PAs have practiced medicine in the United States for some time now, with the first class of PAs graduating in 1967. Back then we were a novel concept—a new provider in the medical landscape with less schooling than a physician but able to complete most (or all) of the same tasks as a physician, at least in certain patient populations. Some called us revolutionary, others scandalous; but despite our critics, PAs have proven themselves over the past 40 plus years in medical offices, hospitals, clinics, community health centers, battlefields, and virtually every other health care setting imaginable.

Our education and training have advanced as well, from the days when community college programs awarded new PAs an associate's degree to today's master's degree programs and rigorous accreditation standards. We have a standardized certification examination, and we have CME obligations as rigorous as those of our physician colleagues. Legally, we are held to the same standard of care as physicians, even though our education is less extensive. We are viewed not as a poorly trained substitute for a physician but rather as a well-trained, complementary alternative. Indeed, the very concept of the physician-PA team has allowed for expansion of services to entire patient populations that would otherwise not have access to quality medical care.

Clayton Christensen, a professor at Harvard Business School, developed a concept that he calls disruptive innovation.1 Usually applied to business, this model says that newer, more adaptable products or services take root at the bottom of the marketplace and push relentlessly to the top, eventually displacing or disrupting those products or services at the top of the marketplace. A truly disruptive innovation is one that allows a whole new population of customers access to a product or service that was traditionally not available to them. An example in medicine might be the advent and rapid growth of the retail clinic model, which has disrupted the standard office-based practice model.

In an interview with Gartner, an information technology research and advisory company, Dr. Christenson said of the health care industry that it is expensive and inconvenient because “it hasn't been disrupted. The hospitals have moved to the very high end of their markets; [they have become] very capable of dealing with extremely sophisticated problems[,] and physicians, similarly, [have] become very capable. The policy-makers' solution is … to somehow get these things to become cheap. It'll never happen. What has to happen is we need to bring technology to less expensive venues of care, to enable them to become more capable. And [we have to do] the same thing to … nurses, so they can do things they used to need a doctor to do.”2

The PA educational model has already accomplished this goal. Using a shorter, more condensed model of the education given to physicians, it produces a provider capable of managing much of the illness and pathology that is a part of American medicine. In shortening the educational model, making it competency based, and thereby making the necessary training cheaper, we have essentially created a new provider who can work alongside physicians to expand capacity; and the existing medical landscape has never been the same. We have grown from the three PAs who graduated from the original Duke class to almost 75,000 at last count.3 We have expanded from extending care to meet rural primary care needs to having providers in virtually every specialty in medicine. In short, we are the “disruptive innovation” that Dr. Christensen has written about.

To maintain ourselves as a disruptive innovation, with all the value that brings to the American health care system, we must tend to our profession carefully. We cannot continue to increase the costs of PA education, or we will no longer be the cheaper, leaner, and more effective alternative to medical school. We cannot continue to abandon our roots in primary care in favor of more lucrative positions in specialties. We must be mindful of the ongoing need for us in rural and underserved areas, and in specialties facing critical shortages, such as nephrology, psychiatry, and primary care. To continue to advance our profession, we must continue to move into new areas, including health care management, emergency medical services directorships, and medical officer duties. Not only is it in our history to be disruptive, it is at the very core of our profession. Remembering this, and acting accordingly, will only benefit us in the long run. JAAPA

Michael Halasy, MS, PA-C, is the assistant supervisor of the PA/NP group, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota.

REFERENCES

1. Christensen CM, Raynor ME. The Innovator's Solution: Creating and Sustaining Successful Growth. Boston, MA: Harvard Business School Publishing Corp; 2003.

2. Clayton M, Christensen DBA. The Gartner Fellows Interview. http://www.gartner.com/research/ fellows/asset_94087_1176.jsp. April 26, 2004. Accessed August 5, 2010.

3. American Academy of Physician Assistants. FAQ. http://www.aapa.org/about-pas/faq-about-pas. Accessed August 5, 2010.