Jr., MD,
at Duke University in 1965, was joined by four other credible models
during the next four years—John Kirklin, MD (surgeon assistant),
Hu Myers, MD (four-year baccalaureate degree program), Henry Silver,
MD (child health associate), and Richard Smith, MD (MEDEX).
In 1970 the AMA House of Delegates, while formally approving the
concept, urged states to modify their statutes and adopt regulations to
permit PAs to qualify as medical practitioners. PA program educators
supported the AMA leadership in charging the Council on Allied
Health Education and Accreditation to develop a system of accreditation
of educational programs as long as representation by the new
profession was included. After some negotiation, this was achieved.
The formation of the resulting Joint Review Committee—which
later became ARC-PA—under the leadership of Malcolm Peterson,
MD, couldn’t have been more timely. The adoption by the AMA
House of Delegates in 1971 of “Essentials of an Approved Educational
Program for the Assistant to the Primary Care Physician”
coincided with congressional action on the Comprehensive Health
Manpower Act, which provided funds for PA training. In an explosion
of activity, this funding stimulus led to the creation of 36 new
programs that were added to the dozen that already existed. The
Joint Review Committee guidelines led to a convergence of training
around the Duke model, although the several MEDEX programs,
while evolving, maintained their identity.
The following year, the existing PA training program leaders
formed the Association of Physician Assistant Programs (now known
as the Physician Assistant Education Association) to share information
and assist new programs in their development. APAP and AAPA
began holding an annual conference to plan for the future.
In 1973, the authors of this editorial, while serving as the first
two presidents of APAP, raised sufficient private foundation funds
to establish a joint national office for both AAPA and APAP in
Washington, D.C., and recruited Donald M. Fisher, PhD, to serve
as executive director of both organizations. For the first time, fulltime
staff was available to advance the interests of the physician
assistant movement nationally.
SongquanDeng/ shutterstock
1989
1997
2000
2001
2002
1988
First edition of the Journal
of the American Academy
of Physician Assistants is
published and distributed.
Navy and Public Health
Service PAs Commissioned
1991
Navy PAs are
Commissioned.
1992
Army and Coast Guard
PAs Commissioned.
AAPA reports 28,500
PAs in active practice;
prescribing authorized in
40 states, the District of
Columbia and Guam.
1998
NCCPA begins requiring
PAs to pass one of the
recertifying exams within
two attempts.
Mississippi is last state
to enact legislation
authorizing PAs to practice
in the state, ending 25
years of effort by local and
national organizations.
The Physician Assistant
History Office is
established as joint effort
of the Department of
Community and Family
Medicine, Duke University
Medical Center and AAPA,
APAP and NCCPA.
A record 4,267 PAs take
the PANCE achieving a
91.5% pass rate.
The Society for the
Preservation of Physician
Assistant History
is incorporated for
educational, research and
literary purposes.
AAPA estimates that there
are 45,000 clinically active
PAs practicing within the
United States.
26 | PA PROFESSIONAL | SEPTEMBER 2010 | WWW.AAPA.ORG

sician Assistant Profession
a n d A l f r e d M . S a d l e r , M D, H i s to r i a n , PA H x
With the professional organizations in place and accreditation
functioning, it was essential to concentrate on the third element required
of any established profession: a credible method of national
certification of graduates of accredited programs. In 1971 the AMA
directed its Council on Health Manpower, under Malcolm Todd, MD,
to assume leadership in sponsoring a national program of certification.
Concurrently, Piemme had been appointed to a planning committee
of the National Board of Medical Examiners, or NBME, that was to
recommend to its executive board that the NMBE, for the first time
in its history, take on the examination of health professionals other
than physicians. The proposal was accepted, and NBME President
John Hubbard, MD, appointed an advisory committee to prepare and
implement an examination for PA graduates.
The first examination was administered to 880 candidates in
December 1973. The following year, reflecting unprecedented collaboration,
a meeting convened by Todd of 14 national organizations
formed the National Commission on Certification of Physician
Assistants, or NCCPA. The new commission’s mandate was to determine
candidate eligibility, set standards and ensure the integrity
of the examination that was to continue to be administered, under
contract, by the NBME. Thomas Piemme, MD, was elected president
of the new commission, and David L. Glazer, PhD, was recruited to
become its first executive director.
Because the states are responsible for licensure and establishing
rules and regulations for medical practice, the detailed work of developing
PA enabling legislation was a state-by-state matter. Following
California in 1970 and Connecticut and North Carolina in 1971,
other states began approving legislation authorizing the practice of
medicine by physician assistants under the supervision of a physician.
Fisher, Glazer and officers of AAPA, APAP and the NCCPA became
heavily involved in state proceedings by serving as advisers and consultants.
They worked to ensure that PA practitioners were graduates
of accredited programs and certified by the NCCPA. Virtually all
states incorporated these requirements.
A crucial task was to persuade state regulatory bodies that rather
than create lists of tasks that PAs might be permitted to perform, as
California had done, delegation should be open-ended, authorizing
physicians to assign any appropriate task or duty that was within their
own scope of practice. The effort was highly successful and gave PAs
wide latitude in which to practice.
In subsequent years, modifications of regulated scope of practice
have come with experience and with increasing recognition of value,
reflected in federal and state reimbursement policies. While most
states have subsequently recognized physician assistants through
the process of licensure, that credential has not changed the fundamental
concept of the formally trained PA envisioned by Stead and
others in the mid-1960s.
PA
Thomas E. Piemme, MD, President-Elect, PAHX is presidentelect
of the Society for the Preservation of Physician Assistant History.
Alfred M. Sadler, MD, Historian, PAHX is historian for the
Society for the Preservation of Physician Assistant History.
2003
2004
2005
2007
2009
2010
PAs are introduced into
England.
Texas becomes 41st state
to authorize controlled
substance prescribing
for PAs.
CMS expands ability of PAs
to have an ownership stake
in a practice receiving
Medicare payments.
The number of clinically
practicing PA reaches
50, 121.
PAs Karen Bass, of
California, Mark Clark
of New Hampshire, and
Mark Hollo of North
Carolina, become the
first PAs elected to state
legislatures.
Eugene Stead, MD,
founder of the PA
profession, dies at 96.
Robin Hunter Buskey
becomes the first PA
elected to the Board of
Directors of the Federation
of State Medical Boards.
2006
Rear Adm. Mike Milner
becomes the first PA flag
officer.
The PA profession
turns 40.
All 50 states, the District of
Columbia and Guam now
allow PAs to prescribe.
2008:
PA Karen Bass elected
Speaker Emeritus of the
California State Assembly,
becoming the first PA and
African-American woman
to hold that post.
The number of PA
programs worldwide
reaches 160 in the United
States, Australia, England,
Canada, the Netherlands
and South Africa.
The estimated number
of clinically active PAs is
75,000 worldwide.
Information used in the
timeline was provided by
the Physician Assistant
History Center, AAPA staff,
and the book “Physician
Assistants, Policy and
Practice, Third Edition”
by Hooker, Cawley and
Asprey.
PA PROFESSIONAL | SEPTEMBER 2010 | WWW.AAPA.ORG | 27

oneonone B y C h r i s to p h e r D o s c h e r
An Innovator Reflects
Richard Smith, MD, on the Path of the PA Concept
Richard Smith, MD, developed a passion for bringing medical care to underserved
populations while on a summer college work camp in Cuba in 1951. He worked in a
rural clinic and saw the excellent quality of care provided by a health care worker who
was not a physician. “I worked with a practical nurse who was in the countryside, and I realized
that I should be in medicine, training people like her. That experience overseas indicated to me
that there was a need for medical professionals who didn’t require 13 years of training.”
Smith followed his passion and made
it his goal to become a medical missionary.
After his graduation from the Howard
University College of Medicine, he
requested that the Episcopal Church approve
him as a missionary to train health
care providers in overseas countries. “I
got the Archbishop of Canterbury to
present my idea to the World Council
of Churches, and they turned it down,”
he said. After stints in the U.S. Public
Health Service and the Peace Corps, an
experience he said gave him “insight,
courage and the experience of seeing
how people could collaborate and work
together when they had a common purpose.”
He then worked in the U.S. Surgeon
General’s Office of International
Health. From there, he landed at the
University of Washington to start the first MEDEX program.
He started MEDEX (a name based on the words “medical
extension”) from the ground up, aiming to create a program
that would both train health care providers and direct them to
areas where they were needed. Smith traveled to communities
with medical shortages to hold town hall meetings about the PA
concept, and rallying the support of physicians and citizens in
those areas. “It was a matter of planning, of getting important
people involved in the very beginning,” Smith said. “The people
who got involved were the most overworked docs, and they were
willing to go around the state and talk to other docs.” Smith also
placed medics in offices of physicians who occupied key places
on the state medical board to ensure they were familiar with the
concept. MEDEX began as a demonstration program in 1968
and its first class of military medics entered the next year. Four
years later, MEDEX opened admission to allied health professionals
and nurses, accepting for the first time candidates who
were not ex-military medics. The program celebrated its 40th
anniversary in 2009.
Smith, who now lives in Hawaii, is
working on a memoir he plans to call
“Stalking Chocolate Mousse.” He explained
the title. “I am the world authority
on chocolate mousse,” he said. “It’s my
hobby, and I pursue it all over the world.”
Ask him where to find the best mousse in
your town, and he’s likely to know. Smith
spoke with PA Professional by phone to
share his thoughts on the early days of
the profession and how it has evolved.
Not many people can say they helped
launch a new profession. What
special challenges did that present?
The challenge was developing the collaboration
of other people involved:
Richard Smith
the patient populations, the doctors,
the state medical board. Then I had to prepare the framework
within which the new program and its new providers would
work. We got the first legislative piece authorizing MEDEX/
PAs to operate in Washington in 1971. I had identified who the
congressional leaders’ doctors were and placed medics in their
offices, so they were familiar with the PA concept. I also identified
the second-highest ranking member on the state board
of medical examiners who was a physician and placed a PA in
his office. Subsequently—with colleagues scattered across our
four time zones—I developed the receptive framework to set
the stage in Washington State and elsewhere and made sure it
wouldn’t fail. These were the guys who controlled the provision
of health care in the states. We talked on the phone a lot, each
of them had their legislators to deal with.
One of the guys in Utah was a fishing buddy of [former
Florida Congressman] Paul Rogers, so we had an in with Congress.
We had a lot of phone meetings. Rarely did I see these
people in person. For example, we found out the Senate finance
30 | PA PROFESSIONAL | SEPTEMBER 2010 | WWW.AAPA.ORG

Photo from Richard Smith’s 1978
book, “Manpower and Primary
Health Care: Guidelines for
Improving/Expanding Health Service
Coverage in Developing Countries.”
The profession is projected to grow to more than 100,000
PAs over the next few years. How do you think it will evolve?
I think the numbers will continue to grow because fewer and
fewer doctors are going into primary care. I got an e-mail about
a month ago from a former student who said that when he started
as a PA in 1969 he was making $800 a month. Last year, he
made $159,000. The need has become dramatically noticeable
as fewer docs go into primary care. What we need to do is try to
keep it under control. The need is for education and training to
do the job, not training and education to get the job. I hope the
PA programs understand that, because it is getting to the point
that it takes as much time to become a PA as it does a doctor.
committee was going to hold a hearing on whether to reimburse
PAs. I got a call from [University of Utah PA program founder]
Bill Wilson, who said this was going to happen. I took two hours
to call all seven MEDEX programs. I said “Everyone contact
your legislators.” They did, and we got the issue off the table of
the finance committee and stopped them from bringing it up.
How do you think the growth of the PA profession will
impact the way physicians practice?
I think it will be an opportunity for the docs to practice their
more sophisticated training in medicine and continue to earn
a good income with some partners. They’ll be able to take care
of more patients.
PA
Was there any resistance to the concept?
The resistance came from the fact that PAs weren’t doctors,
and [critics said] they were practicing medicine illegally. The
dean of the school of nursing wrote a letter to the board of
medical examiners accusing me of malpractice. I wrote the response
to her, and she contacted the president of the American
Nursing Association, who flew to Seattle to try and talk me out
of launching the [MEDEX PA] program. I told her I had left
the Public Health Service to do this, and this was my purpose.
What were your expectations for PAs in the early days?
I expected PAs to provide a major part of the easily performed
primary health care diagnoses and treatment under the supervision
of the doctor, either in the office or remotely, and to
develop a relationship between the two of absolute confidence.
The relationships that developed between the two were incredible.
In some communities, the people in the community
helped build their homes. I just sit back and marvel at all of
this, because it’s just a simple idea. I went out to the town hall
meetings, and the communities helped build this.
PA PROFESSIONAL | SEPTEMBER 2010 | WWW.AAPA.ORG | 31

eflections
B y R e g i na l d C a rt e r , P h D, PA , H i s to r i a n E m e r i t u s , PA H x , A l f r e d
M . S a d l e r J r . , M D, H i s to r i a n , PA H x , a n d L e i l a L e d b e t t e r , M L I S ,
D i r e c to r a n d A r c h i v i s t, P h y s i c i a n A s s i s ta n t H i s to ry C e n t e r
A Sense of Ourselves
Tools to Help You Learn How We Got Here
The PA profession emerged in the mid-1960s as a bold experiment in medical
education and service. The idea that someone besides a physician could practice medicine
in a carefully controlled environment wasn’t new, but the forthright advocacy of
programs to train personnel to do so was. The story of how we came to be and how we took our
place alongside the established professions of medicine and nursing is one of the great tales of
innovation and creativity in American medicine during the last third of the twentieth century.
Although known in part, the story of the profession’s struggle to become fully integrated into
American health care is less well understood and documented.
The Society for the Preservation of PA History, or PAHx,
was formed in 2001 to record the history and preserve the
legacy of our remarkable profession. The society conducts
research and oral interviews to fill out the historical record,
and the PA History Center provides a setting to process and
preserve important documents and memorabilia as well as a
way for the public to access the items that have been collected.
Much of the information archived to date is accessible via our
reading room and our PAHx website. We do this because we
believe that an understanding of the history of one’s profession
is essential to developing one’s professional identity.
The elements of identity were established by the profession’s
founders, all practical idealists who expressed their values and
passion for patient-centered care. In its formative years, the
profession was wonderfully untidy, somewhat ill-defined and
vibrant with fresh ideas about how to educate and deploy PAs to
medically underserved communities. Eventually, some standardization
was required for credentialing, acceptance, sustainability
and a political voice. As trailblazers, PAs worked hard to gain
acceptance, prove their worth and overcome restrictive rules and
regulations.
The lessons learned have endured: The use of a competency-based,
generalist medical and preventive health care
education allows PAs to work in any medical and surgical
specialty; the inclusion of other health professions and
agencies over time has helped validate and strengthen our
accreditation and certification processes; an ongoing sensitivity
to gender and diversity issues has ensured a broadly
representative profession; an appreciation for diverse opinions
and acceptance of new ideas has revitalized our mission
without jeopardizing our values; and respect and honor for
those who have devoted time, effort and resources to our
success motivate others to become involved in our profession.
By understanding the people and events that have shaped
our profession, we are better equipped to inform others about
our collective mission, values and goals. Our leaders and policymakers
can make aligned decisions, avoid past mistakes and
capture opportunities for innovative approaches to providing
medical and preventive health care.
Please explore our website at www.pahx.org. We welcome
your input, your contributions and your support. PA
PA PROFESSIONAL | SEPTEMBER 2010 | WWW.AAPA.ORG | 39