The physician assistant (PA) profession grew rapidly in the 1970s and 1990s. As acceptance of PAs in the health care system increased, roles for PAs in specialty care took shape and the scope of PA practice became more clearly defined. This report describes key elements of change in the demography and distribution of the PA population between 1967 and 2000, as well as the spread of PA training programs. Individual-level data from the American Academy of Physician Assistants, supplemented with county-level aggregate data from the Area Resource File, were used to describe the emergence of the PA profession between 1967 and 2000. Data on 49,641 PAs who had completed training by 2000 were analyzed. More than half (52.4%) of PAs active in 2000 were women. PA participation in the rural workforce remains high, with more than 18% of PAs practicing in rural settings, compared with about 20% in 1980. Primary care participation appears to have stabilized at about 47% among active PAs for whom specialty is known. By 2000, 51.5% of practicing PAs had been trained in the states where they worked. The profession has grown rapidly; 56% of all PAs were trained between 1991 and 2000. In 2000, more than 42% of accredited PA programs offered a master's degree, compared to master's degree programs in 1986. Although many critical issues of scope of practice and patient and physician acceptance of PAs have been resolved, the PA profession remains young and continues to evolve. Whether the historical contribution of PAs to primary care for rural and underserved populations can be sustained in the face of increasing specialization and higher-level academic credentialing is not clear. J Allied Health 2007; 36:1 21-1 30.
IN THE EARLY 1960s, the idea of a new type of medical health care provider began to take shape in the United States, promoted initially by physicians at Duke University. Alternatively referred to as "externes," "physician assistants (PAs)," and "medexes"1 in the early literature, the basic idea was to create a new type of care provider who would take on many of the routine and less complex aspects of health care. As conceived by early proponents of the concept, PAs would work under the direct supervision of physicians, and the scope of PA practice would be determined by the physician supervisor.1"3 Conflict arose early between the medical proponents of PAs and skeptics in both the medical and nursing communities. Some nursing associations in particular saw the PA idea as a sexist response by a predominantly male medical community to the growing independence of nurses.1 Many in medicine, including the American Medical Association, were also concerned about the proper scope of practice for Pas, prescriptive authority, and the amount of independence that PAs might have from physicians.2,4
Despite the doubts, concerns, and occasional outright hostility to the PA idea, the first PA training programs opened in the late 1960s and early 1970s3·4 and aimed to train nonphysician health care providers who would help fill expected gaps in the generalist physician workforce, especially in rural areas and in underserved urban areas. Most of the early concerns and doubts about the PA idea were quelled as PAs began to earn the confidence of patients, other health care providers, regulators, and insurers. Early health services research on PAs generally found that PAs were cost-effective and safe providers of health care.4 Through the 1980s and 1990s, the scope of PA practice expanded, educational and board certification requirements were increasingly standardized, and the regulatory environment evolved in ways that supported the expansion of the profession,4-9 including full prescriptive authority in most states.7·9 Specialty roles for PAs also emerged during the 1980s and 1990s, and by 2000 many PAs were working in surgical and medical subspecialty practices, far from the primary care specialties that provided almost all the jobs for PAs in the first years of the profession. …