The government's investment in the PA profession

INTRODUCTORY PARAGRAPH: Generalist medicine and dentistry have had their ups and downs over the past 30 years with the coming and going of health reform and managed care and the expansion and contraction of national programs launched by the Robert Wood Johnson Foundation and the Association of American Medical Colleges in its generalist physician initiatives. While much attention has been given to these efforts, little notice has been paid to the role of federal policy and the Title VII, Section 747 programs on the production of the nation's generalist clinician workforce. And yet, when carefully studying, for example, the history of the Title VII Training in Primary Care Medicine and Dentistry grant program, there is little doubt the impact has been significant on both professions. If for no other reason, from 1972 to 2008, this federal program poured nearly $3.9 billion (adjusted to 2008 dollars) into the health professions educational system for one explicit purpose: to produce welltrained family physicians, general internists, general pediatricians, physician assistants, and general dentists.

ABSTRACT: This article reviews the legislative history of Title VII of the United States Public Health Service Act. It describes three periods of federal support for health professions training in medicine and dentistry. During the first era, 1963 to 1975, federal support led to an increase in the overall production of physicians and dentists, primarily through grants for construction, renovation, and expansion of schools. The second period, 1976 to 1991, witnessed a shift in federal support to train physicians, dentists, and physician assistants in the fields of primary care defined as family medicine, general internal medicine, and general pediatrics. During this era, divisions of general internal medicine and general pediatrics, and departments of family medicine, were established in nearly every medical and osteopathic medical school. All three disciplines conducted primary care residencies, medical student clerkships, and faculty development programs. The third period, 1992 to present, emphasized the policy goals of caring for vulnerable populations, greater diversity in the health professions, and curricula innovations to prepare trainees for the future practice of medicine and dentistry. Again, Title VII grantees met these policy goals by designing curricula and creating clinical experiences to teach care of the homeless, persons with HIV, the elderly, and other vulnerable populations. Many grantees recruited underrepresented minorities into their programs as trainees and as faculty, and all of them designed and implemented new curricula to address emerging health priorities.

ABSTRACT: Federal support through Title VII, Section 747, has played an important role in promoting the use of physician assistants (PAs) in primary care and in the growth and institutionalization of PA educational programs in the United States. Federal workforce policy approaches include PAs in strategies to (1) increase the supply of generalist providers, (2) better balance the distribution of providers to rural and medically underserved areas, and (3) improve the diversity of the health workforce. Evidence from several decades shows that, likely because of Title VII program incentives, PAs have met expectations in terms of practicing in primary care specialties and serving in rural and medically underserved areas. Yet, increasingly, market forces and decreasing federal support for Title VII are affecting these trends, with PAs, like physicians, being drawn to specialty practices.

There is considerable use of PAs in all practice settings in US medicine. For several decades, PA training programs have demonstrated that they are efficient means of preparing clinicians who provide considerable benefit to society in return for a modest public investment. At present, when the climate seems not to favor public subsidy of health professions education, it may be wise for policy makers to consider strategies that address the long-term needs of the health care workforce and the public for primary care clinicians.

ABSTRACT: Once again, experts predict a shortage of health care providers by 2020. The PA profession was created in the 1960s to address a similar need. Currently, there are 141 accredited PA training programs in the United States, 75 of them established in the 10 years between 1993 and 2002. Historically, PA education and practice models have been responsive to the ever changing landscape of health care. It may be the profession's flexibility and adaptability that has enabled it to survive and flourish in a competitive service environment. The growth of new PA programs mandates a need for continuing faculty development, as increasing numbers of educators come equipped with minimal teaching experience. PA faculty development addresses these new recruits' needs to develop model curricula, implement new courses, and enhance instruction—all with the goal of improving both access to and quality of health care.

The author describes the impact of Health Resources and Service Administration Title VII, Section 747 (Title VII), contracts in addressing this need. Title VII-funded PA education projects, considered innovative at the time of implementation, included both faculty development workshops that promoted active learning of basic teaching and administrative skills and new curricula designed to enhance faculty teaching in genomics and practice management. These projects and others resulted in enduring professional resources that have not only strengthened the PA community but also enjoyed broad applicability within other health professions groups.

DISCUSSION

History demonstrates that support from the federal government was monumentally important in the establishment of the PA profession. Other funded professions such as physicians, dentists, and nurses were well established at the onset of government investment in medical workforce. In contrast, the PA profession was at its infancy at the start of this process and thus was fundamentally shaped by it. The profession's historical folklore, that the profession was established purely as a primary care entity aimed at providing clinicians for medically underserved populations, exhibits little appreciation of the federal government's role in making it that way. In fact, without federal funding, neither the venerable pioneer programs nor the first wave of programs established in the early 1970s likely would have ever existed. These early programs provided the graduates who established the first state practice laws, earned the respect of patients and physicians, and succeeded in carving out a niche as an established profession that was able to respond successfully to the many workforce challenges to come later. Federal grants, typically with reporting requirements, encouraged the gathering and publication of data that demonstrated the skills, physician acceptance, and patient satisfaction of early PA graduates.

However, in the big picture, the federal government's investment in the PA profession was only a fraction of a much larger enterprise that spanned more than 40 years with the goal of increasing access to medical and dental care by training more primary care providers and increasing their diversity. Following the creation of Medicare in 1965, demand for primary care medical and dental services increased dramatically, particularly in numbers of patients from low socioeconomic backgrounds. This point in history intersects with the origins of the PA profession and the beginning of family practice as a recognized physician specialty requiring residency training. Two articles by Reynolds set the stage by explaining the philosophical and historical background of federal programs to encourage primary care training. The Office of Management and Budget (OMB) under the Bush administration has judged that Title VII programs have not demonstrated specific outcomes and effectiveness, and as a result, over recent years these programs have been nearly eliminated.

Cawley documents the federal government's substantial role in the creation and nurturance of the profession by direct investment in institutions and programs and weaves these facts into their impact on the history of the PA profession, making this manuscript a must-read for PA historians. Similarly, Glicken documents the impact of federal funding aimed at PA faculty development. Many of the methods devised by these projects have since taken their rightful place in the current toolbox of PA faculty resources. With the considerable growth of PA enrollment and programs in the 1990s, these efforts were crucial in helping to meet the faculty development needs of the large influx of new PA teachers.

The federal government played a major role in the birth and early development of the PA profession, and more recently, encouraged diversification and cultural competency in the profession. Workforce projections indicate that the demand for primary care providers will soon grow substantially and that our patients will become increasingly diverse. In view of these challenges, a review of the US government's track record in supporting health care provider training is timely. JAAPA