The first generation of PAs is about to retire, or at least to leave the active workforce. The first large cohort of PAs trained during the 1970s and is now making retirement choices. Instead of dropping out of the medical workforce at the traditional age of 65, some are choosing to remain in practice (to some extent), though not necessarily maintaining the same activity level or doing the same kind of work. (1) Prior to full retirement, changes occur such as reduction in workload and narrowed scope of practice. Such adjustments have implications for medical care provision and PA workforce planning, but the precise levels of activity and capacities are unknown.
These are people who came of age in the 1960s, where the 70 million children from the post-war baby boom became teenagers and young adults. For many of them, the PA profession represented an opportunity to enter a previously restricted occupation, to make a contribution to a rapidly changing society, and to bring new perspectives to a flawed health delivery system. The graying of this generation of PAs is a milestone in the history of the profession that deserves examination and comment.
The tone of the 1960s saw a cultural movement away from the conservative 1950s and resulted in revolutionary ways of thinking and real change in the social fabric of American life. No longer content to be images of their parents' generation, young people of that era had fresh notions regarding education, values, lifestyles, laws, entertainment, and health care. Many of the revolutionary ideas that began in the sixties are continuing to evolve today, including civil rights, national social welfare programs (like Medicare and Medicaid), the space program, and a broad and creative initiative then known as the new health practitioner movement.
The enduring significance of this movement was that it represented, in the minds of many, a failure on the part of the medical profession to meet the health care needs of American society. The health care demands of our nation had outgrown the capacity of the conservative medical establishment. In terms of health care, the 1960s chant of change translated into new, more responsive types of health care providers. The rationale for the creation of PAs (and NPs) was bound up in perceptions of a physician shortage, and in particular, a shortage of primary care providers. (2)
It is important to note that the movement was far more encompassing than the creation of the physician assistant profession. PAs were but one of a number of types of health care providers proposed during that time, including nurse practitioners, certified nurse midwives, a variety of providers with a background in nursing, and others with names like MEDEX, health assistants, and health associates, some of whom eventually mainstreamed into the PA profession.
We all know the story of the origins of the PA profession in the 1960s: Eugene Stead; the founding of the Duke, Child Health Associate, and MEDEX programs; the first organizations; and so forth. We know much less about the following—but much more formative—years in the decade of the 1970s. It was this era and that generation that shaped the profession in distinct ways, for example, the consolidation of the selection of the name, the emergence of major educational models, and the advancement of legislation for practice and prescribing authority.
The first generation of PAs came to this occupation having served in the military or worked in some other field. They were corpsmen, paramedics, Peace Corps volunteers, nurses, social workers and others with various prior health careers. Nearly all programs were inaugurated with federal funds, and a little over half were at land grant schools. By the early 1970s, the MEDEX movement had 8 PA programs operational. Faculty members were primarily doctors and other professionals, as few were PAs themselves. In 1973, there were 41 PA training programs (all receiving federal funding through the NIH Bureau of Health Manpower Education) with an estimated 1,430 students enrolled and “several hundred” in practice. (2)
From a few hundred PAs in the 1970s to over 80,000 in the US 40 years later, the PA movement is entering into another phase—retiring the first generation and launching a generation that will never know what it was like without PAs in our society. It is a global phenomenon with PAs on four continents and growing.
The article by Hooker and colleagues in the January 2012 issue of JAAPA (“The characteristics of clinically active older physician assistants”) makes a useful contribution to our knowledge of the evolving demographics of the PA profession, and in particular, to the retirement patterns and activities of older PAs. We learn that the first generation of PAs has a set of distinguishing characteristics, ones that reflect the early image of the PA profession: mostly male, primary care orientation, greater willingness to practice in rural and underserved areas. That more of this generation of PAs are in primary care and are employed in rural communities compared to succeeding generations should really be no surprise to those familiar with the origins of the PA profession. The declining number of more recent graduates in practice in rural and underserved practice settings is painfully obvious. And compared to a modern cohort of PAs, that fewer of the first generation of PAs are women reflects the fact that many of the initial recruits to the profession were ex-military males.
For this generation of PAs, primary care was the mission and the focus of the educational experience, and practice opportunities in specialty and subspecialty settings were relatively uncommon. This contrasts markedly with the modern patterns of PA practice, where two-thirds of all PAs are in specialties.
It is not yet clear what the retirement patterns of PAs will be. Undoubtedly, they will reflect to some degree the attitudes expressed by other Baby Boomers, including an unwillingness to simply ride off into the sunset but instead a desire to continue to work, or certainly be active in a variety of life endeavors, well beyond the traditional retirement age of 65, which is regarded by many now as a artificial and arbitrary marker. Boomers are likely to flaunt this convention, consistent with their classic “question authority” attitude.
Importantly, in addition to their substantial clinical accomplishments and contributions, credit must also be given to this first generation who were so active in the formation and development of our professions organizations, particularly the Academy and state Academy chapters. It was these PAs who led the state-by-state charge to obtain the practice and prescribing authority that embeds the PA profession in medical practice codes.
REFERENCES
1. Hooker RS. Physician assistants and retirement. JAAPA. 2011;24(11):68.
2. Sadler AM. Introducing a new professional: the health practitioner. In: Lippard VW, Purcell EF, eds. Intermediate-Level Health Practitioners. New York, NY: The Josiah Macy, Jr. Foundation; 1973.
Jim Cawley is Professor and Chair (Interim), Department of Prevention and Community Health; and Professor, Department of Physician Assistant Studies, The George Washington University, Washington, DC. This blog post expresses his personal views and does not express or represent the views or policies of AAPA.