Editor's note: This article appears in the Journal of Health and Human Experience, Volume III, No. 1, pp 77-99, under the title "Empathy and Dedication: Hospital Corpsmen to Physician Assistants - A Wasted Talent Pool in a Time of Need", by a NAPA member David Lash. It is reproduced here in fulll with the permission of the Journal and the Author. You may download a PDF version with retains the original article layout here.

Empathy and Dedication:
Hospital Corpsmen to Physician Assistants -
A Wasted Talent Pool in a Time of Need

David Lash, MPAS
Physician Assistant Veterans Health Administration
Captain James A. Lovell Federal Health Care Center

Author Note

This article provides an important insight into the critical role of physician assistants for American health care. The article makes use of a creative combination of academic reflections combined with historical experiences (see below “newscasts”) from the lives of those in this health care service. The author acknowledges the contributions of the Navy physician assistants who shared their personal experiences to make this creative article a possibility. The author is solely responsible for the contents of this article. The contents do not reflect the policy of the Veterans Health Administration [or of NAPA; -ed]. The images used are from the Department of Defense and therefore are in the public domain. All correspondence should be directed to the author. The author has no financial conflicts of interest.

Abstract

Navy hospital corpsmen are relied upon to make life and death decisions when treating the combat injuries of the Marines and other military members to whom they are assigned to serve. They provide hemorrhage control, airway reestablishment and support, cardiac support, and pain control, as well as treating whatever injury their patients have suffered. The corpsmen stabilize the patients for transport to the shock trauma units and then other corpsmen assistant the doctors, physician assistants (PA), and nurses with the combat treatment provided in these more advanced treatment areas. Many of these hospital corpsmen pursue further careers as physician assistants, both in and out of the Navy. Unfortunately, the civilian community largely ignores the medical skills they developed and honed in combat once these sailors leave the Navy.
Keywords: Physician assistants, hospital corpsmen, workforce shortage, primary care, veterans, Veterans Affairs

Introduction

The United States health care system is facing a decline in the primary care workforce and access to primary care as physicians increasingly seek specialty positions or retire from clinical medicine. The U.S. is projected to have more than 130,000 fewer healthcare providers than needed by 2025. One in five (i.e. 60 million) Americans currently lacks adequate access to primary care due to the health care provider shortage. This shortage coincides with an increasing demand for primary care practitioners in rural and underserved communities, an increase of required primary care services defined through the Affordable Care Act, an aging population, and an increase of 123,000 service men and women being discharged from the Armed Forces over the next 3-4 years. According to a recent USA Today report 50% of critical VA health care positions remain unfilled. (USA Today, 2015; Becker’s Hospital Review, 2014;
AAMC projections, 2015; Conde Nast 2016; HRSA Health Workforce Reports, 2013; Health Affairs, 2013)

The VA operates one of the largest health care delivery systems in the nation, consisting of 150 medical centers and over 800 community-based outpatient clinics. Since 2001 and the start of the Global War on Terrorism enrollment in the VA health care system has increased significantly as well. (GAO’s 2015 High Risk Report)

Physician Assistants, the Corpsman and VA Connection

Newscast 1
A SEAL Team Medic, deployed in support of the Global War on Terror, provides emergency first aid to one of his SEAL Teammates. He stabilizes his fellow SEAL and the sailor is picked up by a medivac, surviving the battle injuries. The Corpsman later teaches trauma and long-term medical care to fellow Special Operations Corpsmen and Medics. After becoming a Physician Assistant (PA), he is the lead provider on a mobile trauma team in Helmand Province, Afghanistan. His team deploys on missions outside of the desired medivac flight time/distance perimeter to provide a more vigorous medical response to allied forces engaged in battle. He is now the Senior Provider and Medical
Department Head of a Special Operations Team. This PA saved countless lives in the worst of conditions, and through the skills of those he teaches and leads he is still saving lives. The physician assistant (PA) profession was established in 1965 to address the shortage of physicians in the U.S. The first class of physician assistants was composed of former U.S. Navy Hospital Corpsmen. The program’s intent was to take advantage of the combat healthcare experience of Vietnam era military trained medics and corpsmen to fill the workforce shortages in medical primary care that existed in the 1960s. The curriculum for the first PA program was based on the fast-track training of medical doctors during World War II. (Wikipedia, 2016; Journal of Physician Assistant Education, 2007).

The physician assistant (PA) profession was established in 1965 to address the shortage of physicians in the U.S. The first class of physician assistants was composed of former U.S. Navy Hospital Corpsmen. The program’s intent was to take advantage of the combat healthcare experience of Vietnam era military trained medics and corpsmen to fill the workforce shortages in medical primary care that existed in the 1960s. The curriculum for the first PA program was based on the fast-track training of medical doctors during World War II. (Wikipedia, 2016; Journal of Physician Assistant Education, 2007).

Heroic military medical personnel rescuing the wounded in World War II on Normandy.

Newscast 2
A Navy corpsman providing medical support to the Marines during the battle of Fallujah is promoted for saving the lives of Marines while under enemy fire. During a subsequent deployment to earthquake ravaged Haiti he coordinated the evacuation of 133 critically injured patients and assisted military surgeons in the surgical and postsurgical care of earthquake survivors requiring amputations. His dedication to his Marines and his empathy for human suffering serve him well as the surgical PA that he is today.

In 1967, the first employer of PAs was the then-Veterans Administration (VA), now known as the Department of Veterans Affairs. Currently the VA is the largest single employer of PAs, employing around 2,000 PAs. Over the next 3-4 years employment opportunities for PAs is expected to increase at a steady rate of 38%, much faster than the average for all other occupations. The PA occupation has been named as the single best master’s degree for the several years. The National Commission on Certification of Physician Assistants reports that 78% of recent PA program graduates are receiving multiple job offers, with 52% entertaining three or more offers. (Wikipedia, 2016; Forbes, 2014)

Newscast 3
A Navy corpsman serving as a Combat Medic and heavy weapons gunner on a Special Operations (SPECOPS) boat crew in Iraq earned a Bronze Star with Valor for his actions under fire, providing medical care to wounded Marines calling out for his assistance while being targeted himself by the well entrenched enemy. He was awarded a purple heart for the injuries he received while attending to the wounds of “his” Marines. Later, while assigned as a SPECOPS Combat Medic Instructor, he attended college classes at night to qualify for PA school. After graduating as a PA he was subsequently assigned as a Battalion Medical Officer with the 3rd Battalion Marines and deployed back to the warzone as a Medical Officer. The faces of his Marines had changed but the severity of their injuries were known to him. His experience as that SPECOP Corpsman was key to his expertise in treating yet another cadre of his Marine Corps family suffering from the injuries inflicted during service to their country.

The Need is Expanding and Increasingly Complicated

Today’s Veterans have been exposed to a multitude of often complex physical and/ or mental invasions of their well-being. They were required to leave their loved ones for agonizingly prolonged periods of time. They have been forced to live in harsh conditions where many around them were actively trying to kill them. For months at a time, from the time that they get up in the morning until the time that they go to bed at night, every single day they are not sure that they will still be alive at the end of that day. They are sure that some of their adopted family members, and their team “IS” their family, will not be alive at the end of the day. Imagine getting out of bed every day knowing that someone in your family would be killed before the day is over. You hope that it will not be you. You are relieved when it is not you; and that is closely followed by the guilt that it was another family member instead of you.

According to a Gallup poll taken in 2014 after the incident published concerning the VA Medical Center in Arizona, Veterans continued to prefer that more of their medical needs be met by the VA. The poll demonstrated that Veterans favor an expansive role for the VA in meeting Veterans’ care over a more limited one. Fixty-six percent say the VA should care for all Veterans’ medical needs for the duration of their lives, while 38% believe the VA should only care for those medical issues related to the Veterans’ military service. (Gallop poll, 2014)

In 1991 22% of all PAs were employed by the federal government. That percentage dropped to 9% by 2008, where it remains today. In 2014 PAs had the highest total loss rate (10%) in the VA, more than any of the other top ten VA occupations deemed difficult to recruit. A recent VA OIG report determined that PAs were third when compared to all other VA occupations with the largest staffing shortages. In 2016, 37% of VA PAs were eligible to retire. That is an approximate loss of 600 PAs. That workforce loss will result in a loss of approximately 1.15 million Veteran-eligible patient care appointments. By 2021 an additional 48% of VA PAs will be eligible to retire. (AAPA report, 2015)

Newscast 4 & 5
A Navy corpsman assigned as a Search and Rescue Aircrewman participates in 49 helicopter rescues. These rescues were executed in nearly inaccessible canyons, on treacherous shore cliffs, and on steep rock canyon walls. He repelled down from the helicopter to injured people, stabilized their vital signs, applied lifesaving first aid, placed the injured into stretchers and hoisted the patients to hovering helicopters. His duties also involved accessing aircraft mishaps in remote or hard to reach locations, stabilizing and evacuating survivors, as well as retrieving the remains of those who did not survive. This corpsman was ultimately accepted to PA educational programs/institutions. As a PA, the now Naval Officer was assigned as the Officer-in-Charge of a Shock Trauma Platoon in the war zone of Afghanistan. His platoon was the primary casualty treatment and stabilization/transport facility for American war casualties and Afghan civilians overwhelmed by the war being fought all around them in the Afghan province. One Afghan family’s survivors transported their severely injured loved ones 10 miles, through mountainous and desert terrain, bullets and explosions everywhere, even in wheel barrels, to request treatment in the American medical “facility.” Unfortunately the treatment was too late.

In yet another war zone deployment a combat hardened PA was assigned as the Lead Advisor to the Afghan Surgeon General. Assistance provided included advice on the day to day operations of medical departments. Medical clinic organization, administration, staffing, logistics and finance were also provided. The PA was a key element in the planning for the reestablishment of Afghan medical schools and medical training pipelines. The PA is currently providing leadership to U.S. sailors and providing orthopedic medical care to military members and their families.

Military medical personnel bringing humanitarian aid to the poor of other countries including children of those most wounded.

Wasted and Ignored Skills

Newscast 6 & 7
A Navy corpsman spends years training with and providing medical care to the U.S. Marines and is then selected for and subsequently provides medical care to a SEAL Team. He then gets selected for PA school. The corpsman melds those many years of experience as an operational hospital corpsman with his new PA education. He reports to the war zone to provide medical care to a combat support base that included up to 10,000 U.S. and allied military forces, and support civilians. While serving there, the PA provided combat casualty life saver training to allied forces from Japan, Jordan, Saudi Arabia, Kuwait, and Oman. He was ultimately promoted into the medical unit’s leadership position.

Another PA who is a prior corpsman deploys to Iraq in a Shock Trauma Platoon treating numerous severe combat casualties and saving many lives. The PA subsequently deploys to Iraq in a Forward Surgical Team and once again assists in saving the lives of American and Allied Marines and Soldiers injured while fighting alongside Iraqi government troops. Called upon to deploy once again, the PA reported to Afghanistan as the Medical Officer with a Provincial Reconstruction Team. The PA provided advice and guidance on recreating medical infrastructure and supervised medical care to the team. The PA later deployed to both Qatar and Jordan as the Medical Officer-in-Charge with Combined Forces Special Operations Command. The PA is currently a primary care provider taking care of military personnel and their families.

On a yearly basis around eleven thousand former military corpsmen and medics leave the service. The unemployment rate for Veterans aged 34 and younger, the age group encompassing the majority of discharged Veterans, is consistently higher when compared with their peers who did not serve in the military. Military corpsman and medics are trained to manage pain, including administering narcotics. They treat life-threatening battlefield injuries, stabilizing their comrades until their medical support can arrive, or their patient can be evacuated from the battlefield. They perform intubations and IV administration, treat colds, stomachaches, and other common primary care complaints. They prescribe and distribute medications on the battlefields, on the ships in the fleet, and on the military installations of all of the U.S. Armed Forces. These corpsmen have saved the lives of many of their Marine Corps family members, in horrific combat situations, under lethal enemy fire, bullets zipping by within earshot, explosions all around them, Marines are heard always calling for “DOC,” who are many times wounded themselves, and with medical backup hours away. (EMS1 News, 2012)

Civilian EMTs are certified at the basic level and are not allowed to perform the basic level of medical care routinely provided by military corpsmen and medics who are not deployed in combat. Even with the military corpsmen’s and medic’s superior training and experience, a comment made by an official of the National Registry of EMTs printed in EMS1 News SEP in 2012 stated that “Veterans should complete the full range of paramedic courses through CIVILIAN schools, no matter their experience level.” (Capitalization mine). Perhaps this “official” needs to be deployed to the war zone and see if s/he can manage the mayhem on the battlefield, and perhaps s/he can at least stay out of the way as the corpsmen and/or medics around him/her save countless lives. According to the statement made by a U.S. Congressman, also printed in EMS1 News in September, 2012, “Many Veterans use federal benefits to pay for civilian schooling in skills they’ve already mastered. We are literally wasting millions of tax payer dollars requiring someone to attend training they have already completed, which could be spent on more advanced qualifications.” (EMS1 News 2012)

Newscast 8
After 16 years providing medical support to the U.S. Naval fleet, a Hospital Corpsman is accepted to PA school. Subsequent to graduating from PA school and receiving a commission as a Naval Officer, she reported to a Naval Health Clinic and was soon promoted to the Senior Medical Officer position (Senior Health Care Provider). Not accustomed to sitting on the sidelines, the PA volunteered for deployment into the war zone and was assigned as the Executive Officer of a Shock Trauma Platoon and Forward Resuscitative Surgical Suite at a Combat Outpost in Iraq. The PA and her medical team treated the injuries and saved the lives of numerous combat casualties. After a brief time back in the U.S. she deployed as the Regimental Surgeon (Senior Health Care provider to a Marine Regiment) responsible for the health care of 2,500 sailors and marines. When not treating combat casualties and administering the medical department she found the time to earn the Plans, Operation, and Medical Intelligence subspecialty. This PA implemented the Medical Home concept in the regiment, significantly improving access to medical care, keeping the maximum number of Marines combat ready at any given time. She was always looking for ways to improve the lives of those around her and authored both the “Going Green (USMC)-A Naval Officer’s Toolkit” and the Navy’s Emergency Medicine Physician Assistant Fellowship Program. This prior corpsman, now a PA, went on to complete a Congressional Legislative Fellowship, advising a Congressman on national security, foreign relations, and Veterans Affairs. She is now serving as a Legislative Liaison to the Navy Surgeon General.

Prior Corpsmen and Physician Assistants Can Fill the Need

An article appearing in the Journal of Health Affairs in 2013, discussing the primary care workforce gap in the U.S., notes that research has determined that physician assistants can safely perform many aspects of the primary care previously performed only by physicians. The article continues to recommend further that a “primary care extender” could be established along the model of the Emergency Medical Services Technicians (EMTs). As it states:

EMS is almost entirely delivered by EMTs and paramedics. EMTs extricate people from car crashes, control bleeding, splint fractures, and provide basic life support. Paramedics conduct detailed patient assessments, insert intravenous lines, administer a wide range of oral and prenatal drugs, and perform certain lifesaving procedures. EMS professionals practice under the license and supervision of a physician medical director. Because EMS professionals work in the field, their actions are largely guided by clinical protocols and standing orders. However, they can obtain medical direction by radio
or telephone if this is required. This approach enables a small number of physicians to meet the pre-hospital care needs of the United States. ( Journal of Health Affairs, 2013).

Always prepared. Ever serving.

Newscast 9
A Navy corpsman is “baptized” into combat during Operation Desert Storm with the Marines. The combat experience included seeing the charred remains of numerous Iraqi soldiers who had been incinerated by Coalition ground and air forces. Undeterred by this horrific battlefield experience, following the deployment, the corpsman began taking nighttime college classes after putting in a full day in an operating room. He made numerous additional deployments with the Marines on routine training and deployment exercises around the world, before being accepted into PA school. Then came the Global war on Terror. The PA was deployed with the Marines to Camp Fallujah Iraq during some of the most intense fighting of the entire Iraqi war. He was kept extremely busy treating and tracking the casualties from three separate Marine Corps infantry battalions. The fighting was fierce, the injuries were graphic, and yet countless lives were saved through his efforts and those of his team.
After a rest (from combat) back to the U.S. the PA was deployed to a reconstruction team in Khost, Afghanistan, serving as the U.S. medical representative to the Afghan Provincial Government, and as the Provincial Public Health Officer. The PA supervised the rebuilding of health clinics to give the local Afghan population access to basic health care. He supervised the procuring and providing of medical supplies and equipment for the clinic. He established a children’s nutritional supplement program to address the endemic malnutrition, purchased clean water treatment units to give the population a source of uncontaminated drinking and cooking water, and purchased garbage incinerators to dispose of the numerous disease causing piles of refuse that littered the area. This PA’s efforts provided a safer and more humane environment for the Afghan population in the province.
The PA and his medical team were the first responders after an infamous suicide bomb attack on a nearby CIA compound. Their efforts saved the lives of six severely wounded U.S. personnel, however nine others could not be saved. He served out his time in the U.S. Navy and is now a Family Medicine PA in a U.S. community utilizing his skills to protect the health of the next generation of potential veterans.

And finally...
A Navy Corpsman gets accepted to a PA school, and upon graduation is deployed to Iraq. The PA worked in a Shock Trauma Platoon treating the casualties of the U.S. Marines and allied forces fighting for Iraqi freedom. He later was assigned to a SEAL Team and deployed to the warzone in support of the Team’s combat operations. He is now the head of a Naval medical clinic providing medical care to U.S. Sailors, Marines, and their family members.
A PA joins the Navy and is deployed with a Marine Corps Air Wing Support Squadron in the Iraqi warzone. She provided essential medical and casualty support to the Marine Corps pilots supporting America’s war on Global Terrorism. Her experience has enabled her to progress into leadership roles in the Navy.
Another Navy corpsman is commissioned as a PA. After additional training as an Aerospace Physiologist she served as the Operational Officer at the Navy’s busiest Aviation Survival Training Center overseeing the high-risk water survival and altitude chamber training of aircrew and SPECOPS personnel deploying in support of the Global War on Terror.

Conclusion

Health care provider shortages is the root cause of the problem of Veteran’s access to health care in the VHA. Use of “primary care extenders” in the model of the EMTs would allow credentialed health care providers to focus on the diagnosis and treatment of patients. Using all members of the health care team to the optimum extent of their capabilities would give physicians more time to address the more serious or more challenging patients that only physicians can treat.

According to the VA Office of Inspector General (OIG) Report of January 2015, the five VHA occupations with the largest staffing shortages were Medical Officer (physician), Nurse, Physician Assistant, Physical Therapist, and Psychologist.

The VA is traditionally a draw for former service members seeking employment. Veterans trained as medics and corpsman may once again offer a solution to the primary care shortages. In the past, medics and corpsmen were considered exceedingly able candidates for primary care work and as rural providers. Their broad training was considered an untapped reservoir of needed attributes and clinical skills.

Many former corpsmen and medics choose the PA profession as an avenue to increase their medical knowledge and to utilize their acquired medical skills, while acquiring even greater medical skills as PAs. Historically, the very first PAs were all employed by the VHA. Many other corpsman and medic veterans choose the nursing profession. The current generation of former corpsman and medic veterans would likely follow the historical pathways and choose the VHA if given the opportunity. (Wikipedia, 2016)

The vastly untapped talent pool of prior corpsmen and medics should once again be pursued and utilized by the VHA. In addition, the VHA needs to increase targeted recruitment and retention initiatives towards physicians, nurses, and PAs (VA OIG, 2015).

Even with additional targeting towards physicians, the declining pool of available primary care physicians will require the VHA to rely more heavily on PAs. To attract more of the extremely talented and experienced PAs leaving the U.S. military, as well as others, the VHA must pay competitive salaries to PAs when compared to the salaries paid in the civilian community. In addition the VA should grant full practice authority to PAs throughout the VHA regardless of the opposition of other health care professionals. PAs have been and do provide fully independent practice throughout the armed forces, on the battlefield, and in remote and inaccessible locations, and have been doing so since the late 1990s. Outdated beliefs and fears by others will cause the continued lack of veteran access to the healthcare that the veterans unquestionably have earned. The VHA is the largest medical system in the world and should be on the cutting edge of medical practice in this country. The VA must
seize the opportunity to employ prior corpsman and medic veterans, and to utilize all medical professionals to the full extent of their training and experience. To do any less is to ignore their sacrifices --- sacrifices that were given freely in the blood, gore, and mayhem of combat.

Failure of our commitment to our Veterans is never an option!

References

• American Academy of Physician Assistants (2015, March). Report to the House Committee On Veterans’ Affairs, AAPA.
• Bloomberg, S. (2012, September). Combat medics betrayed by civilian job market, EMS1 News.
• Colver, J., Blessing, J. & Hinojosa, J. (2007). Military physician assistants: Their background and education, The Journal of Physician Assistant Education, 18(3).
• Dall, T., West, T., Chakrabarti, R. & Iacobucci, W. (2015, March). The Complexities of Physician Supply & Demand, Projections from 2013-2015, Center for Workforce Studies of the Association of American Medical Colleges.
• Dill, K. (2014, June). The best and the worst master’s degrees for jobs in 2014, Leadership, Forbes.
• Government Accounting Office (2015). Managing Risks and Improving VA Health Care, High
  Risk Report.
• Grounder, C. (2013, January). The case for changing how doctors work, Conde Nast.
• Hoyer, M. (2015, August 20). Half of critical positions open at some VA hospitals, USA Today.
• Jones, J. (2014, July). Majority of U.S. veterans say access to VA care difficult, Gallop poll,
  Gallop World Headquarters.
• Kellerman, A., Saultz, J., Mehrotra, A., Jones, S. & Dalal, S. (2013). Primary care technicians: A solution to the primary care workforce gap, Health Affairs.
• National Commission on Certification of Physician Assistants (2013), Statistical profile of Physician Assistants.
• Punke, H. ( Jan 2014). 8 Physician Shortage Statistics. Becker’s Hospital Review, Integration & Physician Issues.
• U.S. Dept. of Health and Human Services, Health Resources and Services Administration (HRSA), Bureau of Health Workforce Analysis. (2013, November).
• National and Regional Projections of Supply and Demand for Primary Care Practitioners 2013-2015.
• U.S. Dept. of Veteran’s Affairs. (2015, January) Determination of Veterans Health Administration’s Occupational Staffing Shortages.
• Wikipedia (May 2016). Physician Assistant, Healthcare occupations, Wikimedia Foundation, Inc.