I examined in some detail the actual practice of medicine. After sampling the rich diet of medicine, most doctors settled for a small area. If the office was set up to see patients every 10 to 15 minutes and to charge a certain fee, the practice conformed. If the outcome was poor or if the doctors recognized that the problem was too complex for this pattern of practice, the patient was referrd.

Doctors seeing patients at half-hour or 1-hour intervals also developed practice patterns and set fee schedules to conform. The specialists tended to treat diseases and leave the care of patients to others. Again, they cycled in a narrow path.

The average doctors developed very efficient patterns of practice. They operated 95% of the time in a habit mode and rarely applied a thinking cap. Because they did everything that involved contact with the patients, time for family, recreation, reading, and furthering their own education disappeared.

Why this intense personalization of medical practices? All doctors starting practices ran scared. They wanted to make their services essential to the well-being of their patients. They wanted the patient to depend on them alone. After a few years in this mode, they brainwashed themselves and actually believed that only they could obtain information from the patient and perform services that involved physical contact with the patient.

During this time I was bnilding a house with my own hands. I could use a wide variety of materials and techniques in my building. I reflected on how inadequate my house would be if I was restricted to only four materials. The doctor restricted to a very slim support system could never build a practice adequate to meet the need of modern medicine. He or she needed more components in the system. The physician assistant was born!

Nurses, laboratory technicians, and other health professionals were educated in their own schools, mostly hospital related. The new practitioner----the PA-was to be selected, educated, and employed by the doctor. PA not being geographically bound to the management system of the hospital, the clinic, or the doctor's office could oscillate between the office, the hospital, the operating room, and the home.

A 2-year curriculum was organized at Duke Medical School with the able assistance of Dr. Harvey Estes. who eventually took the program under the wing of his department of Family and Community Medicine. The object of the 2-year course was to expose the student to the biology of humans and to learn how doctors rendered services. On graduation, PAs had learned to perform many tasks previorisly done only by licensed doctors and could serve a useful role in many types of practices. They performed those tasks that they could do as well as their doctor mentors. If the mentor was wise, the PA mastered new areas each year and increased his or her usefulness to the practice.

Setting no ceilings and allowing the PA to grow has made this profession useful and satisfying. Restricting PAs to medical supervision has given them great freedom. Ideally, they do any part of their mentors' practice that they can do as well as their mentors.

Because of the close association with the doctor and patient and the varied duties of the PAs, they have an intimate knowledge of the way of the medical world. They know patients; they are aware of the triumphs and failures of medicine; they know how doctors think and what they do with information collected about patients. For these reasons, they are in demand by all businesses that touch the medical profession. The world is open, and PAs are grasping their share.

We all owe a debt of gratitude to the first five students who were willing to risk two years of their lives to enter a new profession when there was little support from doctors, nurses, or government. From the beginning, patients responded favorably, and each PA gained confidence and satisfaction from these interactions. Patients made and saved the profession. We hope that every new PA will acknowledge this debt and continue the excellent work of the original five.

Eugene A. Stead, Jr., M.D. Florence McAlister

Professor Emeritus of Medicine

Duke University Medical Center

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