Sometimes I worry about the PA profession. Of course, as I approach my 60s, I worry about a lot of things now that I once took for granted. Yet there are moments when I take pause about where the profession is going and the opportunities missed along the way.

Many would ask: What's the problem? What's to worry about? Isn't it hard to express serious concern for the profession when it is clearly in a booming period of its evolution, with rosy outlooks, widespread public acceptance, plentiful jobs, rising salaries, expanding scopes of practice and global spread?

Still, in my darker moments, I worry for the future of the profession, its direction and where it might lead us. I am not concerned for our future existence or that we will see any imminent decline in our professional status and activities. Without question, the PA profession in America is one of the stellar health workforce policy successes of the past half-century, one that will have a long and prosperous existence. My concern is a more subtle one based on trends and patterns I see as a researcher and observer of the PA profession and as a person who at one point believed that I saw the future of medicine, and it was named the PA.

Altruism and Self-Interest

When the PA profession began its existence, its direction was based on the premise that we would be a bit of a different creature in medical practice. Different from physicians, that is. Our heritage was one where PAs would practice in primary care medicine and not follow the trend of physician specialization and subspecialization. We also would practice in areas of medical need and embrace then-new concepts of prevention, wellness, workforce diversity, holistic approaches and patient-centered practice.

We would be clinicians who practice with physicians but who would not be "mini-docs," as some derogatorily termed us. We would forego considerations of high salary and comfortable practice settings to improve the delivery of health services to the disadvantaged in society.

Yet I see disconcerting evidence that we are straying from these ideals and indeed are emulating our physician colleagues. Our practice distribution statistics show that fully 65% of us are in specialties and subspecialties. Fewer PAs work in the primary care specialties and in medically underserved areas and rural communities. The proportion of ethnic and racial minorities among us remains low. We have drifted toward lucrative specialties like plastic surgery, dermatology and orthopedics, where we make well-off physician practices even more well-off.

Our sense of a social mission-to improve health care delivery for our fellow citizens-has become distorted by our commercially oriented and highly fragmented health delivery system. The decisions of newly graduating PAs unfortunately are motivated more by debt-related financial considerations than by humanitarian and altruistic reasons.

Following Physicians (And the Money)

My lament is that PAs have not struck out in some of these distinctive directions but instead largely have followed the patterns and inclinations of their physician colleagues. American medicine has become a highly commercialized business, and PAs and physicians alike now appear to give greater emphasis to money and limitation of practice rather than service and professionalism. Clearly, our modern health care industry environment fosters such attitudes and directions, and PAs, like physicians, for better or for worse are products of this vast and highly entrepreneurial system. It is tough for PAs to swim upstream.

Yet is it any wonder that PAs would emulate their physician colleagues, given the similarities in their education and close practice relationship? Bear in mind that even the most service-minded PA first needs to find physician practices that already are in underserved areas and in generalist practice. I think of the hope that once existed for PAs to be very different types of clinicians from physicians and to bring new elements to clinical practice, elements that physicians did not bring, and respond to the social mandate to meet population health care needs.

There is, of course, the possibility that such a direction could still occur. Many PAs remain strongly devoted to the original ideals of the PA profession and want to "change the system" to improve health care delivery for all citizens. If we are to do this, we must send the message that we are not willing to be complacent (like some physicians) with simply getting our slice of the pie, economically speaking, and leaving it at that. We should be activists for change in the health system, wearing our hats as clinicians and as citizens.

Remember Our Roots

The health care system is by all accounts a mess. I hear few physicians decrying the system. That is probably because the system provides substantial advantages, economically and socially, for physicians. They typically are not forced to practice in underserved regions or in undesirable specialty areas. The opportunity exists for PAs to say that we are providers who are ready to meet society's expectations for improvement in health care delivery.

There is still time for us to make that case to the American people. As close as we are to physicians, we should not emulate them in every respect. We need to consider expressing our own identity and positions that draw from the social themes of our roots.

James F. Cawley is professor and interim director of the PA program at the School of Medicine and Health Sciences at The George Washington University in Washington.

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