This year marks the 40th anniversary of the PA profession. When the first PA program began, conditions in American medicine and society were in turmoil. Unrest was in the air following the assassination in 1963 of President Kennedy, the ascension of the civil rights movement, the death of Malcolm X, the Watts riots and the escalation of the war in Vietnam. Lyndon Johnson's Great Society was enacting landmark federal programs such as Medicare, which would prove to have major long-term impact on American life. Amidst these events, in a small trailer on the campus of Duke University, a new type of health care professional was being created. From this very humble birthplace, the PA profession began and soon caught the attention of the medical community and the public.

Although most PAs in practice have been educated over the last decade and are busy clinicians focused on patient care, it is worth taking a moment to reflect on the history and development of the profession.

The New Health Practitioners

The idea of the PA as developed by Drs. Eugene A. Stead Jr., Richard A. Smith, Hu Crim Myers and Henry Silver was merely one component of a larger movement to produce new types of health care providers. The notion of nonphysician health care providers was spreading throughout health education fields. Programs to train new practitioners appeared in many institutions during the mid to late 1960s. Most of these training programs involved the creation of clinicians who had extensive nursing and/or military medical backgrounds.

The "new health practitioner" movement gained strength as dozens of training programs developed during the late 1960s and early 1970s. Often, these programs were considered experimental and were begun primarily because federal grant support was available to support such efforts. Typically, these training programs were one to two years in length but sometimes shorter, practically oriented and designed to deploy providers quickly to alleviate what was considered then to be a physician shortage.

They went by many different names: health assistant, health associate, primex, MEDEX, physician assistant, physician associate, nurse practitioner, surgeon assistant, syniatrist, child health associate, clinical associate and many others. Somehow, from all of this experimentation with new providers, two lasting models emerged: the physician assistant and the nurse practitioner.

PAs: A Success Story

For the PA, success initially depended upon acceptance by physicians. When the American Medical Association gave its blessing by urging state legislatures to pass laws that would permit PAs to practice, the movement gained legitimacy. As states passed practice laws, more training programs developed, and the concept took shape in the practice setting. Often when PAs were introduced into practices, resistance was not uncommon from other health care professionals. PAs trained in the 1970s remember well the suspicion and doubt as they entered practice.

Looking back, the PA profession can only be described as a health workforce policy success. Acceptance of the PA by health care professionals and patients was far more common than rejection. One remarkable characteristic that was evident as the PA profession grew in the 1970s and 1980s was the spirit of new PA graduates to prove to physicians and other health professionals that they had the capacity to be safe and effective clinicians.

This first generation of PAs, often ex-military corpsmen or others with considerable previous medical experience, typically were the first PAs to train on a particular ward or unit and/or the first to be hired by medical practices. These PAs shared a sense of belief and investment in the concept, and by dint of hard work and dedication to patient care, they convinced the medical community of their worth. Health services research done on PAs and their contributions to medical practices further confirmed their effectiveness and soon thereafter, one by one, states passed laws permitting their practice and allowing prescribing.

Following a low period in the early 1980s when a number of programs closed, and the commonly held belief was that PAs would be crowded out by the then-forecasted physician surplus, the profession began to flourish. In the early 1990s, applications to programs started to rise and many new programs were founded. In the later 1990s, growth exploded with the number of programs doubling in a span of five years and the annual output of graduates rising to nearly 5,000 per year.

Preserving Our History

Forty years on, it is remarkable to observe how fully integrated the PA has become in U.S. medical practice. Acceptance is now a given. The scope of clinical practice responsibilities and level of function of PA could not have been predicted 40 years ago. PAs work in virtually every clinical specialty and setting imaginable. In the modern era of team practice, PAs are now integral to the health care team. How this all came about is a story waiting for scholarly examination. For the next six months, as I prepare for a sabbatical leave to work in the Department of the History of Medicine at Johns Hopkins School of Medicine, my hope is to further document and analyze the emergence of the PA profession in U.S. medicine. Our history is notable, an unlikely but important success story. We must make sure that this history is preserved.

James F. Cawley is director of the PA/MPH program and professor and vice chair of the Department of Prevention and Community Health, School of Public Health and Health Services at The George Washington University in Washington. He also is professor of health care sciences at the university's School of Medicine and Health Science.