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Physician Assistant Education in the United States
 

Physician Assistant Education in the United States

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    Physician Assistant Education in the United States Physician Assistant Education in the United States Document Transcript

    • Physician Assistants Physician Assistant Education in the United States P. Eugene Jones, PhD, PA-C Abstract As physician assistant (PA) programs average and 29 months of prior health Although the PA profession has prospered developed in the 1960s, curriculum care experience who matriculated since inception, concerns exist regarding models emerged around the central with a baccalaureate degree into a workforce issues such as the appropriate themes of physician-dependent practice master-degree PA program. In the balance of autonomy and supervision, and competency-based education. 2005 application cycle, the number of role delineation, and the continuing By 2007, there were 136 accredited applicants per available seat was 2.25 trend toward specialization. The omission programs in the United States, with for both allopathic medical schools or inaccurate classification of PAs within 108 (79%) offering a master-degree and PA programs. The transition to a U.S. health care access and workforce curriculum. PA program preclinical and predominately master-degree curriculum literature projects an incomplete picture, clinical curricula are typically evenly resulted in new challenges for PA faculty and it is important to consider the divided in length, and the typical U.S. development, and the number of PA contributions PAs have made and will PA program has a full-time attendance educators with terminal academic continue to make in addressing the curriculum of 26.5 continuous months. degrees continues to lag behind the nation’s health care needs. In academic year 2005–2006, the typical educational needs of training programs. PA student was a 27-year-old white The topic of PA specialty training and Acad Med. 2007; 82:882–887. woman with a 3.4 overall grade point recognition remains controversial. Editor’s Note: A Commentary on this Article Dr. Charles L. Hudson proposed and this tenet has continued to serve as a appears on page 827. “assistants to doctors” as a new health founding principle of the PA profession.4 I n this article, I describe what began 40 care provider model to work only with physician supervision and not as According to the American Academy of Physician Assistants (AAPA), PAs are years ago as a social and health workforce independent providers.2 This idea was defined as experiment with the introduction of the generally met with approval by the physician assistant (PA) profession in the medical community, and in 1965 the PA health care professionals licensed to United States. To explain how and where concept materialized when Dr. Eugene practice medicine with physician PAs fit into the U.S. health care system, I supervision. PAs employed by the Stead of Duke University School of federal government are credentialed to discuss perspectives on accreditation Medicine started the first program. He practice. As part of their comprehensive elements and workforce and educational proposed that PAs “would be trained to responsibilities, PAs conduct physical demographics, as well as political and assist the doctor . . . in such a way as to exams, diagnose and treat illnesses, order controversial topics. facilitate better utilization of available and interpret tests, counsel on preventive physicians and nurses.”3 health care, assist in surgery, and in virtually all states can write prescriptions. Historical Background Within the physician–PA relationship, By the late 1960s, combat-experienced PAs exercise autonomy in medical decision Beginning in the early 1960s, the decline medical corpsmen were returning from making and provide a broad range of in general practice physicians in the Vietnam with no equivalent civilian career diagnostic and therapeutic services. A United States led to commissioned pathway, and the PA profession became PA’s practice may also include education, reports encouraging the development of a desirable workforce opportunity for research, and administrative services.5 family practice residency programs.1 veterans with advanced medical skills. During the same period, an additional Fueled by the increasing public demand Emergence of PA educational programs response was suggested: in a 1961 address for access to health care services, the PA to an American Medical Association As new PA programs continued to concept continued to evolve.4 (AMA) conference on medical education, develop through the 1960s, similar curriculum models emerged around the Commitment to the central themes of physician-dependent physician-dependent relationship practice and competency-based Dr. Jones is professor and chairman, Department of Physician Assistant Studies, UT Southwestern While the Duke curriculum was being education. What began as a student Medical Center, Dallas, Texas. developed, a ruling was obtained from population of predominantly male Correspondence should be addressed to Dr. Jones, the office of the North Carolina Attorney military veterans became a more diverse Department of Physician Assistant Studies, UT General regarding the role PAs would mix as the Vietnam era passed. By 1971, Southwestern Medical Center, 5323 Harry Hines have in relation to the Medical Practice there were 16 PA programs, with many Blvd., V4.114, Dallas, TX 75390-9090; telephone: (214) 648-1710; fax: (214) 648-1003; e-mail: Act. The ruling stated that PA practice based on the Duke model and hosted (eugene.jones@utsouthwestern.edu). would not include independent authority, at university medical centers such as 882 Academic Medicine, Vol. 82, No. 9 / September 2007
    • Physician Assistants those at the University of Alabama at 1985 (P.L. 99 –129) required federally- their compliance with the standards. Birmingham, Bowman Gray University, funded PA programs to emphasize Collaborating member organizations that Emory University, George Washington primary care training and deployment. collectively monitor and assess program University, University of Oklahoma, The next year, passage of the Omnibus compliance are the American Academy of Johns Hopkins University, and Yale Budget Reconciliation Act of 1986 Family Physicians (AAFP), the American University.6 Federal funding via the (P.L. 99 –509) authorized Medicare Academy of Pediatrics (AAP), the AAPA, Comprehensive Health Manpower Act of reimbursement for PA services in the American College of Physicians 1972 enabled a rapid increase in new PA hospitals and other settings.8 This (ACP), the American College of Surgeons program development. Designed to help landmark decision was followed by a (ACS), the AMA, and the Physician address the growing shortage of primary report from the U. S. Congress Office of Assistant Education Association health care providers in rural and Technology Assessment stating, “Within (PAEA).11 Although the ARC-PA medically underserved communities, this the limits of their expertise, PAs provide does not prescribe curriculum length, funding supported 43 PA programs care that is equivalent in quality to the preclinical and clinical content must between 1972 and 1976.4 care provided by physicians.”9 The include supervised clinical practice combination of these and other factors experiences, instruction in interpersonal By the early 1980s, external influences led to a renewed interest in PA education. and communication skills, and a temporarily dimmed workforce prospects number of patient-assessment and for PAs. The report of the Graduate By 2007, there were 136 accredited patient-management topics. Clinical Medical Education National Advisory programs in the United States, with 106 education is required in a variety of Committee projected an excess future (79%) offering a master-degree curriculum. settings to reflect breadth and depth of supply of clinicians and several PA New York has the greatest concentration of content, and includes outpatient and programs closed soon thereafter.7 PA programs (19), followed by Pennsylvania inpatient settings as well as emergency Many PAs left the workforce, and new (15), California (10), and Texas (8). and long-term care facilities. This is graduates of PA programs were required Fifteen states have one PA program, and typically accomplished in academic to become creative jobseekers. Anecdotally, six states have none (Figure 1).10 teaching facility settings, and inpatient while I was on active duty in 1985, the clinical rotations are usually conducted then-U.S. Navy Surgeon General was in an experiential team format consisting touring military facilities employing large Current State of PA Education of PA students, medical students, numbers of PAs. While summarizing and residents, led by a staff attending Program accreditation requirements workforce projections, he told the physician on a clinical rotation assembled PAs, “You need to find The Accreditation Review Commission assignment basis. The required content something else to do.” on Education for the Physician Assistant, areas of the preclinical curriculum are Inc. (ARC-PA) is the sole accrediting anatomy, physiology, pathophysiology, The lull in PA program growth was agency responsible for establishing the pharmacology and pharmacotherapeutics, short lived, and passage of the Health standards for U.S. PA education and and genetic and molecular mechanisms Professions Training Assistance Act of for evaluating programs to ensure of health and disease. In the clinical curriculum, the required areas are emergency medicine, family medicine, general internal medicine, general surgical care (including operative experiences), geriatrics, pediatrics, prenatal care, and women’s health. PA program preclinical and clinical curriculum content is typically evenly divided in length, and the mean U.S. PA program content is administered to full- time students during 26.5 continuous months.10 In essence, PA education more closely resembles a condensed version of medical school than does any other health professions curriculum. PA programs and academic health center relationships During the first five years of PA program accreditation (1972–1976), 32 of 38 programs (84%) were developed within academic health center (AHC) settings with close medical school affiliation or direct sponsorship. Conversely, during Figure 1 Distribution of physician assistant programs in the United States, by state, 2007. the most recent 10-year cycle of Academic Medicine, Vol. 82, No. 9 / September 2007 883
    • Physician Assistants accreditation, (1998 –2007) only 5 of 35 from 2002 to 2006, PA students are PA workforce distribution newly-accredited programs (14%) were older, less ethnically diverse, and Although the original concept of the PA similarly affiliated.11 disproportionately represented by model was to help alleviate the shortage women. of primary care clinicians in medically Although the ARC-PA standards for underserved communities, in reality accreditation do not mandate AHC or For academic year 2006 –2007, there were approximately 5,700 available first-year the patterns of PA distribution have more medical school sponsorship, Standard closely resembled a microcosm of A1.05 states that accredited programs PA student seats with an expected 5,300 new graduates (assuming a 7% academic physician distribution. For example, the must be established in schools of distribution of PAs in the primary care allopathic or osteopathic medicine, attrition rate), for an expected average first-year enrollment of 42 students per settings of family medicine, general colleges and universities with appropriate internal medicine, and general pediatrics clinical teaching facilities, or medical program.14 According to the 2006 AAPA census, 70,612 individuals were eligible to was 50.8% in 1996. By 2006, only 36.1% education facilities of the federal were reportedly practicing in these government. This sponsorship flexibility practice as PAs. This number assumes 15% workforce attrition and includes all settings (Figure 2).15 Although a higher has resulted in an increase in the number proportion of PAs than physicians of newer programs within private and PA graduates.15 continue to work in primary care practice liberal arts universities. settings, the data suggest that PAs also Clinical practice eligibility requirements tend to follow the specialization trends of Tuition and expenses To attain state licensure and eligibility for the supervising physician employment clinical practice, PAs must graduate from In academic year 2002–2003, the total pool. an ARC-PA-accredited program and projected expenses incurred by PA pass the Physician Assistant National students (including tuition, books, Certifying Exam, administered by the Postgraduate PA education equipment, and fees) for the duration of National Commission on Certification The topic of PA specialty training and the program was $36,154 for residents of Physician Assistants (NCCPA). PAs recognition, whether by credential or and $43,628 for nonresidents, or 41% of must document 100 hours of continuing certification, is very controversial among the same projected expenses incurred by medical education every two years and practicing PAs, educators, and leaders of medical students.10,12 successfully complete a comprehensive the major PA professional organizations. written recertification examination In a May 2006 address to the AAPA PA student demographics every six years to maintain certification. House of Delegates, the chairman of In academic year 2005–2006, the typical NCCPA is the sole PA certifying body the NCCPA Board of Directors stated PA student was a 27-year-old white in the United States, and all states, that “the public, including our patients, woman with a 3.4 overall grade point the District of Columbia, and the U.S. have an expectation about the care average and 29 months of prior health territories require NCCPA certification being delivered by PAs practicing in care experience who matriculated with a for PA licensure or regulation. specialty settings. Patients have a right baccalaureate degree into a full-time Professional standards are developed and to expect that their PA has the training, master-degree PA program. From 1987 monitored by appointed representatives knowledge and skills to deliver the to 2004, the number of international of the AAFP, AAP, AAPA, American specialty care they are receiving. medical graduates enrolled as PA students College of Emergency Physicians, ACP, Unfortunately, at this point, no set ranged from 0.2 to 1.64 per program, ACS, American Hospital Association, standard exists for PAs practicing in with an 18-year mean of 0.6 per year, or AMA, American Osteopathic Association, specialty areas.”19 At the same session, 1.7% of enrolled students. From 1983 AAMC, PAEA, Federation of State the AAPA president voiced strong to 2005, the percentage of nonwhite Medical Boards, U.S. Department of opposition: “We will do everything we enrollees was 20.2%, with a low of 13.1% Defense, and the U.S. Department of can to defend the flexibility of this in 1983 and a high of 24.4% in 2004.10 Veterans Affairs, as well as by PA and profession—to move from specialty to According to the Central Application nonmedical public directors-at-large.16 specialty—while at the same time Service for Physician Assistants (CASPA), protecting the patient.” This debate has a comparison of the grade point averages PA competencies contributed to a renewed interest in the (GPAs) of PA and allopathic medical Four national PA organizations—the content, delivery, and recognition of school applicants reveals that the GPAs of AAPA, ARC-PA, NCCPA, and PAEA— postgraduate PA education. allopathic applicants were 0.3 higher in collaborated to define PA competencies science, 0.225 higher in nonscience, and in an attempt to address public In addition to the 136 entry-level PA 0.275 higher overall, aggregated over demand for higher quality and greater programs in the United States, there are application years 2002–2005. In the accountability in health care. Based on 41 operational postgraduate training 2005 application cycle, the number of the Accreditation Council for Graduation programs recognized by the Association applicants per available seat was 2.25 Medical Education list of general of Postgraduate Physician Assistant for allopathic medical schools and PA competencies for medical residents, the Programs in 17 medical and surgical programs.13 When comparing allopathic PA competencies are medical knowledge, specialties (see Table 1). The typical medical student matriculant data from interpersonal and communication skills, program is 12 months in length, based on the Association of American Medical patient care, professionalism, practice- a didactic and clinical curriculum similar Colleges (AAMC) with CASPA and based learning and improvement, and to that of physician residency programs, PAEA annual report matriculant data system-based practice.17,18 and offers a certificate of specialty 884 Academic Medicine, Vol. 82, No. 9 / September 2007
    • Physician Assistants medical schools.25 Some propose that a clinical PA doctoral degree would elevate and enhance the profession and that employers and patients would have a higher level of confidence in PAs with such degrees.26 Although this position suggests that the degree, rather than the profession, earns recognition, nonphysician clinical doctorates have reportedly had minimal influence on status, compensation, and reimbursement, and the pharmacy doctorate has reportedly led to growing job dissatisfaction when health care expectations clash with reality.27 Despite concerns that the PA profession may eventually become marginalized if a clinical doctorate fails to materialize, educational researchers have not defined a unique body of PA knowledge, skills, or attributes that differ enough from that of medical education to justify the existence Figure 2 Percentages of U.S. physician assistants practicing in various specialties, 2006. of a clinical doctoral degree for PAs.25,28 Health workforce data omissions training. Although interest in these increasing the number of doctors or programs is at an all-time high, current taking nurses out of nursing roles.”23 Health workforce supply-and-demand production from all postgraduate models that exclude PA clinical programs combined is limited by Degree creep and the clinical doctorate productivity estimates fall short of enrollment to approximately 110 issue providing accurate projections, and the graduates per year.20 dearth of data on PA estimates has been The recent profession-wide transition previously reported.29 Data from a to a predominantly master-degree national study of PA productivity curriculum resulted in new challenges Future Directions and patterns report that PAs produced 83% for PA faculty development. The number Controversies of outpatient visits compared with the of doctorate-prepared PA educators output produced by one physician continues to lag behind the educational Although the PA profession has full-time equivalent (FTE), with some needs of training programs. With the prospered since inception, controversies variation between differing specialties.30 majority of programs now at the master- remain regarding workforce issues such When family medicine PAs were degree level, a recent faculty pipeline as the appropriate balance of autonomy compared with family medicine study projected the availability of just one and supervision, role delineation, and the physicians, the estimate was 84% of doctorate-prepared PA faculty member continuing trend toward specialization.21 physician productivity for PAs. If per U.S. program by 2010.24 In addition The division of medical workforce labor extrapolated to the estimated 70,612 PAs to the need for more PA faculty with in the United States has undergone eligible for clinical practice, 26.5% of doctorate degrees to prepare master- substantial change in recent years, and whom work in family medicine settings, degree-level students, emerging and AHCs have accommodated resident the PA productivity estimate represents controversial educational issues include work restrictions in part by increasing the the equivalent output of over 15,700 FTE PA specialty training and recognition, use of PAs in hospital settings. There family medicine physicians, or over 15% postgraduate training program is growing evidence that residency of active family medicine/general practice accreditation, and the potential programs may be incorporating PAs physicians in the United States.31,32 introduction of clinical doctoral degrees in a variety of ways to transfer tasks as an entry-level credential for PA previously accomplished by residents.14,22 Although PAs have been included in practice.25 Additionally, other nations are some health workforce studies, such as considering or have already incorporated With nonphysician clinical doctorates the trend model proposed by Cooper et the use of PA models as a means to help now available for audiologists, nurse al,33 other reports have failed to include increase access to health care. In the practitioners, occupational therapists, PAs or have grouped them along with United Kingdom, nonphysician “medical pharmacists, and physical therapists, the nurse practitioners and nurse midwives care practitioners” are reported to be “an topic of a clinical doctorate for PAs has into nonphysician clinician productivity effective strategy for increasing medical emerged as a polarizing subject of intense models.34,35 PAs are frequently classified capacity, without jeopardizing quality in debate among PA educators, many of in the ill-defined allied health provider frontline clinical services,” and their whom feel that such a degree pathway category that typically includes other deployment “may offer advantages over already exists at allopathic or osteopathic clinicians such as chiropractors and Academic Medicine, Vol. 82, No. 9 / September 2007 885
    • Physician Assistants 2 Hudson CL. Expansion of medical Table 1 professional services with nonprofessional personnel. JAMA. 1961;176:839–841. Distribution and Enrollment of Postgraduate Physician Assistant Training Programs in 16 Medical and Surgical Specialties, 2007* 3 Stead EA. Conserving costly talents: providing physicians’ new assistants. JAMA. No. of Total annual 1966;198:1108–1109. Specialty programs enrollment 4 Gifford JF. The development of the physician Cardiothoracic surgery 3 3–5 assistant concept. In: Carter RD, Perry HB, ......................................................................................................................................................................................................... Critical care 1 2–5 eds. Alternatives in Health Care Delivery: ......................................................................................................................................................................................................... Dermatology 1 2 Emerging Roles for Physician Assistants. St. ......................................................................................................................................................................................................... Louis, Mo: Warren Green Publishers; 1984. Emergency medicine 5 10–15 ......................................................................................................................................................................................................... 5 American Academy of Physician Assistants. Hospitalist 2 13 Information about PAs and the PA ......................................................................................................................................................................................................... Neonatology 1 2 profession. Available at: (http://www.aapa. ......................................................................................................................................................................................................... org/geninfo1.html). Accessed May 21, 2007. Neurology 1 2 ......................................................................................................................................................................................................... 6 Ballweg R. History of the profession. In: Neuroradiology and sleep medicine 1 1–2 ......................................................................................................................................................................................................... Ballweg R, Stolberg S, Sullivan EM, eds. Neurosurgery 1 1 Physician Assistant: A Guide to Clinical ......................................................................................................................................................................................................... Obstetrics–gynecology 1 4–6 Practice. Philadelphia, Pa: W.B. Saunders Co.; ......................................................................................................................................................................................................... 1994. Oncology 1 2 ......................................................................................................................................................................................................... 7 Graduate Medical Education National Orthopedic surgery 5 10–16 Advisory Committee. Report to the Secretary, ......................................................................................................................................................................................................... Psychiatry 2 5 Department of Health and Human Services, ......................................................................................................................................................................................................... Rheumatology 1 1–2 Geographic Distribution Technical Panel, ......................................................................................................................................................................................................... Volume III. Washington, DC: Government Surgery 12 44–48 Printing Office; 1980. DHHS publication no. ......................................................................................................................................................................................................... Trauma 2 3 HRA 81-653. ......................................................................................................................................................................................................... Urology 1 2 8 Hooker RS, Cawley JF. Physician Assistants in ......................................................................................................................................................................................................... American Medicine. 2nd ed. New York, NY: Total 41 106–116 Churchill Livingstone; 2003. * The 34 programs listed in the table are in addition to the 136 entry-level physician assistant programs in the 9 Office of Technology Assessment. Nurse United States. The table’s programs are recognized by the Association of Postgraduate Physician Assistant practitioners, Physician Assistants, and Programs. Certified Nurse-Midwives: A Policy Analysis December 1986. Washington, DC: U.S. Congress, Government Printing Office. acupuncturists. These inaccurate variables, with some models including Health technology case study 37. classifications fail to adequately account services provided by an assortment of 10 Simon A, Link M. Twenty-Second Annual for the physician-like services provided differing nonphysician clinicians. Report of Physician Assistant Educational by PAs in clinical settings. However, the omission or inaccurate Programs in the United States, 2005–2006. classification of PAs in much of the Alexandria, Va: Physician Assistant Education Association; 2006. U.S. health care access and workforce Discussion literature projects an incomplete picture, 11 Accreditation Review Commission on Education for the Physician Assistant Web Most recent workforce predictions point and it is important to consider the site. Available at: (http://www.arc-pa.org). to an increasing shortage of physicians, contributions PAs have made and will Accessed May 21, 2007. and the AAMC responded in 2006 continue to make in addressing the 12 Association of American Medical Colleges. with a call to increase medical school nation’s health care needs. Given the Medical Educational Costs and Student Debt. enrollment by 30% during the next workforce distribution and productivity Available at: (https://services.aamc.org/ decade.34 This action has been met with a comparisons between physicians and Publications/index.cfm?fuseaction Product. displayForm&prd_id 121&prv_ id 137). similar call for increased PA program PAs, the educational and clinical Accessed May 21, 2007. enrollment.36,37 The representation of cost-effectiveness of PAs should be 13 PAEA Networker. Available at: (http://www. minorities in health professions training regularly included in discussions on the paeaonline.org/Networker/1106 Networker/ programs continues to fall short of division of medical labor. Additionally, 1106index.htm). Accessed May 21, 2007. reflecting the national distribution of the content, duration, and academic 14 Orcutt VL. The Supply and Demand for minorities, and their representation host affiliations of PA educational Physician Assistants in the United States: A among PAs is also inadequate and falls programs should be continually Trend Analysis [dissertation]. Denton, Tex: below that of allopathic physicians. This reassessed to determine whether the University of North Texas; 2007. discrepancy must be addressed, given the current accreditation model, which 15 American Academy of Physician Assistants. increasing diversity of the population. allows location, length, and content 2006 AAPA Census Report Available at: Additionally, the increasing feminization flexibility, is in the best interests of (http://www.aapa.org/research/06census- intro.html). Accessed May 21, 2007. of the PA profession may lead to changes patient care.39 16 National Commission on Certification of in workforce productivity if similar Physician Assistants. About Us: Board of practice patterns for female physicians References Directors. Available at: are found with female PAs.38 (http://www.nccpa.net/AboutUs.aspx). 1 Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America’s Accessed May 21, 2007. Health workforce supply-and-demand Health in a New Era. Washington, DC: 17 Accreditation Council for Graduate Medical models are constructed using many National Academies Press; 1996. Education. ACGME General Competencies 886 Academic Medicine, Vol. 82, No. 9 / September 2007
    • Physician Assistants and Outcomes Assessment for Designated 24 Orcutt VL, Hildebrand A, Jones PE. The Publications/index.cfm?fuseaction Product. Institutional Officials. Available at: (http:// doctoral pipeline in physician assistant displayForm&prd_id 160&prv_id 190). www.hmc.psu.edu/competencies/pdfs/ education. J Phys Assist Educ. 2006;17:6–9. Accessed May 21, 2007. ACGME%20GENERAL%20COMPETENCIES. 25 Jones PE, Cawley JF. Doctoral degrees for 33 Cooper RA, Getzen TE, McKee HJ, Laud P. pdf). Accessed May 21, 2007. PAs: questions and issues. Perspect Phys Economic and demographic trends signal an 18 National Commission on Certification of Assist Educ. 2005;16:8–9. impending physician shortage. Health Aff. Physician Assistants. Physician Assistant 26 Gruppo LQ. Clinical doctoral degrees—are 2002;21:140–154. Competencies: Online Center. Available at: we ready? Perspect Phys Assist Educ. 2005;16: (http://www.nccpa.net/PAC/Competencies_ 34 Association of Academic Health Centers. 5–7. The Policy Agenda to Expand the Health home.aspx). Accessed May 21, 2007. 27 Sile WL, Randolph DS. A clinical look at Workforce. Available at: (http://www.aahcdc. 19 National Commission on Certification of clinical doctorates. Chronicle Rev. 2006;52: org/policy/workforce.php). Accessed May 21, Physician Assistants. Chairman’s speech at B12. 2007. the house of delegates, Monday, May 29, 2006. Available at: (http://www.nccpa.net/ 28 Dehn RW, Jones PE. Physician assistant 35 Pew Health Professions Commission. News_06AAPAConfAnnouncement.aspx). education: will we meet the need? Perspect Critical Challenges: Revitalizing the Health Accessed May 21, 2007. Phys Assist Educ. 2005;16:33–36. Professions for the Twenty-First Century. 20 Association of Postgraduate Physician Assistant 29 Scheffler RM, Waitzman NJ, Hillman JM. Available at: (http://www.futurehealth.ucsf. Programs. APPAP programs by specialty. The productivity of physician assistants and edu/compubs.html). Accessed May 21, 2007. Available at: (http://www.appap. org/ nurse practitioners and health work force 36 Salsberg E, Grover A. Physician workforce prog_specialty.html). Accessed May 21, 2007. policy in the era or managed care. J Allied shortages: implications and issues for Health. 1996;25:207–217. 21 Cooper RA, Henderson T, Dietrich CL. Roles academic health centers and policymakers. of nonphysician clinicians as autonomous 30 Larson EH, Hart LG, Ballweg R. National Acad Med. 2006;81:782–787. providers of patient care. JAMA. 1998;280: estimates of physician assistant productivity. J Allied Health. 2001;30:146–152. 37 Cawley JF. Physician assistant supply and 795–802. demand. JAAPA. 2005;18:11–12. 22 Cawley JF, Hooker RS. The effect of resident 31 Association of American Medical Colleges. work hour restrictions on physician assistant AAMC Statement on the Physician 38 Kletke PR, Marder WD, Silberger AB. The hospital utilization. J Phys Assist Educ. 2006; Workforce. Available at: (http://www.aamc. growing proportion of female physicians: 17:41–43. org/workforce/workforceposition.pdf). implications for U.S. physician supply. Am J Accessed May 21, 2007. Public Health. 1999;80:300–304. 23 Parle JV, Ross NM, Doe WF. The medical care practitioner: developing a physician 32 Association of American Medical Colleges. 39 Whitcomb ME. The shortage of physicians: assistant equivalent for the United Kingdom. Physician Specialty Data: A Chart Book. a challenge for the physician assistant Med J Aust. 2006;185:13–17. Available at: (https://services.aamc.org/ profession. J Phys Assist Educ. 2007:18;5–6. Did You Know? In 1945, doctors at Joan & Sanford I. Weill Medical College of Cornell University were the first to use streptomycin in the treatment of tuberculosis in humans. For other important milestones in medical knowledge and practice credited to academic medical centers, visit the “Discoveries and Innovations in Patient Care and Research Database” at (www.aamc.org/innovations). Academic Medicine, Vol. 82, No. 9 / September 2007 887