For a half-century, Yale's Physician Associate Program has evolved with the times

WHEN BURDEEN CAMP, PA-C ’73, entered Yale School of Medicine’s (YSM’s) newly established Physician Associate (PA) Program in 1971, she knew she was embarking on a journey into unknown territory. “The fun part of starting a new profession is that what we were going to be was undefined,” she recalls. “I just knew that I wanted to take care of patients.” At the age of 22, she was the youngest student in the program—and the only woman.

Today, as Yale celebrates the 50th anniversary of its first graduating class of PAs in 1973, which included Camp, the role of the PA has evolved into an essential part of a patient-centered health care team. With a broad scope of practice, PAs deliver care across all settings, from primary care to medical and surgical specialties. Working on a team along with physicians, nurse practitioners, nurses, and other health care professionals, they have the capacity to order and interpret tests, diagnose conditions, formulate treatment plans, prescribe medications, counsel, and maintain the health of patients. In the past 50 years, Yale has graduated more than 1,400 physician associates—and, now, most of the graduates are women.

In Camp’s time, that was not the case. “The profession grew out of the military in the mid-1960s,” says Alexandria Garino, PhD, PA-C, associate dean for Physician Associate and Assistant Education at Yale School of Medicine. Vietnam veterans, mostly male and particularly those who served as medics, found themselves returning home without any professional outlet for their new clinical skills; at the same time, the country was suffering significant physician shortages.

At Yale during this time, Jack Cole, MD, Ensign Professor of Surgery and chair of the Department of Surgery, saw a need to address what he viewed as the troubled state of emergency medical care and nationwide issues in the field of trauma response. In 1969, Cole started Yale’s first program to train physician assistants, which Yale named the Physician Associate Program. He recruited Paul Moson, PA, MBA, a graduate of Duke’s second PA class, along with collaborator and co-founding director Alfred Sadler, MD. As one of the first PA programs in the United States, Yale’s was the first to emphasize acute and emergency care, while maintaining a generalist focus. “The Yale Physician Associate Program is not only one of the oldest in the country, but it is also unique in its focus on critical thinking and leadership in teams,” adds Nancy J. Brown, MD, the Jean and David W. Wallace Dean of the Yale School of Medicine and C.N.H. Long Professor of Internal Medicine.

Creating a profession’s scope of practice

Students in Yale’s first class, like Camp, had a role in shaping what the role of the PA would look like going forward, and in determining how a health care professional, who was neither a doctor nor a nurse but a knowledgeable medical provider, was going to be integrated into patient care. “We had never seen what we thought we were going to be in action, in a clinical sense,” says Camp. “The first challenge was to prove to the established medical community that we were thinking medical professionals, capable of formulating a differential diagnosis and ordering the appropriate tests to diagnose a problem.”

Camp, like many Yale PA graduates in the past 50 years, rose to the challenge. She became a leader in the field who, in turn, trained other PAs as the role gradually became established, and the number of PAs and PA programs grew throughout the country. In addition to Camp’s clinical practice as an oncology PA, she joined the faculty at Yale and advocated for the profession on a state and national level, serving as speaker of the American Academy of Physician Assistants House of Delegates from 1983 to 1984. She was also a founding member of the Connecticut Academy of PAs and the Connecticut Physician Assistant Foundation. Today, she is retired from the PA profession and coordinates a large team of medical volunteers for the Special Olympics of Connecticut.

“Our program’s most important contribution to health care and to the profession is our alumni,” says Garino. “Our alumni are outstanding clinicians and leaders in their communities and nationally, working to improve the health of patients and populations. Early alumni were pioneers who created the profession’s first scope of practice regulations as they cared for patients. They had to break down many barriers and demonstrate the value of the profession.”

That forward-thinking effort continues today. The program counts among its alumni many PA educators, leaders of health centers, heads of professional organizations, researchers (including a MacArthur Fellow), and many who work to improve the health of patients and influence health policy.

Leveraging the power of interprofessional collaboration

Though the Yale PA Program’s education of PAs has evolved in the past years in step with changes in medical knowledge and health care delivery, the early tenets of the program remain largely in place. As it did from the program’s early days, Yale maintains its focus on training medical generalists. “Even though many PAs work in specialized areas of medicine, PAs apply a broad understanding of medicine to every patient encounter,” says Garino. “We continue to educate PAs with a focus on critical thinking and team-based care, graduating competent clinicians in 28 months because we focus on the fundamental skills needed to provide evidence-based, holistic care to patients.”

The curriculum offers a solid foundation in various aspects of medical knowledge, explains David Brissette, MMSc, PA-C, assistant professor in the Physician Associate Program and the program’s interim director. “We provide an integrated curriculum that combines basic science, clinical medicine, and professional skills development to help students understand the interconnectedness of medical knowledge,” says Brissette.

Meanwhile, the program also has implemented innovative changes that set it apart and helps further develop the role of the PA as an integral team member in patient care. For example, interprofessional education allows PAs to train side-by-side with physician and nursing trainees at Yale. The Interprofessional Longitudinal Clinical Experience (ILCE) course, developed as a collaboration between the Yale School of Medicine and the Yale School of Nursing, began as a pilot course in 2014 and became part of the firstyear curriculum in 2017.

In the ILCE course, PA, medical, and nursing students learn alongside each other in a variety of settings, including clinical experiences, small groups, history taking, physical exams, oral presentation skills, and early clinical reasoning. “We aim to build bridges early in the training in the hope that they are better able to work collaboratively, in order to prepare them for the real world in which collaboration and teamwork are essential,” says Brissette.

Will Cushing, PA-C, MMSc ’02, graduated from the program before the inclusion of ILCE, but in his professional capacities exemplifies the role PAs play coordinating care across professions. While in clinical practice as a PA hospitalist at Yale New Haven Hospital (YNHH), he also serves as YNHH’s executive director of Hospital Medicine, leading a variety of medical professionals, including PAs and nurse practitioners. He also acts as a clinical instructor in ILCE. “The Yale PA program’s history of promoting interprofessional collaboration has been instrumental in allowing me to be effective in my clinical, educational, and administrative responsibilities,” says Cushing.

Meeting changing needs in the community

Going forward, PA education at Yale continues to evolve and adapt to the changing medical landscape, with an emphasis on compassionate, culturally sensitive care. PA education at Yale, says Garino, will maintain its focus on creating an inclusive learning community that values diversity. “We recognize that patients have better outcomes when clinicians understand the nuances of a patient’s experience,” says Garino. “So we are working to refine the systems and structures needed to diversify the Yale PA community and educate our students on the importance of health justice and equity.” As health care becomes increasingly team-led, and as the PA profession takes root internationally, the program also will continue to provide robust clinical learning experiences that provide students with a global understanding of health care and its challenges.

There is no doubt PAs have come a long way in 50 years. Burdeen Camp recalls that when she decided to enter the Yale program in 1971, she saw an “unfortunate” article in Life magazine examining the new PA profession, titled “Less than a Doctor, More than a Nurse.”

“That magazine doesn’t even exist anymore,” scoffs Camp, yet the PA soldiers on.