INTERVIEWEE: Dr. Alfred "Fred" Sadler
INTERVIEWER: Dr. William "Bill" Wilson
DATE: February 5, 2003
PLACE: Carmel, California
SADLER INTERVIEW NO. 1
WILSON:My name is Bill Wilson. Today is February 5th. We're in Carmel, California, to record the history of Dr. Alfred Sadler. Dr. Sadler was among the handful of pioneers who started the PA profession. And it's my pleasure to be able to be the person who is here to interview him. Dr. Fred Sadler.
SADLER:Good morning. The year is 2003, Bill. You didn't say that.
WILSON:So if I'm—
SADLER:Just in case this film is available 50 years from now. What year was that, anyway? Oh, it was 2003—
WILSON:(laughs) that’s right, institutional memory.
SADLER:—2003. This is a treat, to see Lyle and Bill. I haven't seen you for—let's see—25 years, maybe, more. We're sitting in my living room in Carmel. I'm off today.
I love to talk about the PA world and how that world began. It was certainly a privilege and an honor to be present at the beginning. (Cat meowing) There's a cat walking around here. So don't mind the cat.
I grew up in Allentown, Pennsylvania. I was born in New York City. The important genetic information about me is that I have an identical twin brother named Blair. Blair and I did collaborative work together in health law, as you'll hear more about, and worked together in the early development of PA's. We both graduated from AmherstCollege in 1962. I went on to HahnemannMedicalSchool in Philadelphia on a scholarship, and Blair went to University of Pennsylvania Law School. I Interned in Surgery at the Hospital of the University of Pennsylvania. We decided to go into the US Public Health Service together in 1967. We started out at the National Institutes of Health to tackle a variety of health law problems and became very involved in organ transplantation. [We studied the legal and ethical issues extensively and consulted on and helped write the Uniform Anatomical Gift Act, which was adopted in every state by 1971. This enabled the nationwide sharing of cadaver organs and tissues that exists today.]
We turned our attention to the emerging field of physicians' assistants and nurse practitioners. The Duke PA program had started in 1965, under Dr. Eugene Stead. The Colorado pediatric nurse practitioner program had begun under Dr. Henry Silver, in 1965. MEDEX began in 1969 with Dr. Richard Smith, who'd been a Peace Corps doctor, and was impressed with what non-physicians could do. The concern of NIH and more generally, DHEW (now DHHS), was to explore how PA's would fit in with existing health professionals such as doctors and nurses. We were asked to examine the credentialing and legal issues relating to PA's, by Roger O. Egeberg MD, the Assistant Secretary of Health and Surgeon General and Dr. Kenneth Endicott, who later became director of the Bureau of Health Manpower. We studied all the state laws and began to visit programs. At Duke we met Dr. Stead and Thelma Ingles (who helped him start the PA program) and Drs. Harvey Estes and Bob Howard and Martha Ballenger who were among the principals. They were looking at many of the same issues that we were. We went to Colorado and met with Dr. Silver and Loretta Ford RN, DrEd. and then to Seattle and Richard Smith. It was clear to all of us that a separate practices act for PA's would restrict the new profession unnecessarily. The PA's in the military and overseas had worked flexibly because they were not restricted by laws the way nurses or physical therapists were. Our recommendation was simply to amend the medical practices acts of the various states to make it clear that nothing in the medical practice act would prohibit a doctor from turning over part of his or her role to a specially trained person. The key words were, "operate, diagnose, treat, and prescribe." Those are the functions—
WILSON:That would be—
SADLER: Only a doctor could operate, diagnose, treat, and prescribe, at least in an unrestricted way. Those key functions, representing the broader physician functions, were to be delegatable to specially trained personnel. [We completed a detailed position paper for the Surgeon General, which subsequently became the federal position. Most training programs followed this path. The task for each state was to pass an amendment to the medical practice act to allow the practice of PA’s (Blair and I helped achieve this in Connecticut in the early 1970’s).] Some states were more elaborate and added regulatory language that in some cases was very detailed about how a program should be set up and what education the graduates would receive. Others were basic and used two or three sentences that said essentially: "Nothing in the medical practice act shall prevent delegation of these authorities to a PA”.
Blair and I moved on to Yale in 1970 to continue our medical legal collaboration. Yale’s Department of Surgery had received a large grant from the Commonwealth Fund of New York to develop solutions to the problems of emergency medicine and trauma. [Accidents and their aftermath were labeled “the neglected disease of our society” by the National Academy of Sciences.] Dr. Jack W.Cole was Professor and Chairman of the Department of Surgery, who I had known in medical school; we kept in touch. Dr. Cole invited us to join him to direct the program in Trauma and Emergency Medicine. Blair and I were very impressed with PA's and we asked him if we could include a PA program as part of the Trauma Program grant. He was very supportive. Thus we had the authority, the impetus and the money to start the program at Yale. In the fall of 1970, the first class of five students was enrolled. We asked a PA named Paul Moson, who was one of the first graduates of the Duke program to join us. He and I met with the faculty at YaleMedicalSchool and the Yale School of Public Health and developed a curriculum from scratch. We recruited students and trained them over 24 months.
We collaborated with Ann Bliss RN, an outstanding clinical nurse who had a Master's Degree in clinical psychology and social work and was very interested in expanded roles and what nurses could and couldn't do. She helped us understand the background of organized nursing and what their views were about expanded roles of nursing and what their view about PA's were likely to be.
In 1971, we were asked to write a position paper for five private Foundations, called, "A White Paper on Physician Assistants: Looking at the Future". The Foundations were The Commonwealth Fund, The Rockefeller Foundation, The Carnegie Corporation, The Foundation for the Aid to Crippled Children, and The Macy Foundation. In the course of our studies, we traveled and met other people in other programs, officials at the National League for Nursing, the American Nurses' Association, and learned that organized nursing was not happy with idea of PA's. In fact, organized nursing had spent most of its last 20 years trying to be separate from doctors and separate from hospital administration. They were looking for independence. Nurses didn't want to be “handmaidens” of doctors any more or “handmaidens” of hospital administrators either.
On the other hand, what Duke had learned, with Thelma Ingles and Dr. Stead, was there was a lot to be gained by taking in non-nurses and starting a new project, a new program—not that nurses were excluded—that would work with doctors, tied legally to the practice of medicine. In fact, one very important bit of history that we learned from the Duke leaders was that they originally started out with advanced nurses. They took some of the best cardiac nurses, in the early 60's, and decided to train them at an advanced level to work with patients coming out of ICU after heart surgery or after a heart attack, to do a lot of the care that residents in cardiology and cardiac surgery—
WILSON:Understood.
SADLER:—didn't have time to do. So that, I think, was one of the reasons for developing a ”midlevel practitioner”. They started with highly qualified nurses. The pilot project was going well and they wanted to get the program credentialed by the National League for Nursing, who came to Duke and turned down the program. The reason the program was turned down was there was too much medical input. It wasn't taught by the nursing school. So Thelma and—and if I can call her by her first name; I got to know her and Dr. Stead quite well, just delightful, creative people—decided, well, we're not going to give up. Let’s try Plan B. Plan B was built on the fact that 6,000 independent duty military corpsmen were coming out of the service, every year, because of the huge demands in Vietnam, and these corpsmen, in this case, mostly men, were very well trained and were looking for a job in civilian medicine. There wasn’t a slot for them in civilian medicine. They could go be an orderly, or they could do something outside of health. Dr. Stead and Thelma Ingles said "Let's have a new program." And “physicians' assistants” was the name they came up with, in 1965 I believe.
It was very important to us that we write about this background, which is what we did, and try and make it clear to others that there were “lessons from nursing”—which was actually the chapter in our book and not make the same mistake with PA’s. Let's not try to be independent from doctors. Let's not compete. Let's not have tight boundaries about what PA’s do. Let’s be flexible. We also believed that it was very important that PA's stay close to doctors, and we recommended an interdependent mode of practice. (Cat meowing) That's Bubba the cat, by the way, looking for attention. She is not a nurse practitioner, a PA or a doctor. She's just a cat.
We continued to train PA’s at Yale and in 1972 decided to take our Foundation paper, which was comprehensive, and expand it into a book. The Physician's Assistant: Today and Tomorrow, produced by Yale University Press. [Ann, Blair and I came up with a number of recommendations, many of which became part of the national debate. In 1975, we updated and greatly expanded the book, added the subtitle “Issues Confronting New Health Practitioners” and published a second edition through Ballinger Press of Cambridge, Mass.]
One of the joys for me was working with others at other programs. Bill, I enjoyed meeting your colleagues at Salt Lake City and the other MEDEX people. Dave Lawrence in Seattle was actually a college classmate of mine at Amherst—
WILSON:(inaudible).
SADLER:—was the quarterback on our football team, class of '62. Go Jeff's! Beat Williams.
WILSON:(laughs)
SADLER: Dave, wherever you are, you're still the best. He became, as you know, the director of the MEDEX program in Seattle and later, was president of Kaiser out here. More programs got started in other places, including at George Washington, where I met Tom Piemme MD, who also was actively involved in the training of new health practitioners. A meeting at Duke called the Annual Duke Conference on Physicians' Assistants was held. Soon there were ten programs, then 20 programs, and people from credentialing and other fields attended. We decided to have a national meeting. We needed to have an organization. The PA’s coming out of Duke and elsewhere needed to be registered and listed somewhere so they could get jobs. A Registry was formed, by Dr. Bob Howard, who was the first PA Program Director at Duke. He was the first president of the American Registry on Physicians' Assistants.
WILSON:Ruth Ballweg asked me to have you clarify the relationship in history of the Registry vis-à-vis the NCCPA. Because nobody knows how that happened.
SADLER:Great.
WILSON:OK? I'm glad you mentioned that because I would have forgotten.
SADLER:The Registry was set up really as a place to put, in one setting, the list of all the graduates of PA programs, so that, if a state legislature wanted to find out was this person a legitimate graduate of the Duke program or wherever, they could. At these early meetings in the early 70’s, we soon realized we had a lot more to worry about than simply registering PA's. We needed to discuss curriculum, and what worked in your program and what worked in our program. MEDEX was a very decentralized curriculum, with just six weeks, as I recall, originally, or three months—correct me if I'm wrong, Bill—
WILSON:It was three months.
SADLER:—of didactic training at the university center and then going out with a preceptor—
WILSON:Right.
SADLER:—for the rest of the training. At Yale and at Duke and some of the others, we had a more centralized training. How could we learn from each other? And how did we teach? How much basic science? How broad should this be? Should there be subspecialty elements? Many of the same issues were being addressed by medical education. We needed to talk about that and decided to form an Association. We called ourselves the Association of Physician Assistant Programs, APAP. I was elected the first President [I had also served as President of the Registry after Bob Howard]. We started meeting and holding conferences. We recognized the need for certification and testing of physician assistant graduates.
WILSON:Standalone. Just—yeah.
SADLER:At that time, the National Board of Medical Examiners, based in Philadelphia became very interested. Dr. John Hubbard was the president. Dr. Edie Leavitt, who later became president, was one of his chief deputies. And they were looking at credentialing of physicians. The GAP report, a report on the future of medical education, examined credentialing of physicians in general and subspecialty training in particular. They became aware of PA training and were willing to consider, for the first time, testing and credentialing non-physicians. A group was convened in the early 70's, of which Blair and I were the chairs. There were about 15 of us. I remember Archie Golden from Johns Hopkins, Tom Piemme from George Washington
WILSON:Bob Kane, from—
SADLER:Bob Kane Right. Chuck Lewis I think was involved. Some of the MEDEX leaders were too. Our charge was to develop a certifying exam. Barbara Andrew PhD, of the National Board in Philadelphia, was assigned to actually write the test.
WILSON:She was a psychometrician.
SADLER:Yes.
WILSON:And then we got money from the foundations and the feds to help us do it, and were—
SADLER:Yes
WILSON:We had to get— it was a lot too. Because—
SADLER:It was a big undertaking
WILSON:Yeah.
SADLER:We used some studies at Hopkins, where they'd looked at the functions of what people do, physicians doing primary care, and stepped back from that to develop core knowledge and skills for primary care.
WILSON:Task analysis or—
SADLER:Yes, task analysis
WILSON:—needs assessment.
SADLER:We focused on a clinical exam, with less emphasis on basic science. In addition to the multiple choice questions and answers, there were clinical problem test questions. There was a hands-on physical exam part of this—
WILSON:Right.
SADLER:—in which, as part of the exam, the student graduates would be observed doing a physical exam on volunteers—
WILSON:So—
SADLER:—who would be simulated patients. It took a lot of creative activity to make this exam work. The National Board was looking at a lot of the same issues for physicians, trying to make physician testing more clinically directed rather than basic science-directed. We identified a body of knowledge and test for that, rather than making a test that was so difficult that nobody could pass it and then play with the cutoff level to separate the ‘good’ from the ‘bad’. If we could define everything a PA should know, ideally, the programs could go back and teach that, and every PA theoretically could get 100 on the test. I'm being simplistic, of course in my summary of this. It was a fascinating exercise. Since that time the National Board has continued to provide the test. And we're in 2003, so its 30 years. Because it was 1973 that—
WILSON:Yeah, '73 it was the first exam.
SADLER: Another part of credentialing was how do you credential programs? The AAMC, Association of American Medical Colleges, works with the AMA to support a joint commission on accreditation of medical schools and residencies. We knew we wanted to work with organized medicine and we met with the Association of American Medical Colleges. In fact, the first several annual APAP meetings were always held in conjunction with the AAMC annual meetings. We felt—
WILSON:Yes.
SADLER:—it was very important to be close to organized medical education and organized medical practice.
WILSON:With the exception of the first one, this was in Wichita Falls, Texas. Remember?
SADLER:No, that was actually our first annual PA meeting after the Duke annual meeting went nationwide.
WILSON:Yeah.
SADLER:That was not just an APAP meeting.
WILSON:Actually, that was the academy's meeting.
SADLER:That was an academy meeting. Yes.
WILSON:Yeah. That's right.
WILSON:But we did have—the APAP meetings.