Vietnam created physician assistants for rural, native care

By: Jared Leighton .

Man driving four-wheeler in a snowy open field.
Man driving four-wheeler in a snowy open field.
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Though the Vietnam War left physical, mental and emotional scars that remain today, it also prompted the first physician assistant training programs that gave returning veterans a meaningful career when their military service ended.

That PA training, which includes many of the same college classes as medical students but no residency requirement, also proved invaluable over the past 50 years to deliver care to underserved rural areas and Native American reservations, its original intent.

Like a lot of health systems, Sanford Health relies on more than 100 PAs to serve as physician extenders. They give care that a medical doctor would otherwise have to provide where it’s not possible or practical to have an MD.

When Jason Rogers, a Sanford Health PA in Bismarck, North Dakota, took the Armed Services Vocational Aptitude Battery test, or ASVAB, it told him he should practice medicine. His passion was in aviation, so after joining the Army and learning to fly helicopters, Rogers switched to a medical unit and learned about the PA program.

He completed that training and was sent to a flight surgeon course, which allowed him to both fly and care for aviators, then went through training in emergency medicine, occupational health and ultimately the ear, nose and throat program.

“Where I’m at, I’m easily able to move from career to career,” Rogers said.

He’s also part of the North Dakota National Guard’s 81st Civil Support Team, one of 57 teams in the U.S. and its territories that attend high-profile events and stand ready to respond to alerts of unknown substances. The team has staffed the presidential inauguration, Boston Marathon and other major events.

His role is to medically clear everyone who puts on a hazardous materials suit, monitor them and check them afterward. If a response is needed, Rogers also helps coordinate by identifying the number of hospitals necessary and aiding incident command.

As part of his military service, he must spend 20 percent of his time in a medical treatment facility, which is what led him to Sanford Health in Bismarck, where he examines ear infections, reads and interprets hearing test results and provides preoperative and postoperative care, among other things. He sees people young and old who often travel hundreds of miles from rural areas and reservations.

Like the original PAs of the 1960s, Rogers is fulfilling a deficit in health care by serving as a physician extender to those populations.

UND starts 3rd program in U.S.

That’s something that Robert Eelkema, M.D., knows a great deal about.

At 87, he still lives in Grand Forks, North Dakota, where he started the third physician assistant training program in the U.S. at the University of North Dakota, which graduated its first class in 1972.

Eelkema saw around him many physicians in rural North Dakota retiring without replacements. About the same time, Duke University was launching the first PA program, followed by the University of Washington, which began a second program focused more on rural areas, which Eelkema used as a blueprint.

Those original efforts sought to draw on veterans returning from Vietnam who had experience as Army medics or Navy medical corpsmen. After the training, which typically lasted two years, the new PAs joined the physician they trained under in practice and earned a starting salary between $8,000 and $12,000, or $54,000 to $81,000 today.

Physician shortage

Following World War II, physicians trended more toward specialization, in part incentivized by federal policies that reimbursed specialists at higher rates than generalists. This reduced the number of generalists at the same time that the overall supply of physicians also trended downward.

Some areas felt this shortage much more acutely than others: rural areas, American Indian reservations and inner cities. In rural areas, in particular, doctors felt stretched to the breaking point, and many left for larger suburban areas where the workload would be more bearable.

While doctors traditionally protected their field from encroachment by other professions, given the shortage, they welcomed the role of PA. A physician assistant would cover the routine tasks of a medical doctor, freeing up the physician to attend medical seminars and professional meetings without having to close his practice.

The Vietnam War witnessed innovation in efficient delivery of medical care by trained personnel in combat. These returning veterans brought home with them experience in medical improvements and team care.

At the same time, to deal with the physician shortage and health care disparities, the country experimented with a number of new approaches to health care delivery, including rural primary care clinics and the creation of new health professions, among them physician assistants. It was thought that PAs could remedy the geographical maldistribution of a shrinking number of generalists by being trained to work in rural clinics and that veterans could fill this role.

Promoting PAs in popular culture

To highlight the need for more health care providers, the American Medical Association took out a full-page ad in Life magazine (below, courtesy of the AMA Archives) showing a Vietnam veteran washing the windshield of a car, with the large caption, “We want to put this man in the hospital.” The explanation below it clarified that he had served as a medic in Vietnam but was now pumping gas, and instead should be part of the PA program.

 

Similarly, the AMA’s president wrote a four-page piece for Reader’s Digest, another best-selling periodical, offering a “Prescription for the Family-Doctor Shortage.” That solution was, of course, the physician assistant. The AMA advocated that physicians pass all routine functions onto PAs. The article urged readers to show it to their doctors to gain support for this crucial medical reform.

The promotion of PAs even made it into the funny pages. In one strip of Orphan Annie, the character Chipper, an ex-medic and corpsman, shows Joy a brochure describing paramedic and physician assistant programs. Completely out of sync with other strips in the Orphan Annie series, even it set aside a day to promote PAs.

PAs in North Dakota

Because of the state’s large rural and native population, the University of North Dakota became an early adopter of the physician assistant program, graduating the third PA class in the U.S., after Duke and the University of Washington.

“We went ahead full steam without a lot of knowledge,” Dr. Eelkema said. “But we knew that the people needed help and that the people coming into the program were bright and well-trained in trauma.”

The PAs were generally well received.

A 1971 Grand Forks Herald newspaper article highlighted the town of Velva, in north-central North Dakota, which had grown from 2,500 to 5,000 people in just one year. With just one doctor, who happened to be sick on a given day, a dozen patients would have had their appointments canceled. They were given the opportunity to see his PA instead. All but one said yes.

Perhaps even more surprising was the degree of interest in the program. The article reported that the 20 men in the first class were chosen from a stack of more than 500 applications by veteran medics.

The UND program also focused on Native American health care and received a large grant from Indian Health Services to do so. In 1974, 10 American Indians graduated from the program to work on eight reservations in North Dakota and Montana.

Their help was desperately needed: Life expectancy was 43 years, infant mortality was 3 to 4 times higher than elsewhere and tuberculosis afflicted 4 1/2 times as many Native Americans as whites, among other stark health disparities. There were only 56 Native American doctors in the United States at the time, and only three of them worked in Indian health care.

Adjusting to rural life

While the demand for PAs was high in rural areas, some of them didn’t adjust well to small-town life.

“The big problem was that a lot of the independent-duty corpsmen were from the big city,” Dr. Eelkema said. “We had a hard time keeping them in the places we were training them.”

And after four or five years, there were no more returning veterans to draw on, so the UND PA program started to pull more students from the general population.

Sanford Health PA Ann Owens is one such person who attended the UND program many years later. She originally went to nursing school and practiced for five years in Bismarck and then went back to UND to become a family practice physician assistant. She completed her preceptorship in the area of Hillsboro, North Dakota, and Halstad, Minnesota, where she grew up.

“Once I had kids, I knew I wanted to be back around my family, small town, the whole works,” Owens said. “I knew that was going to be pretty important.”

She enjoys working in the area because of the familiarity. She’s also fulfilling a health care need that would become a steep deficit should she leave. The region has just two medical doctors, one PA (her) and no nurse practitioners. However, Owens does not feel overburdened and said they enjoy flexibility among them.

On a recent day, Owens saw patients from 2 weeks to 63 years old for a variety of ailments: concussions, a rash, pneumonia, a pre-operation physical, chest pain, behavioral problems, and the usual winter coughs, colds and influenza.

It’s never boring.

“Whatever your schedule looks like in the morning is not what it will look like throughout the day. Things change as the day goes on,” she said.

The PA profession today

Like Owens, Rogers said he enjoys his career path.

Less than 1 percent of PAs pursue a medical degree because job satisfaction is high, burnout is low and there’s ample opportunity to move from one subspecialty to another, he said.

Not only do they generally report being happy in their positions, PAs are still fulfilling a vital need for health care in underserved areas 50 years after the idea was born out of war.

“I would not become a doctor if I could do it all over again,” Rogers said. “I feel privileged to serve my country and to do so as a PA.”

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