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Yale’s Physician Associate Program nears 40

A medical profession that began in the 1960s has become an essential participant in health care.

In 2002, a year after graduating from high school in Brigham City, Utah, Gabriel Rocha enlisted in the U.S. Army. He decided to become a medic, in large part because the position included airborne training and he thought the idea of jumping out of planes sounded adventurous and exciting. But it wasn’t long before he got to see what a medic’s job is really about. In 2003, the United Nations headquarters in Baghdad was bombed; many of the casualties were brought by helicopter to the aid station where Rocha was deployed.

“People had been dug out of the rubble,” he recalled. “There were burns, shrapnel injuries, blunt force trauma, and head injuries.” The number of wounded was so overwhelming that even the senior medics were treating patients independently, along with the doctors and physician assistants.

Rocha worked closely with the PAs—as physician assistants have been known since the mid-1960s, when their profession was born—as well as doctors. “Basically, you couldn’t tell the difference between them, that’s how knowledgeable and professional the physician assistants were,” he said. That event, like so many others, combined with the daily occurrence of treating Iraqi civilians—including many children—who came to the aid station for care, convinced Rocha that he wanted to pursue a career as a PA.

“When I joined the military I wasn’t thinking at all about the health care field, but then I saw how rewarding it was, taking care of patients and helping people,” Rocha said. “Becoming a PA just seemed like the most direct and efficient way possible to get to do what I wanted to do, which was help others.”

Rocha, who is in his second year of Yale’s 28-month Physician Associate Program, is following a trail blazed almost 40 years ago by a previous generation of former military personnel who used medical experience acquired on the battlefield as a springboard to a civilian career in health care. (The terms physician assistant and physician associate can be used interchangeably.)

A new program fills a gap

The physician assistant profession began at Duke University in 1965; it was originally designed to train assistants who could relieve the burdens of overworked general practitioners. In the early 1960s, the Graduate Medical Education National Advisory Committee had issued a report that identified a shortage of primary care providers in rural and underserved areas. It was thought that physician assistants could help fill that gap.

At the same time, the nascent profession quickly provided an opportunity for medical corpsmen returning from Vietnam to find a civilian application for their battlefield experience. During the war, about 30,000 men with medical experience were being discharged each year; of those veterans, 6,000 had extensive medical training.

“These guys saved lives and made tremendous sacrifices,” said Alfred Sadler Jr., M.D., who served with his twin brother Blair as founding co-director of Yale’s PA program, which began in 1971. “It was a way to show our appreciation and to help them assimilate into civilian life.”

Sadler said the birth of this new medical profession was also aided by a national mood of openness toward progressive solutions to social problems. “We encountered no real obstacles to what we’d set out to do,” Sadler recalled. “The late ’60s and early ’70s was a time of great innovation in health care in the United States.” Noting the creation of the National Health Service Corps in 1972 and President Lyndon Johnson’s Great Society initiative, which had established Medicare and Medicaid in 1965 and 1966 respectively, Sadler said “there was a willingness to experiment with new health care models.”

Yale’s program got its start when Jack Cole, M.D., then the chair of surgery, received a trauma training grant from the Commonwealth Fund, a private foundation dedicated to improving the health care system. Sadler, who, along with his brother, a lawyer, had written the original 911 emergency dispatch legislation and created the region’s emergency medical service infrastructure, thought PAs would be ideally suited to emergency medical care. (In 1968 the Sadler brothers also drafted and helped implement the Uniform Anatomical Gift Act, which governs organ donations in all 50 states.) As director of Yale’s trauma program within the Department of Surgery, Sadler convinced Cole to use the grant money to create a PA program—or, as he put it, “the medical school’s first experiment in non-physician education.”

Almost four decades later, Sadler calls the experiment “a tremendous success.” The numbers would seem to support the growing popularity and acceptance of PA programs globally, as well as at Yale. In 1973, Yale graduated five students who received a certificate in physician associate studies. Since then, Yale has graduated 895 physician assistants. Nationally, 77,000 PAs are practicing in virtually all medical specialties, including surgery. There are now 145 accredited PA programs in the United States, with a growing number in foreign countries, including the United Kingdom, Canada, Japan, and many African countries studying the American PA model with an eye toward implementing something similar.

Setting the standards

Ann Bliss, R.N., M.S.W., was part of the team that launched Yale’s PA program and established national guidelines and standards. “When we got started,” she recalls, “not many leading medical schools had taken this up.”

She said the architects of Yale’s PA program set two basic rules: “One was to take college graduates.” The second rule was that “It had to be equal. We didn’t want anyone saying nursing is for girls; medicine is for boys.” They also set out to create a program that would produce leaders in the new profession, in keeping with Yale’s mission as a university.

The founders were determined to create a challenging course of study with both didactic and clerkship components. “We were one of the first programs to launch a full-fledged curriculum,” Bliss said. “We didn’t want our students to graduate without acquiring clinical skills and acumen.”

The other important ingredient for success, Bliss said, was accepting students who embraced the philosophy of the PA program. Bliss was responsible for evaluating each applicant’s psychological readiness. In addition, “I watched their backstage behavior. For instance, were they rude to the secretaries?” she said. “We wanted people who would take a more humanist approach to patient care, who were team players,” and who would work well with the doctors.

The curriculum established by Bliss and the Sadler brothers—a nine-month didactic phase followed by 15 months of clinical rotations resulting in a PA certificate—remained the same until the late 1990s. In 1995, students approached Lawrence S. Cohen, M.D., HS ’65, then special advisor to the dean, requesting that Yale PA graduates receive a master’s degree instead of a certificate. They argued that by offering a degree, Yale would be able to compete for the top students and that a Yale degree would in turn improve the graduates’ job prospects.

Cohen raised the issue with David A. Kessler, M.D., J.D., when Kessler took over as medical school dean in 1997. The new dean appointed a committee led by Walter Kernan, M.D., professor of medicine, to review the program. “The PA program had been a bit under the radar at the institution for a number of years,” Kernan said. “It was doing a great job of training PAs, but its visibility in the larger academic community of the medical school wasn’t high because it had never been fully integrated into the training of medical students and residents.”

The committee found that Yale was in the minority in giving its PA graduates certificates rather than degrees. “But we decided we didn’t simply want to grant a degree to get the best students,” Kernan said. “We wanted to grant a degree only if the curriculum warranted a graduate degree.”

After a thorough analysis of the curriculum, including comparing it to the curricula of the university’s nursing, medical, and graduate schools, the committee determined that with certain changes, a Yale PA education would be worthy of a master’s degree. Their main suggestion was that PA students should be required to write a thesis like their medical school counterparts. The program wasn’t long enough for students to conduct independent research and analyze the results; however, they could produce a finished product comparable to a biomedical research grant application.

The other recommendation was that the medical school had to take more ownership of PA training. “At the time we met, it was common practice for the PA students to get their training away from campus and away from Yale-New Haven Hospital at other hospitals and community practices,” Kernan recalled. “We felt that the faculty of the medical school needed to be more engaged in the teaching of these students.”

After the committee’s recommendations were implemented, the program grew in length to 25 months to give students time to write a thesis, and students began doing their clinical rotations alongside medical students at Yale-New Haven Hospital. In addition, it became a requirement that PA instructors have a strong affiliation with or a faculty appointment in the medical school. Directed by Associate Dean Mary Warner, M.M.Sc., PA-C, the PA program is under the umbrella of the medical school, with academic oversight from the deputy dean of education and administrative oversight from the medical school dean. Starting in 1999, PA graduates began receiving a full master’s degree.

Kernan says that the move from granting a certificate to conferring a degree was a necessary next step in the program’s coming of age. “I heard from some PA students just recently,” he said. “They said that if Yale were not granting degrees, they wouldn’t have come here.”

Another milestone for the PA program came in July 2003, when the national Resident Review Committee (RRC) mandated that resident physicians be held to an 80-hour work week. “We went into crisis mode,” said Robert Udelsman, M.D., M.B.A., the William H. Carmalt Professor of Surgery and Oncology and chair of the Department of Surgery. “If residents were held to an 80-hour work week, there was no way we could comply with our then-workload, which has since tripled.”

The solution? More PAs. There were two full-time PAs on surgical services before the RRC mandate; now there are 26. “It’s been extraordinarily successful,” Udelsman said. “It basically solved the crisis.” Beyond that, Udelsman says the presence of PAs to help with floor management of patients has benefited the physicians as well as patients. “The PAs are here long term, whereas the residents cycle through,” he said. “The PAs have played an incredibly important role in stabilizing services. They are fully integrated into our patient care model, and without them we could not function at the level that our patients and their families deserve.”

The most recent change in the PA program, which went into effect a year ago, was to extend it from 25 to 28 months. The three extra months were added to the didactic phase to enable instructors to cover all the material that is now required. “We found it increasingly difficult to cover all the mandated topics,” said PA Program Director Warner, “and we also wanted to reduce the stress on our students and give them enough time to participate in the Yale community.”

Assistant v. associate

Yale may have joined the majority of PA programs a decade ago in offering a master’s degree, but it has remained resolutely independent when it comes to the name of the Yale program—for reasons that run deeper than mere tradition. In the early days, more than half the PA programs nationally were called physician associate programs, but as time went on, the preferred term became physician assistant, which is the term used by the American Medical Association (AMA).

“It comes up for debate within the profession every five years or so,” said Warner, “But we feel that assistant sounds hierarchically lower and that associate is a more accurate reflection of the PA’s role with respect to patients and physicians. Our program is called physician associate, because that’s what it was called when it started, and I’m not changing the name; the alumni would revolt.”

But this debate enters into a deep current that runs through the profession—one that seeks healthy relationships between men and women, care and cure, colleagues and subordinates.

From the outset, there were those who questioned the need for another allied health profession. After all, nurses, a known quantity to both physicians and patients, had successfully been carrying out many of the same functions for years. Indeed, as early as 1969, the AMA had held discussions with the American Nurses Association about the possibility of nurses becoming physician assistants. The women’s liberation movement was starting to resonate with professional women, however, and the nurses emphatically rejected the proposal for fear that they would become handmaids of patronizing male physicians. That refusal to broaden the scope of their practice led directly to the creation of the new midlevel profession of physician assistant, which was largely male-dominated in its beginning.

The profession of nurse practitioner was established at around the same time as the PA program; however, the two programs have different curricular emphases, according to Warner. “We emphasize medical sciences in PA training, similar to the medical school model,” she said, “whereas advanced practice nursing emphasizes integration of the physical and psychosocial assessment, health promotion, and disease management. Another difference in the two professions is that PAs work with physician supervision while nurse practitioners may opt for independent practice in many parts of the country. ”

When the PA program got started, the majority of students were military veterans, but as time has passed the profession has become feminized as women have turned to it as a way to strike a balance between a meaningful career in health care and family life.

Warner, who became a certified PA in 1992, is one such woman. She had planned to become a doctor since she was a child of 10. After college, she worked for two years in a health care environment to gain some experience and pay off student loans. It was then that she met her first PA and became intrigued. She began to weigh the years of medical training required to become a physician against her desire to raise children and decided that becoming a PA was the better route to take.

“I thought this would be a very efficient way to do a lot of what I love without having to turn off or postpone the rest of my life,” she said. Has it been a good decision? “Absolutely.” The added plus, which Warner didn’t foresee when she started out, is that unlike medical students, who must choose a specialty, PAs train in a generalist model. That means that they can move from one specialty to another with on-the-job training from a supervising physician.

After getting her PA degree from Emory University School of Medicine Physician Assistant Program, Warner worked in orthopaedic surgery for three years. Then she switched to cardiac surgery for five years before returning to orthopaedic surgery. When she came to Yale, she worked in emergency medicine.

Mathew Simmons, M.M.Sc., PA-C ’06, went so far as to apply to and get accepted by a medical school, Florida State University College of Medicine, before deciding to become a PA instead. “The summer before my senior year, I volunteered in an operating room at a local hospital,” Simmons recalled. “The whole time I didn’t feel great about medical school. Then I got engaged and realized I wanted to put my family and home life first. My stepdad is a doctor, so I know how much you have to sacrifice.”

Simmons, who works in a gastroenterology practice in Florida, has no regrets about not going to medical school. “I still have plenty of responsibility, and I take care of patients every day,” he said. “It’s very challenging and intellectually stimulating.” The only downside, Simmons said, is the frequently asked question, ‘Are you going to go on and become a doctor?’ “I have to tell them, no, that’s not how it works. It’s a little annoying, but you get used to it.”

According to Warner, about 92 percent of Yale’s PA students receive some form of financial aid, compared to 83 percent of medical students. “If you look at who we train, our students have smaller parental contributions with less money, so time and money are important factors.”

Warner said many people who apply to become PAs are looking for second careers. Thea Cogan-Drew, who enrolled in Yale’s program in 2007 and will graduate in December, worked as a photographer, graphic designer, and art director for several years before she “hit a plateau,” and began looking for a more satisfying career.

“I explored a lot of career options before coming to medicine,” she said. “Then, based on where I was in my life personally and professionally (she is the mother of a 4-year-old son and pregnant with her second child), I decided that the PA degree was the best route for me, as opposed to medical school.”

The National Commission on Certification of Physician Assistants estimates that PAs do 80 to 90 percent of what physicians do but bill at 15 percent less. As the nation grapples with ways to overhaul the health care system to make it more accessible and affordable, many people see an expanded role for physician assistants as a key part of the solution. “From the country’s point of view, it’s an incredibly important program,” said medical school Dean Robert J. Alpern, M.D., Ensign Professor of Medicine.

“Access to cost-effective care is who we are,” said John Bond, PA-C ’76, who has worked as a PA in Vermont since his graduation. “We’re talking about people who are interested in providing care to patients in underserved areas and training those people in less time and at a lower cost. What isn’t there to like about what PAs can do in this time of health care crisis?” YM