"Confusion's Masterpiece": The Development of the Physician Assistant Profession

Bulletin of the History of Medicine

Volumn 72, Issue 2, 1998, Pages 246-278

  Holt, Natalie ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; HISTORY; HUMAN; MEDICAL SOCIETY; PHYSICIAN ASSISTANT; PUBLIC RELATIONS; UNITED STATES;

AMERICAN MEDICAL ASSOCIATION; AMERICAN NURSES' ASSOCIATION; HISTORY, 20TH CENTURY; HUMANS; INTERPROFESSIONAL RELATIONS; PHYSICIAN ASSISTANTS; UNITED STATES;

EID: 0032091086     PISSN: 00075140     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Article

References (135)

1. Charles L. Hudson, "Expansion of Medical Professional Services with Nonprofessional Personnel, "JAMA, 1961, 176: 839-41. Dr. Hudson, who was president of the American Medical Association from 1965 to 1967, prefaces this article with the statement that it does not reflect the opinions of any particular AMA committee. Nevertheless, he does indicate that the AMA's Council on Medical Service, a Special Study Committee investigating the country's physician shortage, the Committee on Nursing, and the Commission on the Cost of Medical Care have been studying several of the issues that have motivated his conception of the externe.
2. Ibid., p. 840. Hudson suggested the term externe to contrast with the medical intern, the name given to physicians during their first year working in the hospital.
3. Ibid., p. 840.
4. Ibid., p. 841.
5. While the original title for the new role was "physician's assistant," the "'s" does not always appear in the literature and was in fact a point of much controversy: to some, it correctly stressed the physician-dependence of the new health-care worker; to others, it was a hassle and a matter of semantics. Later, the term "physician associate" becomes more common, despite a concern that physicians frequently refer to their physician colleagues as "associates." In this paper, the term physician assistant will be used.
6. Hildegard E. Peplau to Richard J. Eales, 6 March 1972, Hildegard E. Peplau Papers, Schlesinger Library, Radcliffe College, Cambridge, Mass. Dr. Peplau's reference to governmental support alludes to the government money assigned to physician assistant training programs in the 1970s, in legislative acts such as the Comprehensive Health Manpower Training Act of 1971 and the National Health Planning and Resources Development Act of 1974.
7. Hildegard E. Peplau, memorandum to presidents and executive directors of State Nurses' Associations, 20 March 1970, Peplau Papers. See also "AMA Unveils Surprise Plan to Convert R.N. into Medic," Amer. J. Nursing, 1970, 70: 691; 724-27.
8. Hildegard E. Peplau, memorandum to presidents and executive directors of State Nurses' Associations, 20 March 1970, Peplau Papers. See also "AMA Unveils Surprise Plan to Convert R.N. into Medic," Amer. J. Nursing, 1970, 70: 691; 724-27.
9. William W. McClure, "'Medics Make the Best Assistant Doctors,'" Med. Econ., 28 October 1968, 45: 222-27, quotation on p. 222.
10. Peplau memorandum (n. 7). Also partially quoted in "AMA Unveils Surprise Plan" (n. 7), p. 691.
11. Quoted in Peplau memorandum (n. 7).
12. American Medical Association, 1969-1978, Digest of Official Actions of the American Medical Association (Chicago: American Medical Association, 1980), p. 282.
13. Ibid., p. 282.
14. Ibid., p. 282.
15. Ibid., p. 283.
16. Hildegard E. Peplau, "The Road Ahead" (keynote address to the Maine State Nurses' Association, 56th Annual Convention, 31 August 1970), Peplau Papers.
17. Hildegard E. Peplau and Gerald A. Dorfman, "Report of ANA's Financial Situation," 28 April 1970, Peplau Papers.
18. Hildegard E. Peplau, "Commitment to Change: A Challenge for the '70s" (paper presented at the Sixth Inter-University Faculty Work Conference, Nechen, Round Hills, South Dartmouth, Mass., 13 June 1970), Peplau Papers.
19. "RN Survey: The Nurse as a Working Professional," RN, July 1968, 31: 35.
20. "RN Survey: How the Nurse Views Nursing and Its Problems," RN, July 1968, 31: 37-40.
21. In handwritten notes taken on a 1972 draft paper entitled "The Demise of Nursing Is Being Predicted - by Nurses and Non-Nurses" (Peplau Papers), Hildegard Peplau scribbled "(Phys. Asst. decision by AMA Trustees - Jan 70 -Thought ANA would fold)."
22. Peplau to Janice Gleason, 26 February 1970, Peplau Papers.
23. Peplau, "Commitment to Change" (n. 17).
24. Ibid.
25. American Academy of Physician Assistants (henceforth AAPA), "Physician Assistant and Surgical Assistant: Dates of Programs Initial Accreditation" (Alexandria, Va.: AAPA, 1994, photocopy).
26. Eugene A. Stead, "Dependence versus Independence and Its Relationship to the Professional Physician's Assistant" (paper presented to the Duke Physician Assistant Conference, Durham, N.C., December 1970), Eugene A. Stead, Jr., M.D., Papers, Duke University Archives, Depository for Medical Center Records, Duke University, Durham, N.C.
27. Eugene A. Stead, interview by Barton F. Haynes, 7 June 1991, transcript, Stead Papers.
28. Eugene A. Stead, interview by author, 3 December 1994.
29. According to an August 1969 article by Donna M. Ledney entitled "Is There a Nurse-Clinician Job in Your Future?" which appeared in RN (August 1969, 32: 34-43) the ANA had not yet taken a stand on the nurse-clinician movement.
30. Stead, interview by author (n. 27).
31. Ibid.
32. Ibid.
33. Ibid.
34. Ibid.
35. Duke had a similar problem with the NLN accrediting its baccalaureate nursing program, which called for a short clinical internship. Duke Nursing School chose to eliminate the program in order to gain accreditation (Ruby Wilson, interview by author, 2 December 1994).
36. Ibid.
37. Ibid.
38. Ibid. The principle of the Hanes Ward was not new. In the late 1920s and 1930s, some hospitals began experimenting with group nursing. As described by Susan Reverby, "hospital patients were 'grouped' in units and cared for by a special cadre of nurses. The system was not unlike what had been called 'divisional specializing' during the nursing shortage of World War I where several patients shared a private nurse. . . . In some ways it was a subcontracting system under which the hospital paid the nurse's wages, but charged the patient directly for this service over and above their hospital bill" (Susan Reverby, Ordered to Care: The Dilemma of American Nursing, 1850-1945 [Cambridge: Cambridge University Press, 1987], pp. 184-85). The concept of group nursing ultimately failed in part because hospital administrators balked at the expense of this system of care-giving, although it was well received by patients, physicians, and nurses.
39. Ibid. The principle of the Hanes Ward was not new. In the late 1920s and 1930s, some hospitals began experimenting with group nursing. As described by Susan Reverby, "hospital patients were 'grouped' in units and cared for by a special cadre of nurses. The system was not unlike what had been called 'divisional specializing' during the nursing shortage of World War I where several patients shared a private nurse. . . . In some ways it was a subcontracting system under which the hospital paid the nurse's wages, but charged the patient directly for this service over and above their hospital bill" (Susan Reverby, Ordered to Care: The Dilemma of American Nursing, 1850-1945 [Cambridge: Cambridge University Press, 1987], pp. 184-85). The concept of group nursing ultimately failed in part because hospital administrators balked at the expense of this system of care-giving, although it was well received by patients, physicians, and nurses.
40. Ruby Wilson, interview by author (n. 34).
41. Ibid.; Stead, interview by author (n. 27).
42. Ibid.; Stead, interview by author (n. 27).
43. Stead, interview by author (n. 27).
44. Thelma Ingles to Alfred M. Sadler, Jr., 16 December 1971, Stead Papers.
45. The Physician's Assistant: A Synopsis (Durham, N.C.: Department of Community Health Sciences, Duke University Medical Center, 1968), p. 1.
46. Dr. Robert Howard at Duke explains that Dr. Stead did not want to use the word nurse in his description of the new health-care role because he wanted the profession to be accessible to men as well as women: see D. Robert Howard, interview by James Gifford, 1991, transcript, Physician's Assistant Program Papers, Duke University Archives, Depository for Medical Center Records, Duke University, Durham, N.C. Also during this period, the results of a Gallup Poll indicated that 99 percent of those surveyed believed that women made better nurses than men. Nursing was considered the most sex-stereotyped profession in the country. See Judith A. Chancy and Patrick Folk, "A Profession in Caricature: Changing Attitudes toward Nursing in the American Medical News, 1960-1989," Nursing Hist. Rev., 1993, 1: 181-202.
47. Luther Christman, letter to author, 10 November 1994.
48. E. Harvey Estes, interview by author, 30 November 1994.
49. Ruby Wilson, interview by author (n. 34).
50. Stead to Charles H. Frenzel, 24 April 1964, Stead Papers.
51. Eugene A. Stead, "Medical Education and Practice," Ann. Intern. Med., 1970, 72: 271-74, quotation on p. 273.
52. Stead, interview by author; William W. McClure, "A 'Medic' in General Practice," Med. Econ., 15 May 1967, 44: 72-78. While Dr. Johnson was in the office, he charged his full fee for patient services. If Mr. Treadwall worked alone, patients were charged 50 percent of Dr. Johnson's fee. Mr. Treadwall, however, worked on a fixed salary with a bonus. See McClure, "'Medic' in General Practice," pp. 77-78.
53. Stead, interview by author; William W. McClure, "A 'Medic' in General Practice," Med. Econ., 15 May 1967, 44: 72-78. While Dr. Johnson was in the office, he charged his full fee for patient services. If Mr. Treadwall worked alone, patients were charged 50 percent of Dr. Johnson's fee. Mr. Treadwall, however, worked on a fixed salary with a bonus. See McClure, "'Medic' in General Practice," pp. 77-78.
54. D. Robert Howard and C. Emil Fasser, "A Progress Report on Duke University's Physician's Assistant Program," Hosp. Progress, February 1970, 51: 48-55.
55. Roland H. Berg, "More than a Nurse, Less than a Doctor," Look, 6 September 1966, p. 59.
56. Kathleen Andreoli, interview by James Gifford, 1991, transcript, Physician's Assistant Program Papers. The author's personal interviews with Dr. E. Harvey Estes, Dr. Eugene A. Stead, and Dr. Ruby Wilson confirm that Andreoli's decision to train physician assistants was not looked upon favorably by many nursing leaders at Duke.
57. Estes, interview by author (n. 45).
58. Stead, interview by author (n. 27).
59. Alfred M. Sadler, Jr., Blair L. Sadler, and Ann A. Bliss, The Physician's Assistant -Today and Tomorrow, 2d ed. (Cambridge, Mass.: Ballinger, 1975), p. 4.
60. Eugene A. Stead, untitled paper, 1964, Stead Papers.
61. Eugene A. Stead, "Training and Use of Paramedical Personnel," N. Engl. J. Med., 1967, 277: 800-1, quotation on p. 801.
62. John J. McQueary to Stead, 14 July 1976, personal collection of Dr. Eugene A. Stead.
63. Stead, interview by author (n. 27).
64. Stead, "Dependence versus Independence" (n. 25).
65. Ibid.
66. Stead, interview by author (n. 27).
67. Sam Ralston, quoted in Eugene Stewart Schneller, The Physician's Assistant: Innovations in the Medical Division of Labor (Lexington, Mass.: Lexington Books, 1978), p. 79.
68. Robert Sigmond, quoted in Department of Health, Education, and Welfare, Nursing Manpower Programs (Washington, D.C.: Government Printing Office, 1968), p. 43.
69. Eugene A. Stead, "The Physician's Assistant - Job Description and Licensing," Med. Times, August 1969, 97: 247.
70. Lester Velie, "Where the Jobs Are - Health Careers Unlimited," Reader's Digest, August 1965, pp. 108-12.
71. James Mau, interview by James Gifford, 1991, transcript, Physician's Assistant Program Papers.
72. Stead, interview by author (n. 27).
73. Mau, interview by James Gifford (n. 67).
74. Victor Germino, interview by James Gifford, 1991, transcript, Physician's Assistant Program Papers.
75. Germino to Stead, 2 August 1976, private collection of Dr. Eugene A. Stead.
76. Estes, interview by author (n. 45).
77. Physician Assistant: History of a Health Manpower Innovation, videocassette, 35 min., Physician Assistant Foundation and Duke University Medical Center, 1993.
78. Ibid.
79. Eugene A. Stead, "At Duke: A New Approach to the Doctor Shortage," Resident Physician, February 1967, 13: 93.
80. Ibid., p. 84.
81. Dr. Smith called the newly trained corpsman a "Medex," a term he derived from the French médecin extension, meaning "extension of the physician." See Steve Murata, "Medex: Another Answer to the Physician Shortage?" JAMA, 1970, 211: 572, 573, 577-79, quotation on p. 573.
82. Ibid., p. 577.
83. Lorraine Clare Pohutsky, "The Origin and Development of Physician's Assistant Programs in the United States (1960-1979)" (Ed.D. diss., Teachers College, Columbia University, 1982), p. 41; "The Physician's Assistants - An Inside Look at Three Programs," RN, October 1970, 33: 36-42; Henry K. Silver, Loretta C. Ford, and Susan C. Stearly, "A Program to Increase Health Care for Children: The Pediatric Nurse Practitioner Program," Pediatrics, May 1967, 39: 756-60.
84. Lorraine Clare Pohutsky, "The Origin and Development of Physician's Assistant Programs in the United States (1960-1979)" (Ed.D. diss., Teachers College, Columbia University, 1982), p. 41; "The Physician's Assistants - An Inside Look at Three Programs," RN, October 1970, 33: 36-42; Henry K. Silver, Loretta C. Ford, and Susan C. Stearly, "A Program to Increase Health Care for Children: The Pediatric Nurse Practitioner Program," Pediatrics, May 1967, 39: 756-60.
85. Lorraine Clare Pohutsky, "The Origin and Development of Physician's Assistant Programs in the United States (1960-1979)" (Ed.D. diss., Teachers College, Columbia University, 1982), p. 41; "The Physician's Assistants - An Inside Look at Three Programs," RN, October 1970, 33: 36-42; Henry K. Silver, Loretta C. Ford, and Susan C. Stearly, "A Program to Increase Health Care for Children: The Pediatric Nurse Practitioner Program," Pediatrics, May 1967, 39: 756-60.
86. Stead, interview by author (n. 27).
87. "Once a Medic, Now a Medex," Life, 12 June 1970, p. 67.
88. Gary Stix, "Call Me??" Health Practitioner, July/August 1977, 1: 21.
89. Ibid.
90. Schneller, Physician's Assistant (n. 63), p. 26.
91. Carroll Cihlar, "The Physician's Assistant: Stephen L. Joyner, P.A.," Hospitals, 1 June 1971, 45: 52-57, quotation on pp. 54-55.
92. Robert L. Kane et al., "Communication Patterns of Doctors and Their Assistants," Med. Care, April 1976, 14: 348-56, quotation on p. 355.
93. Schneller, Physician's Assistant (n. 63), p. 5.
94. Thelma Ingles, "A New Health Worker," Amer. J. Nursing, 1968, 68: 1059-61, quotation on p. 1060.
95. Stead, interview by author (n. 27).
96. Thomas C. Points, quoted in "The Physician's Assistant: Why They're Needed," RN, October 1970, 33: 35.
97. The minutes of AMA meetings are not open for public scrutiny. The Digest of Official Actions and Proceedings of the AMA do not document discussion and debate; they only summarize council reports and print passed resolutions. In 1970, a Carnegie Commission report publicized the need to increase the number of graduating physicians to prevent a nationwide physician shortage that seemed to threaten efficient health-care delivery. The publicity of the report may have shocked the AMA into action, much as the 1910 Flexner Report had done.
98. Estes, interview by author (n. 45).
99. Peplau memorandum (n. 7).
100. x for the Family-Doctor Shortage," Reader's Digest, July 1970, p. 104.
101. Ibid.
102. Estes, interview by author (n. 45).
103. Martha E. Rogers, "Nursing: To Be or Not to Be?" Nursing Outlook, January 1972, 20: 42-46.
104. Ibid.
105. Eleanor C. Lambertsen, "Not Quite MD, More than PA," Hospitals, 1 December 1971, 45: 70-76; 136.
106. AAPA, "Milestones in PA History" (Alexandria, Va.: AAPA, 1994, photocopy).
107. Peplau memorandum (n. 7).
108. Roger O. Egeberg and Leroy A. Pesch, "The Roles for Nurses," JAMA, 1972, 220: 1237-38, quotation on p. 1237.
109. Ingles to Alfred Sadler, 16 December 1971, Stead Papers.
110. Barbara Bates, "Doctor and Nurse: Changing Roles and Relations," N. Engl. J. Med., 16 July 1970, 283: 129.
111. Eli Ginzberg, Men, Money, and Medicine (New York: Columbia University Press, 1969), p. 153.
112. Hildegard E. Peplau, untitled (handwritten draft of paper to be delivered at the "Women Unlimited" Symposium, Vanderbilt Univ., 19-20 Nov., 1970), Peplau Papers.
113. Peplau, "Road Ahead" (n. 15).
114. Schneller, Physician's Assistant (n. 63), p. 17.
115. U.S. Congress, Committee on Interstate and Foreign Commerce, Nurse Training Act of 1974 (Washington, B.C.: Government Printing Office, 1974), p. 14.
116. Lynda Van Devanter, Home Before Morning: The Story of an Army Nurse in Vietnam (New York: Beaufort Books, 1983), p. 85.
117. Ibid., p. 86.
118. Abraham B. Bergman, "Physician's Assistants Belong in the Nursing Profession," Amer. J. Nursing, 1971, 71: 975-77, quotations on p. 975.
119. One of the earliest evaluations of the physician assistant concept concluded that the "availability of enough nurses would damp enthusiasm for a new group of assistants" (Robert D. Coye and Marc F. Hansen, "The 'Doctor's Assistant': A Survey of Physicians' Expectations," JAMA, 1969, 209: 529-33, quotation on p. 530). See also Joseph Kadish and James W. Long, "The Training of Physician Assistants: Status and Issues," JAMA, 1970, 212: 1047-51.
120. One of the earliest evaluations of the physician assistant concept concluded that the "availability of enough nurses would damp enthusiasm for a new group of assistants" (Robert D. Coye and Marc F. Hansen, "The 'Doctor's Assistant': A Survey of Physicians' Expectations," JAMA, 1969, 209: 529-33, quotation on p. 530). See also Joseph Kadish and James W. Long, "The Training of Physician Assistants: Status and Issues," JAMA, 1970, 212: 1047-51.
121. National Academy of Sciences, Allied Health Personnel: A Report on Their Use in the Military Services as a Model for Use in Nonmilitary Health-Care Programs (Washington, D.C.: National Academy of Sciences, 1969), p. 5.
122. Ibid., p. 4.
123. Quoted in Pohutsky, "Origin and Development of Physician's Assistant Programs" (n. 79), p. 51.
124. Ingles to Sadler, 16 December 1971, Stead Papers.
125. Hildegard Peplau, quoted in "PULSEbeat" (New Jersey State Student Nurses Association), 1 November 1970, Peplau Papers.
126. Thelma Ingles and Eugene A. Stead, "The Future of the Art of Nursing" (position paper written as a grant proposal to the Robert Wood Johnson Foundation, 20 September 1974), Stead Papers. Ingles and Stead used the phrase "confusion now hath made her masterpiece" to describe the history of nursing education. The phrase, which inspired the title of this article, is from William Shakespeare's Macbeth, 2.3.72.
127. Ibid.
128. AAPA, "1994 Mid-Year Census Report on Physician Assistants" (Alexandria, Va.: AAPA, 1994, photocopy); AAPA, "Physician Assistants: Partners in Medicine" (Alexandria, Va.: AAPA, 1994, photocopy).
129. AAPA, "1994 Mid-Year Census Report on Physician Assistants" (Alexandria, Va.: AAPA, 1994, photocopy); AAPA, "Physician Assistants: Partners in Medicine" (Alexandria, Va.: AAPA, 1994, photocopy).
130. AAPA, "1994 Mid-Year Census Report" (n. 121).
131. AAPA, "Physician Assistants" (n. 121).
132. Ibid.
133. Linda J. Pearson, "Annual Update of How Each State Stands on Legislative Issues Affecting Advanced Nursing Practice," Nurse Pract., January 1994, 19: 11-21.
134. Lisa M. Wyatt, memorandum to ANA Board of Directors, SNA [State Nurses' Association] Presidents, SNA Executive Directors, and SNA Media Liaison List, 1 December 1993. This memo was provided to the author by a nurse-practitioner who is also a member of the ANA.
135. Ibid.