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

Introduction

In 1961, a forward-thinking physician named Charles Hudson published an article in the Journal of the American Medical Association entitled “Expansion of Medical Professional Services with Nonprofessional Personnel.” ¹ Retrospectively, this article marks the conception of a new health-care role now called the physician assistant. Attuned to the burgeoning population of Americans demanding health services, the growing complexity of medical care brought about by technologies and specialization, and the rising desire of physicians for more leisure time, Hudson conceived of providing assistants, whom he called externes, for physicians. ² These workers would assume the tasks of routine medical care, such as taking patient histories and performing basic physical examinations. A physician employer would extend his “moral and legal responsibility” to cover his externe in exchange for the externe’s extension of the physician’s arms, legs, and mind; individual physicians would be the judges of exactly how much responsibility their assistants safely could assume. Citing military medicine’s successful use of corpsmen, Hudson was optimistic that “laymen with relatively little training can be very efficient assistants.” ³ He was also aware of critics of the externe proposal who believed that the “goals of nursing could be redefined as part-nursing and part-medicine,” thus allowing nursing manpower to fill the role of the externe. However, he believed that “nursing would not find the proposal of a medicine-nursing hybrid consistent with their present goals for nurse education.” ⁴

It was another four years before Dr. Eugene A. Stead, Jr., at Duke University, transformed Hudson’s prophecy into reality by developing the first formal training program for the health-care worker that Hudson had proposed, which Stead renamed the physician assistant. ⁵ As the role developed, it hurdled nearly every obstacle that Hudson had foretold, particularly with regard to the reaction of hospital nursing administrators, nurse educators, and especially the American Nurses’ Association (ANA). Five years after the first program started, the ANA claimed that the American Medical Association (AMA) had designed the physician assistant role to sabotage the ANA’s efforts to define nurses as independent associates of physicians, rather than task-oriented “physicians’ handmaidens.” The fact that most physician assistants were male and earned salaries equal to or higher than those of more formally educated nurses was justification, according to the ANA, for characterizing the development of the physician assistant as a bit of “government supported male chauvinism.” ⁶

The ANA’s allegations represent an intriguing chapter in the story of the physician assistant and indicate the extent to which the development of the new health-care role forms a unique crossroads between the histories of medicine and nursing. Yet, if we take the ANA and the AMA’s first dialogue on the physician assistant as the starting point for understanding the physician assistant development, we distort the historical record. The concept of the physician assistant has its roots at Duke University beginning in the late 1950s, and the motivation for its creation at Duke is important not only for more accurately presenting its development, but also for interpreting organized nursing and medicine’s reactions to the new health-care role.

In the 1970s, the ANA and nurse educators were responding to the AMA’s presentation of a purported opportunity for nurses that demanded they abandon their profession to become dependent on physicians. What many nurses did not realize, however, was that the AMA’s support of the physician assistant came nearly a decade after the notion of training health-care professionals—nurses among them—for advanced clinical care became an important issue among practicing physicians like Stead in North Carolina. The AMA and the ANA’s dialogue on the physician assistant, however, casts a shadow on these years in the development of the profession, and confuses debate over the new profession with conflict between two professional organizations.

The extent to which physician assistants interposed themselves between physicians and nurses has made the history of this new profession dependent on the complex history of the relations between professional medicine and nursing. For the AMA and the ANA...