THIE NEW CURER:
ANTHROPOLOGICAL PERSPECTIVES IN THE
TRAINING OF PHYSICIAN'S ASSISTANTS
Thomas Malcolm Johnscn
A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL
OF THE UNIVERSITY OF FLORIDA
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
DECREE OF DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
Thomas Malcolm Johnson
The writer wishes to thank many people who have been instrumental
in the preparation of this dissertation. Very special thanks are
reserved for the members of the Class of 1975 of the University of
Florida/Santa Fe Community College Physician's Assistant Training Pro-
gram, who were so considerate during the period of field work, and who
remain friends today. The cooperation of the administration of the
training program, especially Richard A. Henry, David E. Lewis, and
James E. Konopa, is greatly appreciated.
The advice, criticism, and encouragement of supervisory committee
members is also appreciated; especially that of the chairman, Dr. Alex-
ander Moore, and also Dr. Solon T. Kimball, Dr. Sam A. Banks, Dr. Richard
C. Reynolds, and Dr. George J. Warheit. Each of these individuals has
been most understanding, both professionally and personally.
The skill and thoughtfulness of Dr. Bruce Boynton, who edited the
entire manuscript, of Mrs. Lis Carl, who helped in typing preliminary
drafts, of Mrs. Julie Hillebrand, who typed the final manuscript, merit
Finally, a real debt of gratitude is owed to Skippy Boynton, who
was patient and understanding in the face of the disruptions of normal
home life accompanying the rite of passage which is the research and
writing of a dissertation.
TABLE OF CONTENTS
Abstract........................ ............................... .. v
Part One Separation: The Cultural Background
Chapter 1. Background of the Physician's Assistant
Training Program............................... 22
Chapter 2. Student Backgrounds............................ 30
Part Two Transition: The Student Subculture
Preface................ ............. ... ...... ......... 59
Chapter 3. Sources of Support and Stress: Student
Perspectives Toward Student Status............. 65
Chapter 4. Materia Medica and Magica: Student Per-
spectives Toward Professional Status........... 103
Chapter 5. Ritual and Symbolism in Transition:
Laymen Become Professionals.................... 125
Part Three Incorporation: The New Curer in Practice
Chapter 6. The Employment of Physician's Assistants....... 140
Chapter 7. The New Curer and the Dilemma of Role
Bibliography..... ................................................. 187
Biographical Sketch.................................... ......... 195
Abstract of Dissertation Presented to the Graduate Council
of the University of Florida
in Partial Fulfillment of the Requirements for the
Degree of Doctor of Philosophy
THE NEW CURER:
ANTHROPOLOGICAL PERSPECTIVES IN THE
TRAINING OF PHYSICIAN'S ASSISTANTS
Thomas Malcolm Johnson
Major Professor: G. Alexander Moore, Jr.
Major Department: Anthropology
A discussion of the physician's assistant concept, an analysis of
the training period of physician's assistant students in the University
of Florida Physician's Assistant Training Program, ard an evaluation of
how both contribute to activities of this new curer il practice are pre-
sented. Research included participant-observation of students in train-
ing, questionnaire data, analysis of written program data, and a review
of literature on physician's assistants.
Proceeding from anthropological perspectives, in which concern is
with the implications of the educative process for the larger society
and culture of which it is a part, as well as a description of the
social system and cultural behavior within the particular educational
setting, the training period is seen as a "rite of passage" through
which aspirants move from one culturally defined status to another, from
layman to professional.
Professional education involves not only the transmission of a
set of skills, but also the acceptance by students of the basic values
and assumptions of the profession, a process of "socialization" or
"enculturation." Within the training period, important variables are
not simply curricular, but involve the perspectives generated by
students as part of a "student culture," and the interactions of these
students with others in the educational milieu, who serve as "role
During the training period, student perspectives influence the
level and direction of effort, as administration and faculty expecta-
tions are profoundly modified by students, themselves. The student
culture can also influence the future direction of the profession.
Whereas, in well-established professions, the expectations of students
prior to entering the program of training, the course of the training
period, and activities after graduation, are strongly influenced by the
power of established professional tradition, in the case of physician's
assistants, a professional tradition has not yet been established.
Uncertainties prevail for students entering training, within the train-
ing program, and among other health care occupations, with whom the
new curer will work.
It is suggested that understanding of student groupings and per-
spectives is especially important in new educational programs because,
in the absence of an established professional tradition, the student
culture may generate professional values unanticipated by those in
positions of planning and policy making. The student group may also
represent an untapped resource for advancing the goals of an educational
program, if faculty and administration become more aware of its inner
workings and its dynamic relationship to the society of which it is a
Physician's Assistant Instructor:
". .. always talk about 'hypermitotic process' when you're
referring to a cancer patient who is going to die. You see,
you need to be able to talk the mumbo-jumbo in front of the
patient without him knowing what you're talking about."
Physician's Assistant Student:
"Wow, there's more shamanism here than there is out with
In all cultures people fall ill, and in most, sick people are
ministered to by especially selected and trained individuals. In pre-
literate societies, such health specialists have been called "shamans,"
a term which derives from the aboriginal language of Siberia, a center
of the most intensive development of shamanism in the primitive world.
Anthropologists have long been interested in such "curers," not only
because of the elaborate and colorful rituals which often surround their
ministrations, but also because of their special status in otherwise
largely egalitarian and undifferentiated societies. As the above
quotes, which occurred during a lecture to physician's assistant stu-
dents, illustrate, one characteristic of the shaman (and of the modern
practitioner) is that they set themselves apart, in a variety of ways,
from the remainder of society. With his specialized training, with his
complex and esoteric skills, and because of the fact that others must
accept implicitly his ability to cure, the curer in preliterate
societies may be viewed as an incipient professional.
Such curers are interesting from this perspective, because as
anthropology has begun to study health care in our highly technologi-
cal and specialized culture, the concept of the professional and the
process of professionalization have become increasingly important.
Through education, a professional gains nearly exclusive control over
his particular field, including access to the important technological
components, so that no layman can use them without his aid, and an
occupation claims exclusive competence to determine proper and effica-
cious methods of performing some task (Freidson 1970b:10). Addition-
ally, an occupation establishes that the success of its services are
dependent upon knowledge and skill which can be obtained only by
becoming a member of the occupational group, and the occupational group
reserves for itself the almost exclusive right to define the criteria
that qualify a person to work as a member of the occupation.
In our culture today, many more people undertake long periods
of professional training in diverse fields, from medicine to law, to
architecture and industry, and this has been the subject of research
which has revealed a general trend toward increasing the number of
professions, and a trend in which the educational or training period
is emphasized (Hughes 1960; Parsons 1954). Medicine is no exception
to these trends, with increasing differentiation and specialization of
medical personnel in practice, and increasing emphasis being placed,
both in duration and substance, on the premedical, medical, and post-
graduate training periods.
From the standpoint of professionalization, physicians have come
to enjoy a position of control over the practice of healing that is
unprecedented historically. With increasing public confidence in, and
demand for, medical services, however, the increase in the number of
medical schools and medical graduates has not been sufficient to meet
primary health care delivery needs. The scientific advances and medi-
cal research of the present century, which has led to a proliferation
of medical facts and techniques, has stimulated a trend toward speciali-
zation in the medical profession. This scientific revolution in medi-
cine, coupled with a change in emphasis from purely medical care to
total and comprehensive health care, has ushered in a period of spiral-
ing costs, both for medical education and medical care. In addition, a
geographic maldistribution of physicians has arisen as practicing
physicians have clustered in urban areas near major health centers.
In short, for these and many other reasons, there has been an
increasing disparity between the need for, and the availability of,
primary health care services, and there has been an awareness within
the medical profession that specialization and the associated long
periods of training are not compatible with the demands for primary
health care delivery.
Many steps have been taken to remedy this situation, including
increasing the numbers of physicians, altering emphasis in medical
curriculum to encourage "specialization" in general (family) practice,
and utilization of computer technology. Nevertheless, it has become
clear that a major resource for increasing primary care delivery
capability is the nonphysician allied health worker, for whom new roles
can be developed so that a greater share of tasks formerly restricted to
performance by physicians alone can be carried out by nonphysicians.
The medical community is now moving to formally train and utilize a new
health professional, the physician's assistant.
It is the training of this newest health professional, the
physician's assistant, that is the subject of this dissertation. As a
new curerr," the physician's assistant is viewed as a special type of
person with aptitudes and skills which, like the modern physician with
his scientific background and the shaman with his magic and parapher-
nalia, set him apart from others and give him a professional status and
role in society.
To fully understand the new professional, his implications for
health care delivery specifically, and for the process of professional-
ization in general, it is essential to understand that which happens
during the period of professional socialization, the events between
commitment and final acceptance into the profession. It is the educa-
tional process which moves the aspirant from one culturally defined
status to another, from layman to professional.
While there are several different types of physician's assist-
ants, and by now many different training programs (Sadler et al. 1972),
formal educational programs for physician's assistants are a recent
innovation. The initial program was developed at Duke University in
1965, and was designed to provide further medical training for former
military corpsmen. It was felt that, after a formalized two-year pro-
gram, including nine months of basic science coursework and fifteen
months of clinical training, corpsmen could competently and effectively
assist the physician and increase the patient population he could serve.
Most programs now are not geared specifically to the medical corpsman,
but rather to a wide variety of students who, either by previous
patient care experience or by interest and aptitude, have the potential
to work in the physician's assistant capacity.
There are many different types of training programs for physi-
cian's assistants which differ in scope and content: some are of shorter
duration and producing primarily task-oriented practitioners ("MEDEX"),
and others are of longer duration and producing a more broadly educated
individual with a sophisticated background in general medical concepts
("Type A"). These latter programs prepare physician's assistants who
are capable of making initial contact with the patient, collecting and
organizing data based on a history and physical examination in such a
way that the physician can readily determine appropriate diagnostic or
therapeutic steps, and who may even perform diagnostic and therapeutic
procedures as well as coordinating the roles of other more technical
assistants. While physician's assistants function under the general
supervision of physicians and physicians are responsible for their
actions, in many cases P.A.'s can perform without the immediate surveil-
lance of the physician. Well-trained physician's assistants have the
knowledge and ability to integrate and interpret findings and to
exercise a degree of independent judgment (Howard and Lewis 1972:1).
For several years following 1965, the status of these emerging
health professionals within the legal framework of medical practice was
uncertain, but as of March 1973, twenty-four states had enacted legis-
lation relating to physician's assistants. In Florida, for example,
legislation defining and regulating the functions of a physician's
assistant, as well as physician's assistant training programs, gives
the State Board of Medical Examiners the responsibility for certifying
physician's assistants to a licensed physician, who assumes responsi-
bility for, and supervision of, the assistant.
Organized medicine has had an ongoing impact on the evolution of
the P.A. concept. The various professional organizations of the medical
profession, such as the American Medical Association, have influenced
legislation involving P.A.'s, had impact on their utilization through
position papers on the need for, and potential functions of P.A.'s, and
maintained guidelines for accreditation of physician's assistant train-
ing programs. In addition, the National Board of Medical Examiners has
developed a national certification examination for graduate P.A.'s.
There have been four national associations established for
graduate physician's assistants. As is the case with most national pro-
fessional organizations, these associations function to promote recruit-
ment, training, certification, and employment of physician's assistants;
to promote professional integrity; to disseminate information of inter-
est to physician-dependent personnel through journals; to promote the
P.A. concept among both professionals and the lay public; to assist in
the development of role definition for the physician's assistant; and
to coordinate the activities of the physician's assistant with the
interests of the American Medical Association.
The concept of the physician's assistant is seen as a creative
solution to the health manpower shortage; as a vehicle for unburdening
highly trained physicians from many routine and delegable tasks to allow
for more time for critical medical problems or continuing medical
education; to allow for utilization of a vast manpower pool of people
with interest and aptitude in patient care for whom there is no room in
medical school; to provide avenues for upward mobility and increasing
opportunity for active patient care management for other nonphysician
health care professionals; to help check the soaring costs of medical
care through utilization of less-specialized and less-costly personnel;
and to provide more quality medical care, in general, by promoting more
patient contact and discouraging the neglect of primary, preventive,
and emergency care which has resulted from medicine's rush to
The emerging physician's assistants, however, have not easily
or completely found a niche among the wide variety of health care
specialists. Envisioned originally as in a dependent relationship to
the physician, and working alongside the physician, the P.A. role offers
great opportunity for conflict with nursing. As a highly skilled
assistant to the physician, the P.A., in both responsibility and
remuneration, may be usurping many of the functions, and much of the
prestige, formerly vested in more traditional allied health roles. In
addition, within the new physician's assistant movement, there appear
to be strains toward a degree of professional autonomy: a potential
erosion of one of the cornerstones of the concept, itself.
In short, there appears to be a great deal of uncertainty, or
even disagreement, with respect to the role of the physician's assist-
ant in health care delivery, and it is for this reason that the educa-
tive process needs to be examined. The process of role development,
crucial to an understanding of this emergent health professional, is an
important aspect of the professional educational milieu.
The data for this dissertation was gathered during a year and a
half work with the University of Florida/Santa Fe Community College
Physician's Assistant Training Program in Gainesville, Florida. The
main methodological mode, one which has long been accepted in social
anthropology, was participant-observation (Becker 1958; Cold 1958;
Becker 1956; Becker and Geer 1957; Whyte 1951, 1955): extensive obser-
vation of and/or participation in the daily activities of the physi-
cian's assistant students during coursework, study sessions, and leisure
activities. During the course of this participant-observation, informal
interviews were continually conducted, not only with the students, but
also with faculty and administration. During the latter stages of the
research period, a questionnaire was developed and administered to the
students, and a week was spent at the Second National Conference on New
Health Practitioners, the national convention for graduate physician's
assistants. Research also included evaluation of written data relevant
to the program, such as funding proposals, minutes of planning meetings,
and administrative memoranda; analysis of student personality profiles
(Myers-Briggs), and progress reports during the course of training;
observation of admissions testing and interviewing; and evaluation of
published data from other programs.
This investigation of the education of physician's assistants,
of their movement from the culturally defined status of layman to that
of professional, is oriented around three major perspectives in anthro-
pology. The first perspective, a seminal part of anthropological
theory for most of this century, involves the concept of "rites of
passage" (van Gennep 1909, 1960). The rites of passage model holds
that any transitions in social status within a given culture take place
in a tripartite sequence, with the major phases of the sequence being
separation, transition, and incorporation. In this formulation, the
individual (or group) undergoing transformation is separated or
detached from an earlier fixed point in the social structure, to enter
a state of marginal or liminal status relative both to the previous
status in society, and the aspired-for status to follow.
In primitive societies, the process which is the hallmark of
the liminal period is some type of instruction, the conversion from
potential understanding to actual knowledge. In such instruction, the
liminal person, such as an aspiring curerr," may be shown "sacred
objects," the use of which may be illuminated through the recitation
of myths; and there may also be a form of direct ethical instruction
by "teachers," "sponsors," or "inductors." It is believed that these
instructional activities alter the capacities of the liminal persons
and make them capable of performing tasks in the postliminal status to
In modern societies, the educational process has also been seen
as a rite of passage (Leemon 1972). Here, too, liminality is essen-
tially a period of transition between "states"; in the case of a
physician's assistant student, no longer a corpsman, nurse, technician,
etc., but not yet a physician's assistant either. This liminal period
is long and is often rather formalized. It is also characterized by
During the liminal period, there are structural and cultural
problems for the individuals in transition: it is necessary for many of
the structural relationships of the preliminal period (such as famiJy
ties, previous employment relationships, and friendships) to be annulled
or rejected. Of great importance, however, is the fact that, despite
the marked reduction or cessation of interaction with the social group
in which the student has been previously interacting, the student
becomes isolated in a new system with new patterns of interaction
(Chapple and Coon 1942:506). Thus, within the liminal period of pro-
fessional education, there exist sets of relations, rights, and duties
among students themselves, and between students and others, such as
instructors, with whom they interact, which compose a liminal "social
structure" and culture of its own specific type.
It is this structure of the liminal period for the physician's
assistant student which constitutes the second major theoretical per-
spective of this dissertation: the "student subculture," or simply,
"student culture" (Becker and Geer 1958; Kimball 1970). For many
years, educational theorists regarded classrooms merely as aggregates
of individual pupils (Dunphy 1972:29) and emphasis was placed on
formal curriculum. More recent studies (Thelen 1949; Trow et al. 1950)
have begun to explore the importance of groupings of students for the
educational process, and the concept of a "student culture" has been
given more clarity and used as a conceptual model for studies of educa-
tional settings (Becker et al. 1961; Leemon 1972).
These more recent studies view classroom or student groups as
"primary groups" (Cooley 1909) with distinctive social structures based
on the relative permanence of face-to-face association, and with
subcultures based on common values, expectations, and reciprocal roles.
This approach is most relevant for anthropology, which does not place
emphasis on the formal curriculum of an educational program.
From an anthropological perspective, the most inclusive concep-
tualization of the process of education is as a "transmission of
culture" (Kimball 1966, 1970), in which concern is not only with what is
taught and learned, but also with the social organization and cultural
processes which are important elements in the educational milieu.
Studies have demonstrated the importance of a "student system" in high
schools in which student peer groups, extracurricular activities, etc.,
have profound effects upon students and the school environment (Gordon
1957; Coleman 1961; Burnett 1964). Becker and Geer's study of medical
students (1958) emphasized that the salient variables of the training
period are not just curricular, but also involve the groupings and inter-
action of students, as well as the interrelations of students with staff,
faculty, administration, and patients. Their study revealed that, as
students came to know each other and confront curriculum, faculty,
administration, and patients in the course of their daily interaction,
they develop common expectations and perspectives characteristic of a
Perhaps the most basic rationale for a student culture rests
with the fact that students are in a liminal status. All students in
our culture, and particularly professional students like the physician's
assistant candidates, are essentially in a period of prolonged
"adolescence": a period of enforced dependency upon an "adult" world
which they cannot yet join (Jencks and Riesman 1968:28). As adults,
however, most students desire to organize their own lives, define their
own limits, and set their own ideals; and are forced to deny or question
the legitimacy of the adult world which they cannot join and which has
so much control over their daily lives. Since students have a hard time
relating to instructors, with whom they cannot compete nor be equal,
they can be seen to construct and relate to a world of their own: of
large student organizations and smaller more fluid groupings, of events
and activities, and of distinctive values and a sense of identity, each
of which is an important aspect of the structure and culture of the
liminal student state. Thus, the student group and the student culture
can be seen as adaptive responses to the liminal status of students in
society, the subordinate status of students relative to other adults,
and common participation in a formalized program of professional
The third major theoretical perspective of this dissertation,
that of symbolic interactionism (Cooley 1956; Dewey 1930; Mead 1934),
concerned with the assimilation of professional roles and values, under-
scores the importance of student interaction within the student culture,
as well as interaction between students and others in the educational
milieu such as instructors, administrators, and patients. Clearly, the
education of professionals involves more than the transmission of a
narrowly defined set of skills which are measurable by examination
(Hoyte 1965); professional education is also a process of "socializa-
tion" or "enculturation" which involves the assimilation and acceptance
by students of the basic values and assumptions of the profession as
they relate to professional roles (Jencks and Riesman 1968:206). In
short, one of the most important aspects of professional education is
the process by which students, with characteristic student roles and
status, assume professional roles and acquire professional status.
The perspective of symbolic interactionism emphasizes the tend-
ency of individuals to analyze and change their own behavior based on
the behavior of others with whom they interact. When applied to the
process of professional education, this perspective stresses the
importance of "role-taking" by students, based on the expectations of
others in the educational milieu with whom they interact. In other
words, the most important influences in the educative process are not
textbooks and teaching aids, but rather, instructors and fellow stu-
dents, who serve as "role-models." In their dealings with classmates,
students continually analyze and modify their own performance to con-
form to the expectations of a "student role," and out of interaction
with instructors, patients, and other professionals in training, stu-
dents acquire the essence of professional roles.
In summary, an understanding of the training of physician's
assistants is crucial to an understanding of their eventual professional
role in the delivery of health care, for which there is, as yet, limited
consensus. This dissertation is a study of physician's assistant educa-
tion from anthropological perspectives. The rites of passage model is
utilized in this inquiry because physician's assistant education moves
the aspirant from the culturally defined status of layman to that of a
This transition is highlighted by a long period in which students
are neither laymen nor professionals. A critical element in this
liminal period of the rite of passage is the relationships between
initiates, the "student culture," which arises as an adaptive response
both to student status, and to student interaction with nonstudent or
professional elements in the educational milieu. In addition to
assimilation of specific skills and facts during the educational period,
the students are involved in a "socialization process," involving the
assimilation of professional values and the basic elements of a profes-
sional role. The basis for this "role-taking" is the interaction of
students, both within the student culture and with professional faculty
Student life, in general, and the acquisition of professional
skills, values, and a professional role are highly influenced by the
shared perspectives, understandings, and expectations which are gener-
ated within the student culture. Such perspectives concern matters
relating, not only to their student status and student activities in
the program environment, but also to their emerging professional status
and professional activities.
It is hoped that, with the impact of the emerging new curer yet
to be fully assessed, and with training programs around the country
still in their nascent stages, this analysis should serve the interests
of both theory and practice. From a theoretical standpoint, the physi-
cian's assistant training programs are interesting because they are
training professionals for an undefined and potentially conflicting
role in the delivery of health care. Indeed, the physician's assistant
concept is not one of a new health professional, but rather the emerging
status appears to be that of a subprofessional, given that the legal
statutes governing practice limit autonomy from physicians. Practically,
it is necessary to assess and modify physician's assistant programs,
while the concept is still undefined, to allow for full and efficient
training and utilization of the new health practitioner. Fundamentally,
however, this analysis is designed to better illuminate the dynamics of
status transitioning through professional education, which is a major
rite of passage in the lives of so many in our culture today.
In the following pages, the presentation and analysis of data is
structured around the rites of passage model: the text is divided into
three main sections, corresponding to the three stages of separation,
margin (transition), and incorporation. In Part One, that of separation,
Chapter One will deal with the cultural background from which the
University of Florida's Physician's Assistant Training Program arose
and Chapter Two will deal with the preliminal status of the students
themselves. Part Two, that of transition, consists of Chapters Three,
Four, and Five, and will be concerned with the liminal or training
period, and the student culture as a dominant feature in the educational
process. Chapter Three will concern student perspectives toward student
status as they are patterned around sources of support and stress in the
program. Chapter Four is concerned with student perspectives toward
professional status and role, as they are introduced to the materials,
skills, knowledge, and values that they will utilize in their future
practice. Chapter Five considers some of the ritual and symbolic
aspects of the process of transitioning. Part Three, that of incorpora-
tion, encompasses Chapters Six and Seven, in which emphasis is on the
impact of the new curer on health care delivery. Chapter Six reports
on the types of employment that physician's assistants are engaged in
nationally as well as locally, the emerging relationships between the
physician's assistant and the more traditional health practitioners in
practice, and the relationship of the physician's assistant to the
patient. Chapter Seven then takes a theoretical look at the dilemma of
role definition for the physician's assistant, and the implications of
role development for the educational process and the process of health
care delivery. The dissertation then concludes with a summary and
discussion of the conclusions which follow from the preceding analysis.
SEPARATION: THE CULTURAL BACKGROUND
"When I was a young man I had dreams
in which I doctored people. I did
not take these dreams seriously."
From the personal experience of
a Northern Paiute Indian as recorded
by Park (1938:27-8).
For several days in early spring, the final candidates to be
considered for admission to the University of Florida Physician's
Assistant Training Program, for the class entering in the following
fall, file into individual interview sessions. The personal interview
is a culmination of an elaborate application and selection procedure.
For the class beginning in September 1974, three thousand
inquiries had been received by the physician's assistant program office,
and three hundred completed applications were eventually received. Com-
plete application forms include a photograph, transcript records from
all academic education, scholastic aptitude test results, and a personal
statement of "why I want to be a physician's assistant."
Based on these applications, the program staff selects a smaller
number of applicants to be evaluated further in a day of testing that
covers chemistry, mathematics, logical reasoning, and a personality
inventory (Myers-Briggs). It is the personal interviews, however, which
allow the program staff to make the final selection for inclusion into
the next entering class.
As the student sits in the interview room he is asked questions
by a panel of interviewers. A physician-administrator, a graduate
physician's assistant, a community college administrator, a community
college instructor, a physician's assistant student, and the head admin-
istrator of the program are usually present during interviews. Each
interview lasts approximately fifteen minutes, and the following ques-
tions, which were most frequently asked, illustrate the areas of great-
est concern to the program admissions staff:
"What would you, as a P.A., like to do?"
"What kind of community would you like to practice in?"
"What do you see as the P.A.'s job? How can the P.A.
assist the physician?"
"How hard did you find the aptitude tests?"
"If you had one minute to do it, how would you convince
me that you would be a good P.A.?"
"Do you have any aspirations to go to medical school?"
"What would your wife (or husband) think about your
being in the program?"
"How will you be able to afford the program?"
(to a nurse) "Can you justify leaving a profession that
is already shorthanded?"
"Would you be willing to cut your hair if it became
"What will you do if you don't get into the program?"
The major concern of interviewers is to identify those applicants whose
preliminal experiences are compatible with program goals.
However, program administrators, themselves, admit that the
selection procedure is largely experimental and based on assumptions of
what a "good P.A. candidate" ought to be like, due to the fact that
there is limited experience not only in the training of P.A.'s, but also
with their eventual utilization. In addition, the backgrounds and per-
spectives of the interviewers are diverse, and each brings to the inter-
view sessions his own opinions and priorities with respect to selection
Generally, however, it is assumed essential that prospective
students have demonstrated past academic success. The training period
is academically rigorous, and applicants with past academic problems
will, in all probability, have even greater problems in the program.
In addition, it is exceptional that applicants without previous health
care experience are considered for acceptance, and, if they are, they
must have demonstrated real strengths in academic areas. Program
administrators also do not want to accept students who have ambitions
to attend medical school after completion of P.A. training, as this
would significantly reduce the impact of the program.1 In addition,
program policies stress recruitment of students who indicate a willing-
ness to work in underserved areas after graduation, or students from
1Although all of the applicants disclaim any intention to try to
attend medical school, it is interesting that 40% of the class studied
reported having thoughts about attending medical school after having
minority groups. Motivation to recruit from minority groups may not be
entirely spontaneous; the federal contract funding the program calls
for active recruitment of such individuals. Applicants must also be
able to assume the financial burden of the program, and be able to cope
with the personal and familial disruptions that such concentrated study
and out-of-town clinical rotations make almost inevitable.
The process of final selection is difficult because of the over-
all high quality of applicants, the small number of applicants who can
be accepted, the diversity among the interviewers, and, perhaps signi-
ficantly, because of the nature of the responses given by interviewees.
In the interviews, many applicants do not demonstrate much knowledge of
the details of the physician's assistant concept, and many of those
that do seem to be parroting back statements from the various media
presentations about the physician's assistant. Few have direct contact
with the work of a physician's assistant. Thus, the specific informa-
tion gleaned from the interviews by interviewers is often more impress-
ionistic than substantive, yet interviews serve the purpose of comple-
menting the more factual data on applicants based on test scores and
While the admissions interview has some importance for the pro-
gram itself, as it provides for a group of inductees with specific
characteristics, it is also an event which marks the initial stage of
separation of students from their preliminal positions in the structure
of society. For those who receive a letter of acceptance, relationships
to family and friends begin to change, preparatory to entering the pro-
gram in September and developing new relationships with the very people
who were present at the interview.
While it is true that the liminal or transitional stage is of
paramount importance in understanding the movement of an individual, or
group of individuals, from one status to another, the period of tran-
sition cannot be fully understood without consideration of the pre-
liminal period. In the case of a professional education program,
knowledge of the historical or background factors is important for an
understanding of its social structure and educational process; who the
inductors are, utilization of facilities, the nature of curriculum, and
the basic assumptions underlying the training program. In the case of
individuals undergoing status change through the rite of passage of
professional education, each arrives at the doorway to liminality with
a unique set of preliminal features, with skills and perspectives
acquired as an incumbent of a preliminal position, which may affect in
profound ways his journey through the training period and the period
of incorporation to follow. Moreover, those who regulate and control
entry into the training program may select for certain characteristics
in background and aptitude. In short, the physician's assistant
aspirant brings with him into the program a whole constellation of
perspectives, values, fears, hopes, and abilities.
Thus, the purpose of Part One is to explore the backgrounds of
both the University of Florida Physician's Assistant Training Program,
and of the aspirants who enter training. The background of the formal
educational program can offer many insights into the training period,
as well as the future roles of those who complete training, and the
student backgrounds can influence, in important ways, passage through
the training period.
BACKGROUND OF THE PHYSICIAN'S ASSISTANT
In the late 1960's, word began to filter south that the physi-
cian's assistant program at Duke Unitersity was proving to be success-
ful. In 1970, a physician on the faculty of the University of Florida
College of Medicine, whose years in private practice in rural Florida
had convinced him of the potential of the physician's assistant con-
cept for health care, began to initiate action to develop a physician's
assistant program at the University of Florida. He knew that there
were communities in Florida where ambulatory health care was not
readily available, and that many rural communities had no physicians
at all. While Florida has an overall physician-patient population
ratio of one doctor per seven hundred population, nevertheless, twenty-
nine of the sixty-seven counties have a ratio of one doctor per 2,800
population. Four of these counties are completely without a phycisian
(Henry 1972a:l). The physician-educator met with state legislators to
write a bill authorizing training and employment of physician's assist-.
ants, and, simultaneously, submitted an application for funding to the
Bureau of Health Manpower of the Department of Health, Education, and
As a result of the political interest generated in the P.A., a
bill (No. 377) was passed by the Florida legislature in the spring
session of 1971 which, as an amendment to the Medical Practice Act,
provides a framework for the development of the physician's assistant
program. The intent of the law is to recognize the growing shortage
and maldistribution of health care services in Florida, and to encourage
a more effective utilization of physician skills by enabling them to
delegate health care tasks to qualified assistants. It also defines
and regulates the functions and education of physician's assistants;
it defines the medical services that the physician's assistant may per-
form and the circumstances under which he can perform them; it requires
that physician's assistant programs be approved by the State Board of
Medical Examiners and sets forth guidelines for determining such
approval; it provides for a procedure by which a physician can make
application for supervision of physician's assistants; and delegates to
the State Board of Medical Examiners the authority to adopt rules and
regulations pertaining to the education, practice, and employment of
Since passage of the original bill, the State Legislature has
demonstrated ongoing interest in the evolution of the physician's
assistant concept through correspondence with project administrators
and other subsequent legislation in support of P.A. training; the
legislature has, for example, recently voted to take over funding of
the program after federal support terminates in 1976. Thus, in Florida,
the physician's assistant has become a medical reality with firm
political and professional support at the state level.
Financial support for the first year of the physician's assist-
ant training program was provided through approval of the contract with
the Bureau of Health Manpower Education of the Department of Health,
Education, and Welfare. These funds were made available by the Compre-
hensive Health Manpower Training Act of 1971; and, at the time, it was
the intent of the government to continue the project on an annual basis
for a period of from three to five years, dependent upon the demon-
strated success of the program, the availability of appropriations, a
continued need, and satisfactory performance by the contractor.
The initial contract proposal from the University of Florida
requested funds to develop a prototype two-year training program for
Physician's Assistants in Internal Medicine, to begin in September of
1972. It was proposed that this prototype program could then be
replicated at the other medical training centers in the State.
Modeled after training programs already in operation, such as
the Duke program, the curriculum included a combination of academic
and clinical training extending over a period of twenty-four months.
The institution of the program required coordination on several fronts:
it was arranged that most of the academic work would be conducted at
Santa Fe Community College, with clinical training being made available
through both the Shands Teaching Hospital of the University of Florida,
and the Veterans Administration Hospital, located immediately nearby.
The community college facilities were considered ideal for
economy of training because several allied health training programs
(such as nursing, x-ray and medical technology, etc.) were already in
operation there. The university medical school was considered essential
because, in addition to the excellent clinical facilities in a major
university medical center, it was felt that the interaction in training
of the health professionals present would enhance the opportunity for
interdisciplinary education and future employment rapport. It was also
established that graduates of the P.A. program would be awarded degrees
from the community college, in addition to the P.A. certificate, at the
successful completion of the program of study.
Curriculum was designed to allow for student mobility in several
ways: it was to be general and broad based enough to allow for movement
between the various medical specialties with a minimal amount of
retraining; to allow the graduate P.A.'s to move about from one locality
and practice setting in the State to another; and to allow the graduate
P.A. to undertake further training, to encourage the acquisition of
greater knowledge and skills, and to assume greater health care
responsibility. The primary function of physicians trained at the
University of Florida is assistance to the primary care physician,
specifically, family practice, internal medicine, and pediatrics.
In the first year of operation, starting in September of 1972,
the didactic (or academic) and clinical aspects of training ran con-
currently. The twenty-two students who had been accepted after selec-
tion that summer spent part of each day at the community college campus
in class, and the remainder of each day in clinical situations at the
university. In the former setting, students were instructed in general
education courses, basic science courses, health science courses, and
special physician's assistant courses.
For the first nine months, this didactic curriculum was par-
alleled by rotating clinical training in all phases of medicine and
surgery, the purpose of this initial clinical work being to provide the
student with a broad exposure to medicine so that he might make more
knowledgeable choices of specialty rotations during the final fifteen
months of training, and also to allow for the student to appreciate the
perspectives of the widest possible variety of subdisciplines within
medicine. For this first year of operation, the program was designed
so that, following the first nine months of training, the student was
asked to select a specialty within which he would undertake a three-
month period of clinical training. The second year was designed to
encompass a continuation of the medical science curriculum, clinical
training within a specialty, and a final three-month internship, under
supervision, within the specialty.
For the second class of students entering the program, numbering
twenty-four, the curriculum format was modified extensively. Whereas
with the first class didactic and clinical coursework ran concurrently
during the first nine months, for the second class the first nine months
were devoted almost exclusively to didactic coursework. During the
latter two-thirds of this period, the students were introduced to
clinical settings through weekly meetings with residents in the hospi-
tal, who supervised the students' first patient contact, during which
they performed histories and physical examinations. The remaining fif-
teen months were to be broken down into ten different clinical rotations
(six required, four elective) of six weeks each, in a variety of spe-
cialties and settings around the state. The curriculum for this second-
year class of students, the group which is the primary object of field
observations for this study, will be discussed in greater detail in
Part Two. It is, then, this general educational format that the
students who are the primary object of this study were confronted with
in September 1973, and which they would follow for the next twenty-four
In concluding this discussion it is appropriate to review very
briefly the position of the U.F.-S.F.C.C. program, not only as it
relates to other programs, but also as it has implications for the
whole structure of the medical profession (Freidson 1970b:47-70). As
an educational experiment, the University of Florida Physician's
Assistant Program has had the advantage of precedents set by other P.A.
programs around the country, although local modifications had to be
made. Like the other programs of its type, however, this local program
is now a part of the educational arm of the formal structure of orga-
nized medicine. The institution and organization of the physician's
assistant program can be seen as a part of medical professionalism.
Its creation has been primarily a political problem, requiring the aid
and approval of the state and various representative organizations of
the medical profession, as well as the support of many individuals in
the cooperating educational institutions. Basically, however, it was
inspired by, and under the guidance of, physicians.
Paraprofessionals in medicine are generally distinguishable from
assistants in other professions in that they are ultimately controlled
by physicians (Freidson 1970a:48). Moreover, within the medical
division of labor, different occupations have prestige determined by
their relations to the dominant professionals. All occupations within
the system are stratified depending upon the varying degree of inte-
gration with the work of the physician, but all are accorded less
prestige by society than the physician himself. The backgrounds of
recruits to paramedical professions also traditionally differ from
those recruited into medicine itself. For physician's assistants, in
general, and for their training in particular, there is potential for
future conflict, because training by the medical profession can be
seen to contribute to an ultimately high status or position of the
trainees in the hierarchy of the medical occupations.
With physician's assistant programs like the Duke and Univer-
sity of Florida programs, the backgrounds of many of the students may
be closer to those of physicians than many other types of paramedical
trainees (see Chapter 2); the training program is lent more status by
virtue of its medical school and university-based affiliation, and
there is a relatively great investment of time in the training program
by the students. All of these tend to mitigate in favor of ultimately
high P.A. status within the health fields, perhaps approximating that
of the physician. At the present time, however, this potential con-
flict is eased by the legal definitions of the status of physician's
assistant, and the fact that physicians presently maintain primary
control of P.A. education.
It seems clear that the ultimate position of the physician's
assistant in the hierarchy of the medical profession may be determined,
in a large measure, by the nature of the recruitment and training of
prospective candidates. As a matter of speculation, when physician's
assistants begin to administer and teach in P.A. programs, an element
of professional autonomy not yet realized will have been achieved and
the ultimate impact of the physician's assistant on health care
delivery, as well as his status in the medical profession, may indeed
be different from what is now envisioned.
As will be discussed in subsequent chapters, the University of
Florida program is presently offering the type of program from which
graduates may move into presently uncharted and potentially variable
areas in the structure of medicine. Such speculation needs to be
postponed, however, until a closer look has been taken at these
students, and their journey through the liminal stage of physician's
The physician's assistant class studied here exhibits a wide
diversity of preliminal experience. Ranging in age from 21 to 41,
with an average age of 26, the class contains seven females and sixteen
males. Only three of these twenty-three have had no previous health
care experience, although several took jobs as orderlies or attendants
only after hearing about the program, recognizing that previous health
care experience was desirable, and after securing an application.
Thirteen of the students have baccalaureate degrees, and the range of
previous health care experience is truly wide, including nurses' aides,
orderlies, laboratory technicians, ambulance attendants, corpsmen,
nurses, and clinic administrators, among others.
It appears that the arrival of this diverse group of individuals
at the liminal stage of physician's assistant training is indeed fortui-
tous. Perhaps because the P.A. concept is still in its nascent stages,
less than one-half of the students reported that they had at least a
fair amount of prior knowledge of what to expect from the program, and
the remainder knew little or nothing. Many found out about the program
originally quite by accident and decided to apply. The following quotes
from students are telling:
"I stopped a guy in front of campus and talked for a few
minutes to him he was a P.A. student. My brother in
medical school encouraged me to investigate it when I
told him about it and I hesitatingly applied."
"I just happened to read a feature about it in the
"My brother sent me a clipping about the P.A. program
from the newspaper. .. at that time I was working as
"I don't know how I found out about the P.A. business
by word of mouth, I guess. At the time I was
working as an apprentice pipefitter and felt my
abilities and experience as a military corpsman were
"I read about P.A.'s in a medical journal."
The immediate and specific concerns of the program administra-
tors as they select candidates for admission, and the circumstances
under which applicants come to find out about the physician's assist-
ant program, however, are not the only preliminal points of interest.
In fact, they may reflect only the very terminal decision-making stage,
overlying earlier and more basic concerns for students and administra-
tors alike. For example, one of the more interesting questions that
arises in the course of interviewing prospective P.A. students specifi-
cally, and in the traditional studies of occupations, in general, is the
question of why the choice is made to embark on a particular career in
the first place (Ginzberg et al. 1951). Studies of physicians (Rogoff
1957; Fabricant 1954) and why they chose to become doctors illustrate
a wide variability in the reasons or processes by which they chose a
career in medicine. Even as one physician may report very vividly an
early lack of enthusiasm for medicine, others are struck by an early
and powerful (though inexplicable) attraction or "sense of calling."
As the following statements from field notes reveal, the motiva-
tions for physician's assistant students choosing a career in medicine
are equally as variable as those of medical students:
"I always thought it (medicine) would be a way of being
a positive force in the lives of people ."
"Medicine is a constructive career in which the inter-
action and relationships with people are rewarding.
And it provides a secure income."
"Well, the public has a positive image of health pro-
fessionals, and I guess I have too I always thought
it would be great to be able to cure people, to relieve
them of discomfort."
"It (choosing a career in medicine) really has to do with
me as a whole man one of my personalities that needs
fulfillment and completion.
"A spiritual element was very important it's diffi-
cult to describe; asking and receiving; really being what
you want to be."
"I never thought about medicine until the army wanted to
make me a medic. I thought, why not? Now I'm really
Thus, physician's assistant students express a wide variety of very
basic reasons for becoming interested or involved in medicine in the
first place. Many reasons are vague and refer to personal "needs,"
others are frankly spiritual or religious, some altruistic, some
materialistic and pragmatic, and some interest is stimulated com-
Although current theories of occupational choice can stress
either the importance of external social factors or internal psycho-
logical factors in the choice process (Ginzberg et al. 1951:20), so
variable are psychological factors such as the type and strength of
motivation in the decision to enter a medical career that it has
appeared unproductive to pursue such problems of immediate professional
choice. With medical students, effort has been directed toward empha-
sis on more social factors such as the time at which the process of
deciding to study medicine begins (Rogoff 1957:111).
In his study of career choice Ginzberg (1951) provides a useful
analytical framework with respect to the timing of occupational choice
determination with his concept of the "developmental approach." The
basic assumption is that an individual never reaches an ultimate career
decision at a single moment in time, but through a series of socially-
mediated decisions over a period of many years, with the cumulative
impact being the determining factor. Ginzberg posits three stages of
career choice, corresponding to stages in the development of the indi-
vidual: the period during which the individual makes what can be des-
cribed as a "fantasy choice" (at about the age of six or seven), the
period during which he is making a "tentative choice" (during early
adolescence), and the period at which time he makes a "realistic
choice" (at about the age of nineteen). In this process, the indi-
vidual becomes increasingly focused, rational, and committed. He
becomes increasingly aware of the barriers which stand in his way, and
the many lesser commitments which he must make to achieve his ultimate
When medical students were asked to recall how old they were
when they first thought of becoming a doctor (Rogoff 1957:111), varia-
tion in the reported time at which the process begins was great. Never-
theless, 51% of the medical students sampled report that they first
considered a medical career before the age of thirteen, and only 14%
first considered medicine after the age of eighteen. Of the physician's
assistant students, on the other hand, only about one-fourth report that
they first considered working in a health field before the age of thir-
teen, and fully 60% of the class did not consider working in a health
field until after the age of eighteen. Thus, although most of the
physician's assistant students held health-related jobs prior to
acceptance into the program, most decided to enter a health-related
profession quite late in life when compared, for example, with medical
Studies have shown that, like the physician's assistant students,
law students also make later career decisions than do medical students
(Thielens 1957:131). For the prospective medical student, there appear
to be definite, early, and overt acts which make the gradual commitment
to working in a health field. Since, for the medical student, the
definite career choice is keyed to the institutional requirements of
the educational system, he is compelled to make the decision early by
enrolling in a premedical course of study in undergraduate school.
Before this time his intentions are probably private and not fully
shaped, though nonetheless present. For the law student, the prelaw
curriculum is neither so clear cut nor so demanding; undergraduate
students may follow varied programs of study and not really decide to
go to law school until their last year of undergraduate training, if
In the previously discussed study of medical students, 85% of
the medical students surveyed indicated that they were younger than
twenty when they made a definite decision to study medicine, yet of the
physician's assistant students, only 48% reported that they had made a
definite commitment to working in a health field before the age of
twenty-one. Almost one-half of the P.A. students, then, were over the
age of twenty-one when they first actively committed themselves to work-
ing in a health field.
This lack of early career decision on the part of physician's
assistants and law students alike, when compared with medical students,
may be attributable, in part, to the fact that at the developmental
stage of "realistic choice," educational prerequisites for the former
are far less specialized and clear cut than are those for medical school.
Academic requirements for entrance into the P.A. program, for example,
stipulate only that to be considered for admission a candidate must have
graduated from high school (or the equivalent), be able to pass a
college-level chemistry course, and have either previous health care
experience or a B.A. degree.
The wide diversity in student backgrounds gives an indication of
the lack of established or well-recognized routes to acceptance into
physician's assistant training at the University of Florida, and the
possibility that either early consideration or commitment to work in a
health field is far less important in P.A. training than in the train-
ing of medical students. In addition, as has already been mentioned,
during the early developmental stages of career choice, those of
"fantasy choice" and "tentative choice," role models in both the case
of physician's assistants and lawyers are not as readily observable as
physicians. Few young people have contact with lawyers (because of the
nature of their professional activities) or physician's assistants
(because there are not many around), when compared with physicians,
whom they see often as patients, and perhaps even more dramatically in
appealing and charismatic splendor through the media.
The timing of a decision to study and work in a health-related
field is related to another aspect of the whole process of career
decisions, the degree of commitment to the chosen career. Whereas some
people, once they have chosen a particular career, have no doubts about
their satisfaction with the career and have no desire to change because
they feel that there is no other career which could satisfy them
equally, others give consideration to alternatives, feeling that their
chosen career is only one of several that they might find equally
Medical students who make early career decisions, for example,
tend to give little consideration to other potential careers, while
those who are older when they make the decision to study medicine tend
to consider medicine as one of several equally satisfying careers.
Since the physician's assistant students tend to be older at the time
of their decision to work in a health field, when compared with medical
students, it is not surprising to find that a high percentage of the
class studied (41%) report that being a P.A. is one of several careers
that they could find equally satisfying, and that 60% have had serious
doubts about their decision since entering the program.
When looking at the physician's assistant students, then, one is
inclined to see a group of individuals with differing degrees of
previous health care experience (88% feel that they had at least a
little medical knowledge prior to entering the program, and over half
feel that they had either a fair amount or a great deal of prior medi-
cal knowledge), many with a rather late-blooming interest in health
care, some not committed to the idea that a career in health care is
the only career that could satisfy them, over one-half of the class
with little advanced education, and many as having stumbled into the
physician's assistant program simply fortuitously or "because it seemed
like a good thing to try." While the selection of these students had
been based on some criteria, those criteria were flexible enough to
allow for the admission of an extremely broad range of individuals, in
terms of their preliminal experiences, to the liminal stage. Actually,
it is tempting to question the suitability of such students, when only
the external social factors are taken into consideration.
As previously stated, current theories of occupational choice
stress either the importance of external social factors or internal
psychological factors in the choice process. In reality, both seem to
be essential ingredients in a truly comprehensive theory. The previous
discussion has indicated that there are many factors external to the
individual which come to bear upon his career decisions, that these
factors operate with varying impact throughout the development of the
individual. Although these external factors are often easier to validate
empirically than the internal, both are essential to a reasonable consid-
eration of career decision. While not, strictly speaking, anthropologi-
cal, a helpful tool, the Myers-Briggs Type Indicator, has been devel-
oped, which can illuminate the correlations among psychological
processes, personality, and career choice. Its use can enhance our
understanding of physician's assistant students, their backgrounds,
their expectations, and how they are selected.
Experience derived from administering the Myers-Briggs Type
Indicator instrument to a variety of health professionals has estab-
lished that the health professions differ, as a whole, from other
professions, in the personality types they attract, and, in addition,
that within the health field itself the health professions differ from
one another, with some types frequently found in, and others rarely
attracted to, any given health field (McCaulley 1974:77).
Based on C. G. Jung's theory of psychological types (Jung 1923),
the Myers-Briggs Type Indicator is an instrument designed to measure
the basic differences between people in the way they take in experi-
ences (perception) and what they decide to do about them (judgment).
Jung's theory holds that much of the random variation in human behavior
is best explained by the basic differences in the way people become
aware of, and come to conclusions about, both the outer and inner
worlds of reality. Since the processes of perception and judgment are
utilized almost constantly in everyday life, the different styles with
which individuals perceive and judge have effects on attitudes and
aptitudes, ways of communicating, and even career choice.
Jung's theory describes two perceptive processes (sensing and
intuition) and two judging processes (thinking and feeling). One of
each pair of mental functions tends to be preferred over the other by
each individual, and through preferential use during early life each
individual tends to develop characteristic attitudes, traits, and
behaviors which can be distinctive of a "type" as measured by the
Myers-Briggs Type Indicator, People who prefer sensing over intuition,
for example, trust experience (the concrete and tangible), have a
greater capacity and memory for details of fact, and tend to be realis-
tic and practical. Intuitive people, on the other hand, are more com-
fortable with theory and abstractions, valuing imagination, possibili-
ties, and relationships in problem-solving. Of the decision-making
processes (thinking and feeling), those who prefer thinking will tend
to be more comfortable in the analysis of facts; will attempt to be
impersonal, objective, and logical; and will tend to prefer jobs
requiring technical skill. Those people who prefer to make feeling
decisions operate subjectively based on their own personal values, try
to be sympathetic and aware of what is valued by others, and generally
feel that human values are more important than logic.
Although people must engage in both types of activities already
discussed, one of the two perceptive and one of the two judging, they
tend to favor one or the other in dealings with the external world and
can be said to have developed either a perceptive or a judging attitude.
Perceptive types prefer to meet life expectantly and tend to be adapt-
able, curious, flexible, and spontaneous; judging types prefer to be
settled, systematic, and organized. In addition, individuals also
differ in orientation toward the inner and outer worlds, being either
introverted or extroverted. People who prefer extroversion direct
attention to people, objects, and events; and tend to be outer directed
and action oriented. Introverts tend to be more comfortable with a
contemplative, thoughtful orientation.
Thus, the four preferences, extroverted or introverted (E or I),
sensing or intuitive (S or N), thinking or feeling (T or F), and judg-
ing or perceptive (J or P), in combinations, form a sixteen-cell type
table, with each of the sixteen types identified by the four letters of
preference for each alternative (see Figure 1). The middle two letters
indicate the manner in which the individuals perceive and judge, and the
first and last letters serve to indicate a general orientation and
attitude of preference for either perception or judgment. With extro-
verts, the final letter indicates which of the middle two processes is
favorite or dominant in dealings with the outer world. With introverts,
the final letter indicates the auxiliary process which is used in deal-
ing with the outer world; since the favorite process is strongly com-
mitted to the inner world of ideas, it is the introvert's auxiliary that
determines his habitual attitude toward the outer world of people.
The Myers-Briggs Type Indicator has not been utilized as a
selection instrument for admission to physician's assistant training,
but it is administered to all applicants who are accepted for the final
interview. If the type indicator does, in fact, reveal basic differences
in the processes by which people deal with life-situations, and are the
product of continually confronting life-situations, then it should be a
revealing means of coming to grips with the internal preliminal charac-
teristics of physician's assistant students, and also of understanding
some of that which happens in the training period to come.
Figure 2 indicates the distribution of types in the physician's
assistant class which was the object of long term participant-
observational research for this study, as well as the class accepted to
begin training in September 1974. Although the numbers in each cell
ISTJ ISFJ INFJ INTJ
Introverted Introverted Introverted Introverted
Sensing Sensing Intuition Intuition
With With With With
Thinking Feeling Feeling Thinking
ISTP ISFP INFP INTP
Introverted Introverted Introverted Introverted
Thinking Feeling Feeling Thinking
With With With With
Sensing Sensing Intuition Intuition
ESTP ESFP ENFP ENTP
Extroverted Extroverted Extroverted Extroverted
Sensing Sensing Intuition Intuition
With With With With
Thinking Feeling Feeling Thinking
ESTJ ESFJ ENFJ ENTJ
Extroverted Extroverted Extroverted Extroverted
Thinking Feeling Feeling Thinking
With With With With
Sensing Sensing Intuition Intuition
Quoted with permission from McCaulley and Morgan (1973:51). ( 1973 by
Mary H. McCaulley and Margaret K. Morgan.
Myers-Briggs Indicator Type Table
J:: T!::::: ISFJ INFJ INTJ
:... 7.8%. 3.9% 5.8%
ISTP ISFP INFP INTP
2.0% 2.0% 7.8% 2.0%
ESTP ESFP EENEP:::: ENTP
-: :: 5.8% 9
:: 7.8% 3.29 5 .8% :- 5
1973 and 1974 U.F.-S.F.C.C.
Physician's Assistant Class
(N = 51)
ISTJ ISFJ i::^!^f::::: INTJ
-- ~--- :;::: :::: 3.2%
ISTP ISF P I:^ K-f'::: :::: ::: ;?:H::::: 2 ::
ESTP ESFP:: ENTP
--- 3.2.% :7.::: 6.5%
ESTJ ::::?: :::::: ENFJ ENTJ
ESTP ESFP ,.EP-- ENTP
1^ ---- --:_-__ ... ........ ----i] 5-. : -:.-- ^^ :
--P ::'SFPZ::"' 6.5T-
Quoted with permission from McCaulley and Morgan
Mary H. McCaulley and Margaret K. Morgan.
(1973:53). () 1973 by
Students in Art Education
(N = 31)
.0 i ...- ..t- .. -. .... ...-.... 6.1%
3.0% i L.:;? :::::::::.$:: : j 6. 1%
ISTP ISFP INFP INTP
0.4% 1.7% 4.4% 1.7%
ESTP ESFP ENFP ENTP
--- 3.9% 8.7% 0.4%
ESTJ i2::::~.i::: : : .: : ENTJ
... .........:: ::::: ::::: :::::
5.2% Z :: 7.0%
Quoted with permission from McCaulley and Morgan (1973:54).
Mary H. McCaulley and Margaret K. Morgan.
Ministers and Divinity Students
(N = 230)
ISTJ ISFJ INFJ INTJ
6.4% 6.8% 4.5% 4.0%
ISTP ISFP ::::ii:ii::ii INT
3.0% 5.3% 11 '::::::: 5.3%
ESTP ESFP &Kf:::1#::l:i: ENTP
in fo Mcai -.... (1974:98) .- /.. 197.
2.2% 5.6% 4 t 8%
ESTJ ESFJ ENFJ ENTJ
7.3% 8.5% 6.8% 4.4%
ion f ( 4 Cc)
by Margaret K.
University of Florida Freshmen
(N = 2,264)
O 1973 by
AdUpLec WL U diu =V* *-- \-- -
l:^ .86 .. i .
ISTP ISFP INFP INTP
.66 .38 .70 .38
S: : ::: : :::::::::: :::::::::i ..8.5 2 2. 2
ISTJ ISFJ INFJ INTJ
8.4% 6.1% 6.8% 7.7%
ISTP ISFP I.:.:-: I ..NTP.
2. 6% 2.6% :J:::.. 7.4%
ESTP ESFP ::AIR'i:: ENTP
2.2% 1.9% A/Fes:::: h 6.3%h
ESTJ ESFJ ENFJ ENTJ
7.0% 5.0% 6.8% 8.2%
Quoted with permission from IcCaulley (1974:108). Q 1974 by Margaret K.
.. T ....... .. .
Ratio: P.A./% U.F. Freshmen
ISTJ ISFJ INFJ INTJ
8.4% 6.1% 6.8% 7.7%
2.6% 2.6% F7.4%
(N = 2,022)
is INFJ INTJ
: ..: :.7 :: .57 .75
ISTP ISFP INFP INTP
.76 .76 .72 .27
ESTP ESFP ::::2WP.:::::: ENTP
-1.05 .Lda::i .92
-:.: :1:. : :: : .8:::: 5':::::: :::: l9
Ratio: % P.A./Z Medical Students
^::::::::,::::: :::::: IINFJ INTJ
.: ....t.:.::: .... ::: 4.8% .2.9%
ISTP ISFP t::'i :FP: INTP
1.2% 4.1% .O:;:.:: 2.4%
ESTP ESFP :::::i ;:::::: ENTP
1.7% 4.1% ::: S:M:::::: 3.1%
::sJ:: :::s :::: ENFJ ENTJ
: i 8.0% 2.7%
4._ _'i .:..__..__. .... .
Quoted with permission from McCaulley (1974:104).
Q 1974 by Margaret K.
Students, Faculty, and Practitioners in
(N = 414)
'T.j:. ::F..::.... INFJ INTJ
iiiiii iiii|ii iii r 2.9%
ISTP ISFP INFP INTP
2.0% 2.0% 6.7% 1.0%
ESTP ESFP ENFP ENTP
2.0% --- 6.9% 4.9%
.'." . .
... :: _"y. ENFJ ENTJ
.::::: ::. .. ... 5.9% 5.9%
Quoted with permission from McCaulley (1974:111).
Q 1974 by Margaret K.
Composite From Three Schools
(N = 102)
are small, the information should help to delineate just what types of
people entered into the process of becoming physician's assistants.
Those types which are most prevalent are shaded.
An examination of Figure 2 reveals a strikingly different pattern
from that of a sample of students in art education (Figure 3) and of a
sample of ministers and divinity students (Figure 4)(McCaulley and
Morgan 1973:52-54). In the physician's assistant class, two predomi-
nant types are the extroverted thinking types (ESTJ and ENTJ), and the
introverted sensing types (ISTJ and ISFJ). Both of the former types are
more comfortable being analytical, impersonal, and objectively critical;
tend to organize operations, situations, and facts; and carefully plan
and schedule objectives. In general, thinking people tend to gravitate
toward jobs where technical skills are needed. As extroverts, these
types of people tend to prefer to be outer directed, action oriented,
and people oriented, with a real breadth of interests.
The other predominant groups in the P.A. classes are the intro-
verted sensing types (ISTJ and ISFJ). Like the extroverted thinking
types discussed above, introverted sensing types operate better with
facts than abstractions, and have the capacity to realistically and
practically absorb, remember, and use them. In dealing with the outer
world, this personality is primarily judging, either thinking or feel-
ing. Both ISTJ and ISFJ people have the basic realism and capacity
for details of sensing types, as well as the planned, settled, and
systematic stability characteristic of the judging types. In short,
these people have been called the "superdependables" (McCaulley and
Morgan 1973:56). Although they are by nature contemplative and
thoughtful in orientation, when these introverts deal with other people,
the ISTJ's who are thinkers, emphasize analysis, logic, and decisive-
ness; but the ISFJ's, who are feelers, emphasize loyalty and considera-
tion, and with tact and sympathy show interest in people and concern for
The two remaining types which predominate in the sample of
physician's assistant students are ENFP and ESFJ. Both, like those
other predominant types already discussed, because of their extroversion,
are most comfortable when concerned chiefly with people. The ESFJ, since
the judging attitude makes feeling his most comfortable way of dealing
with people, values harmonious interpersonal relationships marked by
friendship, tact, and sympathy. With sensing as an auxiliary process,
however, an ESFJ is practical, realistic, and concerned with immediate
details. The ENFP, because perception using intuition is his most com-
fortable way of dealing with the outer world, is expectant, adaptive,
curious, flexible, and spontaneous. As a perceptive type, he attempts
to understand people rather than to judge them, and consequently is
skillful in dealing with them.
In composite, the Myers-Briggs Indicator pictures the physician's
assistant students as preferring to be action and person oriented,
analytical and factual, with ability to attend systematically to detail,
but with a significant number of students also possessing a capacity for
personal warmth and concern for individual feelings. These are quali-
ties which, presumably, seem well suited to delivery of primary health
The distinctiveness of the physician's assistant students with
respect to the Myers-Briggs typology is striking, as has already been
noted, when compared with the students in art education (Figure 3) and
divinity (Figure 4). The preponderance of art students is INFP, a type
which is characteristically most comfortable dealing in abstractions
and employing long-range vision and creativity of expression. INTP's,
a second large group of art students, also characteristically are more
at ease with possibilities, abstract thinking, and complicated problems
of engineering. ENFP's are enthusiastic innovators, seeking new possi-
bilities and new ways of doing things. Divinity students and ministers
differ markedly from the P.A. students and the art students, being
primarily FJ types. With a feeling attitude, these enjoy pleasing
people, tend to be aware of other people and their feelings, like
harmony, often let decisions be influenced by their own or other
people's feelings and personal wishes. With a judging attitude they
are typically characterized by planning, by making quick and often
inflexible decisions, and by a tendency to be satisfied once a judgment
is reached about a person, thing, or situation. Few of either the art
or divinity students come from the practical, realistic, and factually
oriented ISTJ, ESFJ, ESTJ, and ISFJ types, which predominate in the
From the above discussion, it is apparent that the physician's
assistant program has attracted students whose preliminal experiences,
as reflected by personality types measured by the Myers-Briggs Type
Indicator, are different from other groups of specialized students such
as those in art and divinity. It is also possible to demonstrate that
the P.A. students, themselves, represent a specialized type, either by
self-selection, or through selection by program administrators. Figure
5 is a type table for freshmen entering the University of Florida, and
illustrates little clustering or overselection of students from any
types except INFP and ENFP. The fact that the NFP-types predominate in
the freshman class may be due to the fact that intuitives (N), with
their greater facility for symbols and reading, and with interest in
seeing possibilities, meanings, relationships, and theory, and percep-
tives (P), who are adaptive, curious, flexible, and spontaneous, score
higher on the average on college board examinations, which favor this
type of mental activity rather than practical applications (McCaulley
and Morgan 1973:48).
In any event, it is clear that the type table for the physician's
assistant class (Figure 2) reveals clustering in areas other than those
of the entering freshman class (Figure 5). These two tables can be
combined in the form of a ratio as in Figure 6, where the percentage of
the total population of P.A. students representing each personality type
is compared with the percentage of the total sample of entering fresh-
men in each type. A ratio of greater than 1.0 in any type indicates
that a higher percentage of the total P.A. sample falls into that per-
sonality type than does that of the entering freshman class. The shaded
areas represent those types which seem to select themselves into, or be
selected into the Physician's Assistant Training Program to a greater
extent than would be expected by pure chance.
From Figure 6 it seems clear that the Physician's Assistant
Training Program has a greater than expected percentage of SJ types,
the types with sensing and judging, who tend to feel comfortable when
the situation calls for doing something systematically, who are skilled
at handling details and concrete experiences, and who like to have
things organized. These are, ". .. the types who are particularly
qualified to give detailed, systematic care in the health-related
fields" (McCaulley and Morgan 1973:50). Figure 2 also shows a high
percentage of NP types in the P.A. program, a percentage that is
obscured in Figure 6 by the large percentage of NP's in the freshman
sample. These NP's are the innovative and flexible people who, by
virtue of these traits, could also be expected to do well in a new
area of medicine.
Just as the previous discussion has shown that practitioners and
students in unrelated fields can be differentiated on the basis of
Myers-Briggs Indicator Types, the various specialties of medicine can
also be similarly differentiated. The type table for medical students
(Figure 7), while not as much at variance with the P.A. type table as it
is with that for art students, is nevertheless distinctive. Expressed
as a ratio (Figure 8), those types with higher numbers (primarily SJ
types) are represented to a greater degree among physician's assistant
students than among medical students. Figure 7 reveals that medical
students exhibit less clustering, or tend to be more heterogeneous with
respect to personality types, than the University of Florida P.A. stu-
dents. This is also true when comparison is made with two other samples
of primary health care deliverers: a sample of students, faculty, and
practitioners in nursing (Figure 9), and a composite of physician's
assistants from three schools, most of them from the University of
South Carolina MEDEX (Figure 10).
Comparison of all these samples reveals an overall general simi-
larity in psychological type among the health care segments when compared,
for example, with art or divinity students. Yet, within the sample of
health practitioners, differences are interesting. Medical students
exhibit the least "specialization" in terms of psychological type, with
the samples of nurses and physician's assistants primarily from the
MEDEX program exhibiting a distinct clustering in certain areas of the
type tables. That the University of Florida physician's assistants, who
are the objects of this study, fall somewhere between the extremes of
the other groups is clear when a comparison is made, and some interesting
hypotheses can be advanced. It appears that in the case of all these
groups of allied health personnel, SJ types (which have already been
noted for their preference for detail, system, order, and careful exact-
ness) predominate. The University of Florida physician's assistants, in
aggregate, appear to fall somewhere between nurses and physicians in
psychological type tendency; a state which is analagous to the apparent
position of the physician's assistant in the present scheme of health
care delivery. That these SJ types are even more pronounced in the
composite of physician's assistants from three schools may be due to the
fact that many of that composite were selected from the MEDEX-type
program. Such students are selected and trained to be much more task
oriented in their practice, and less educated in more general, primary
care medical functions.
As was mentioned previously, selection for the University of
Florida P.A. program was done without clearly delineated criteria
designed specifically for broadly educated physician's assistants.
Since the program is new, the students were chosen based on criteria
". almost like those for a medical school." Hence, the pattern has
emerged which is more similar to medical students and nurses than their
Counterparts in MEDEX. Hypothetically, at least, the overall University
of Florida P.A. Myers-Briggs profile should be encouraging, in view of
the intended utilization patterns of "Type A" P.A. graduates; from a
personality standpoint, at least, the students studied appear to be the
most heterogeneous (and therefore, perhaps, the most adaptable) of all
the nonphysician, allied health worker samples presented. It is also
encouraging to note, as an aside, that since primary health care fields
(including physician's assistant) seem to be attractive to SJ types, and
SJ types are the most frequent types in the general population, there
should be an adequate manpower pool, from a Myers-Briggs standpoint, for
future recruitment into physician's assistant programs.
It has already been noted that the proposed primary function of
physician's assistants trained at the University of Florida is assistance
to the primary care physician: specifically, family (general) practice,
internal medicine, and pediatrics. A major longitudinal study utilizing
Myers-Briggs assessment, relating the relative attractiveness of the dif-
ferent medical subspecialties to personality type (Myers and Davis 1964),
has shown that the various medical subspecialties tend to attract specific
psychological types whose preferred method of perception and judgment
match the tasks of the specialty. For example, almost twice as many
INTJ's were specializing in pathology twelve years after graduation
from medical school as would have been expected from the number in the
total student group administered the Myers-Briggs instrument during
medical school (yielding a ratio of 1.99) (McCaulley 1974). In Figure
11, the eight most prevalent personality types in the physician's
assistant class have been presented (accounting for 76.1% of the P.A.
students) and the ratio of relative attractiveness of the three primary
care specialties for each personality type, as measured in the above
study of physicians, has been noted. This ratio is the actual vs.
expected frequency of work within the particular specialties by
physicians. Listed in upper case letters are those specialties which
were the most and least attractive for each personality type.
These data would indicate that the types of students being
selected and trained in the University of Florida P.A. Program are of
personality types which, at least among physicians, find one of the
three primary care subspecialties attractive. Apparently the psycho-
logical types represented in the P.A. program are well suited to the
planned function of these physician's assistants: increasing primary
care capability through the use of assistants in general practice,
internal medicine, and pediatrics.
In conversations with students about medical care specialties,
those which were most often mentioned as least appealing were pathology,
dermatology, orthopedics, and surgery. Some of the following comments
taken from field notes, while often naive and contradictory, are
illustrative of the students' feelings about specialization:
"Pathology tends to be primarily research I can
read that in the journals."
"Orthopedics? well, it's just mundane."
"I don't think I would like surgery or pathology because,
of all the specialties, they have the least patient contact."
general practice 1.46
internal medicine .68
internal medicine .98
general practice .73
internal medicine 1.35
general practice .72
general practice 1.16
internal medicine 1.03
general practice 1.16
internal medicine .99
general practice 1.13
internal medicine .81
Relative attractiveness of primary care medical spe-
cialties to eight most prevalent MBTI types in physician's
assistant classes studied as measured by a ratio of actual
to expected frequency of each specialty within each type
among physicians. Percentage of total physician's assist-
ant sample in parentheses. Most and least attractive spe-
cialties for physicians of each personality type in capi-
tal. SOURCE: (McCaulley 1974:101). Revised with permission
from author. ( 1974 by Margaret K. Morgan.
"Dermatology just doesn't appeal to me because it's
not a life-threatening field."
"Orthopedics is out for me because I just don't have
the muscles needed; and ENT well, I've just never
been particularly interested in ears, noses, or throats."
"Psychiatry too vague."
"Geriatrics is too depressing."
"I don't think I'd like pathology because it does not
offer enough patient contact on the other hand,
OB-GYN offers too much, if you know what I mean."
"In surgery you don't get to follow up on a patient
on a long-term basis you don't get to really
"Pathology is work with things and parts rather than
with people like machine against emotion."
"Medical specialties? Well, surgery is mechanics,
pathology is no patient contact, psychiatry is
medieval, and dermatology mostly deals with
"I just feel so inadequate in the area of psychiatry."
"Dermatology? I don't think I'd like making a living
popping kids' pimples."
Thus, in support of the data from the Myers -Briggs scores, the
comments above would indicate that the physician's assistants are inter-
ested in primary care work. When asked on a questionnaire what the most
important considerations were as they thought about their careers, the
students overwhelmingly chose three: having patients who will appreciate
their efforts directly, working under the supervision of a really good
physician, and having the opportunity to know patients well. What con-
siderations do the students care least about? Those most frequently
chosen were being able to have set hours of work, and having prestige
within the medical profession. Given a choice between working at some
research, public health, or administrative job that does not involve
much contact with patients, and working with patients even though tasks
are relatively routine, 90% of the class would choose the latter, with
the remaining 10% willing to try either option. Most significantly, on
the same questionnaire, 90% of the class reported desiring to work in
general practice (65% rural and 35% urban) with the remainder stressing
the desire to work in a specialty such as OB-GYN or pediatrics.
An attempt has been made, in this chapter, to describe and under-
stand the preliminal characteristics of the physician's assistant stu-
dents, both social and psychological, which they bring with them to the
training program itself, and which must have far-reaching effects on
that liminal stage. Most bring with them abilities and aptitudes already
attuned to health care delivery, as most have previously worked (albeit
often peripherally), or wanted very badly to work, in a health care
field. For many, the motives for entering a health field in general,
and the P.A. program specifically, are as naive and late blooming as
the P.A. concept is new. As far as the future role of physician's
assistants is concerned, it is perhaps more realistic to say that they
are naive because the concept is new. While most of the students have
worked previously in health fields, their preliminal experiences cannot
really be termed career-oriented in the sense that they had made long,
or even lifetime, commitments to moving upward through a series of
related occupations and statuses within medicine. Rather, most had been
engaged in a pattern of random job mobility, or in occupations within
medicine in which career instabilities have been greatest; in the areas
requiring the lowest skills and education, the most exposure to
technological changes, and the weakest professional organization.
Thus, for most of the physician's assistant students, the promise
of the P.A. program is that it represents systematic education for a more
secure career. In the developmental terms of Ginzberg, it is perhaps the
first opportunity many have had, and perhaps the last that most will
have, to make a "realistic career choice" which suits their particular
aptitudes and desires to work in a more significant way in medicine.
Most have been willing to give up a settled position in a preliminal
status to take a chance that the finite insecurity of liminal status in
the P.A. program will reap them personal reward postliminally. Most
begin the program with apprehension and many question their decision
during the months that follow.
That the aptitudes and personalities of these particular P.A.
students are well suited for physician's assistant work, however, is
born out by their wide variety of preliminal experience, and their
personalities as revealed by the Myers-Briggs Indicator. With a will-
ingness and need to try to work in careers with a component of human
contact and service, with a devotion to detail and technical skills,
with careful attention to their work, and with a real capacity for com-
munication and innovation, the class as a whole holds great promise.
The students must now enter the transitional stage, the period of
education which alters the preliminal characteristics, inculcates new
values and skills, and makes each member capable of performing tasks in
the postliminal status to follow.
TRANSITION: THE STUDENT SUBCULTURE
". .. The shaman not only learned much
about the rituals of driving out evil
spirits in patients, but he came to
understand himself better."
From a description of the train-
ing of Ute Indian shamans (Opler 1959:106).
It is slightly before eight o'clock on an early September morn-
ing. For the first time, the physician's assistant students are
together, waiting outside the classroom in which an introductory orien-
tation meeting will take place. By both fate and design, the main ele-
ment in the social structure of the physician's assistant training pro-
gram has been formed: the coming together of students into a group. It
is at this initial meeting that the students first develop a sense of
"we" or "us," of group identification which is so crucial to the orig-
inal conception of the primary group (Cooley 1909:23). Before the meet-
ing is to begin, the students are standing about the hall staring aim-
lessly or chatting somewhat nervously. One conversation, quite typical
of many in the hall, goes as follows (author's emphasis):
A: "Boy, I sure had trouble getting up this early!"
B: "Yeah. Say, didn't I see you at interview sessions
A: "I think so. I still can't believe I got accepted!"
C: "What did you do before this?"
A: "I worked as an orderly ."
B: "And I was an ambulance attendant."
As the program administrators arrive at the room to start the meeting,
the conversation reveals a subtle shift:
C: "Well, here we go!"
A: "I wonder what they have in store for us today?"
B: "We'll soon find out .. ."
A: "Hope we don't have to get up this early every morning!"
With that, this cadre of individuals with widely disparate backgrounds
sits down in identical chairs and is handed identical packets of informa-
tion about program regulations, textbooks, course schedules, and group
health insurance. The students then hear the program administrator say:
"For the next twenty-four months you will be almost
totally involved with this program. Your life with
family and friends will probably not be as it was
before. Forget about jobs or other extracurricular
activities. Becoming a physician's assistant is a
twenty-four-hours-per-day, twenty-four-month process."
These two events mark the final separation of students from pre-
liminal status and interaction patterns, and transfer into the period
of liminality, with its own characteristic social structure. During
this stage new interactional forms are to be learned and practiced, as
part of the process of education.
In looking at non-Western peoples, the "social structure" of the
liminal period is bound up in the conception of relations between neo-
phytes and instructors and is very simple:
". .. between instructors and neophytes there is often
complete authority and complete submission; among neo-
phytes there is often complete equality." (Turner 1964:9)
So, too, in the physician's assistant program the key variables of the
liminal period are the student group, the relationships among members of
the student group, and the interactions of student group members with
other individuals outside the group, as they change throughout the
At this first orientation meeting, the processes by which the
students are formally separated from the rest of society, reduced to a
position of generally equal status, and by which the student group
develops a sense of comradeship and group identity can be seen to begin.
The student group is now a structural element in the program environ-
ment, with developing and changing relationships to other elements in
the milieu, as students move through the liminal period.
The formal "blueprint" or pattern of the liminal period is made
up of a nine-month segment of basic science coursework, followed by a
fifteen-month segment of ten different six-week clinical rotations.
During the first nine months, or didactic portion of the curriculum,
students attend classes at both the community college and the university
During the first quarter, all students are required to take
Human Anatomy, and in addition two "core courses" which are required of
all health and related professions students at the community college:
"HF", or Introduction to the Health Fields; and "BE", or The Individual
in a Changing Environment. At the beginning of the program, students
are given diagnostic examinations in Medical Terminology and Chemistry
to determine whether or not they can exempt those two classes, but of
the class studied only one student exempted chemistry and nobody
exempted medical terminology. Each of these courses is also taught by
community college faculty. Students are also required to take Patient
Evaluation and Record Keeping for two quarters, taught by faculty from
the university medical school.
Thus, a typical day in the first quarter of training would see
students arriving at anatomy laboratory for lecture and/or dissection at
eight o'clock in the morning; a return to community college classrooms
for "BE," "HF," or Patient Evaluation; a break for lunch at noon; a
two-hour chemistry lecture; a lecture in medical terminology; an hour
and a half or so for dinner; and, later, evening dissection in anatomy
lab or "study sessions." Such eighteen-hour days are also typical, with
some variation, of the following two quarters. Remaining curriculum
includes courses in medical science, such as Clinical Diagnosis, Human
Growth and Development, Pharmacology, and Minor Surgery, held at the
university medical center and taught by medical school faculty; and
Physiological Chemistry, Microbiology, and their associated laboratory
sessions, held at community college facilities, and taught by community
Towards the conclusion of the didactic portion of training,
students are assigned, in groups of three or four, to residents at the
university medical center or the Veterans Administration Hospital.
Students meet with the residents once a week or so to be introduced to
interacting with patients, to be shown various techniques and abnormal
physical findings, and to get used to working on a hospital ward.
For the fifteen months following didactic coursework, students
are assigned to clinical rotations in the various medical specialties.
These rotations take place in a variety of practice settings, including
hospitals, rural and urban clinics, and private practice settings, all
at various locations around the state. It is during these rotations
that students learn by actually interacting as members of health care
delivery teams, functioning in a variety of practice settings, and under
the supervision of physicians with a variety of interests.
Thus, the educational process of the liminal period is character-
ized by a variety of interaction forms, from the large classroom and the
teamwork of students in study sessions and laboratories, to the dyadic
relationships of the physician as master and the student as apprentice
during clinical rotations.
Perhaps the most critical element in the educational milieu of
the liminal period, however, is the relationships among initiates. The
student group can be seen to develop shared perspectives, understandings,
and expectations, first, toward their student status and student activi-
ties, later, toward their emerging professional status and professional
activities in the program. Both types of perspectives have profound
effect on the educational process.
In short, in our system of professional education, the relation-
ships among students and the resultant "student culture" can be seen as
an adaptive response to the larger organizations of which it is a part,
and of the socialization process to which it is party. It is the pur-
pose of Part Two to examine both this process of transition and the
perspectives of the student culture.
SOURCES OF SUPPORT AND STRESS: STUDENT
PERSPECTIVES TOWARD STUDENT STATUS
As was noted in the preface to this section, the student group is
now a structural element in the program environment, with developing
relationships to other elements in the program to which it must adapt.
The liminal position of members of the group, as well as their perspec-
tives regarding student status, are based on this interaction. The
student group develops perspectives regarding student status based on
support and stress from other elements in the larger social structure.
Program administration is generally the first element in this
program environment that students must confront. As noted in Chapter
One, administration of the U.F.-S.F.C.C. program has two bases: the
Division of Health and Related Professions at the Community College,
and an academic division within the College of Medicine of the University
of Florida. In the initial phases of training, students have more con-
tact with administration at the community college level.
Registration is likely to be the first contact between students,
as a group, and administration. To register for classes the physician's
assistant students have to go through regular community college registra-
tion. This registration is typical of many college registrations: long
lines, many forms to be filled out and approved, periods of waiting with
many other students in allied health programs, and payments of fees. The
students felt that the whole procedure of registration could have been
better organized. Since all of the P.A. students were required to take
the same courses, with the same credit, and the same fees, the students
felt that their registration could be handled on a group rather than on
individual basis; that a counselor could deliver all of their registra-
tion forms and approvals together and save the students all the
"hassles" with administrative "red tape."
These initial problems of registration illustrate a typical
example of what came to be a generalized feeling of "they" vs. "us" on
the part of students toward administration. Much of the early conversa-
tions between students centered around the administrative problems of
registration and orientation, and the earliest student interaction
involved riding back and forth together between the classroom buildings
across town and the main campus where registration is held. In this
manner, "problems" caused by administration served as a catalyst for
early student grouping and interaction.
As a new program, the P.A. training program was filled with small
administrative annoyances for the students: classes misscheduled, books
not ordered on time, and similar evidences of disorganization early in
the program caused students to view the administration with some skep-
ticism. Some statements from students serve to illustrate their
"They are trying to make us do it their way rather than
trying to understand our needs."
"It looks like the administrator of the program is what
I feared, not what I had hoped"
"It is clear that one of the real adjustments we're
going to have to make is learning to exist with
'"This damn administrative red tape there's only
one solution if you don't honor it, you don't
hassle with it!"
"If the administrators here in Health and Related
Professions really wanted to help us get around all
the administrative red tape at the main campus, they
could do it .. but they won't."
These perspectives were developed not only from early program
experiences, such as registration, but also from later contact with
administrators. At times program administrators brought problems on
themselves without realizing it. Late in the first year, for example,
some students were walking in late, or missing completely, their 8:00
A.M. lectures in medical science taught by visiting or guest physicians
from the College of Medicine. In addition, some students were failing
to call in and report absences as they are required to do. One of the
head administrators of the program, upon hearing about the problem,
told an assistant to be in class every morning at 8:00 to take roll.
If the students questioned why roll was being taken, they were to be
told that this would aid program administration in giving them good
letters of recommendation after graduation. The assistant did as he was
told except that he told the students only that the head administrators
had "ordered" him to come take roll. Whether or not the original
rationalization would have been accepted, the students felt that this
was an authoritarian, arbitrary, and capricious administrative decision.
Students were also alienated by administrative decisions to limit
vacations. On several occasions administrative decisions to limit
vacation time were given in rather authoritarian announcements which
reminded students that they had ". committed themselves to a twenty-
four-month period of concentrated training in which every day, including
Christmas Day, should be valuable." Some comments in the "continuing
battle of class attendance and vacations" made by students are telling:
"Wow, kindergarten again!!"
"It's the instructors who never come or come late!"
"I'm thirty years old and I don't have to be told
when to be where I'm supposed to be."
And the following note surreptitiously made its appearance on the chalk
board one morning before class:
"The break between classes will begin next Friday and
end on Monday. Classes will begin with delay and with
your presence on Tuesday. Be prepared to sign attend-
ance sheet, then fall out for spit-shine and white coat
Assistant Program Administrator
During the course of training, student contact with administrators
often took the form of either student-initiated meetings (both formal
and informal) to air complaints, or students' being called in to face
"the committee," (a group of faculty and administrators) when their
academic performance was not up to standards. Student-initiated con-
tacts were about matters of concern to students: the way a particular
faculty member was handling class, the need for more equipment or study
guides, the way in which tests were being graded, etc. In all of these
cases students were going to program administrators with problems in the
program environment which were causing them stress.
Students most frequently went to administrators with complaints
or problems about faculty or course-related problems and, as will be
discussed later, to faculty about administrative problems. In those
situations in which students questioned the performance of faculty mem-
bers, the actual substance of complaints was generally personality-
related. These and other problems were usually not readily amenable to
any immediate administrative resolution. Some of the following are
"There are just too many courses to do everything."
"There's not enough equipment in the lab because of
theft last year, and what is there is always locked
"She's too nervous to lecture effectively always
lectures to the board."
"He's too authoritarian and flip just won't give
straight answers to questions."
"She's great for teaching theory, but bad for technique
"That teacher is just uptight about students' drinking
cokes in class."
"Why should everything be done in nine months? Why
not take a year?"
"Why can't lab grades be separate from class grades?"
Those situations in which students question the "practices" of faculty
members are, in effect, the questioning of the practices of one segment
of the nonstudent world toward the students as a group. In turning to
administration to solve or resolve problems, however, students turn to
a structure which is equally external to the student group.
The mere fact that students turned to administrators about faculty
problems produced problems of its own. In the P.A. program, several
important faculty members are also administrators, and vice versa. Thus,
the normal chain of authority in the program structure is, itself, a
jumble of categories and a confusion of customary nonstudent roles. If
students felt that a faculty member was not performing up to their
expectations, there was no clearly differentiated administration, whether
or not sympathetic, to turn to. Essentially, students ended up turning
to those few administrators who were just administrators for complaints
about faculty members, and to faculty members who were just faculty
members for complaints about administrators. These people were the ones
who are most peripheral to the program, and the least able to do much
about the problems brought to them by students. Thus, from a student
point of view, while they seemed sympathetic, such persons were struc-
turally ineffectual in terms of supporting student causes.
Those people who were both faculty and administrators, who were
the most powerful in terms of altering program policies, were often the
least informed about the specifics of student concerns and heard only
the echoes of student complaint. Administrators do seem to realize the
characteristic nature of student complaint:
"Students always complain it's all part of
being a student."
"If I acted on all the student complaints, I would
spend so much time with trivia that the program
"They must just be nervous about the test later
In most cases, students come out of confrontations with administration
as frustrated as when they went in. Several comments and anecdotes from
a later time in the program are telling:
"This whole program is messed up! I don't know how
many times I've had to go into the office and complain
about one thing or another ."
"If you go to that administrator and complain about
something he just says 'that's the way it is so just
learn to live with it,' and he isn't willing to
change a thing!"
"I don't understand how an administrator, who is
supposed to resolve difficulties, can be so arbitrary,
authoritarian and stubborn!"
"You know, I was told that he once said to a student,
'It's my program, and I'll run it the way I want to.'
it just shouldn't be that way."
"I heard that there was a student last year who was
having academic problems and had to go before the
committee. He told the committee that he just
couldn't seem to read enough. The administrator at
the meeting said 'Well, take two weeks to see if you
can't learn to read better, and we'll see how you're
Perhaps the most noteworthy feature of these comments is their
general lack of substance. There is a considerable amount of hostility
expressed on many occasions, but the conditions or problems which caused
the students to consult with program administrators in the first place
are either not mentioned or assume mythological proportions. Instead,
it appears that animosity arises toward administration simply as adapt-
ive responses to student status. As was mentioned in the introduction,
students are in a period of enforced dependency upon program faculty and
administrators, yet they desire to define their own limits and organize
their own lives (Jencks and Riesman 1968:28).
In a sense, the administrators, as one component of the program
environment, can be viewed as having a great deal of control over student
life. It seems that the attitudes of the P.A. students and administra-
tion toward each other are comparable to those in other academic settings:
administration is almost uniformly maligned, and students are viewed as
chronic complainers. Understanding these perspectives rests not so much
with the specific problems which are raised, but rather with the recog-
nition that students, as a group, are seeking to maximize control over
their own lives. The mere fact of collective complaining, and the
formation of group perspectives regarding administration, serves to pro-
vide a source of strength born in group consensus.
The elements in the program environment which students confronted
most often, however, were faculty and the associated schedule of classes.
The class schedule and the requisite out-of-class studying is the largest
part of student life and student concern for the first nine months of
the program. It is not unexpected that much of group interaction and
the formation of group perspectives are structured around classroom
Students being confronted by a curriculum are essentially being
told what to do and how to do it by nonstudent elements in the program
environment. Becker et al. (1961), in their study of medical students,
showed clearly that students are quick to discover that they have a good
deal of freedom in choosing not only how much work to do, but also in
what directions to exert their energies. It is the "group perspectives,"
already noted as important factors in the plans of action followed by
physician's assistant students in interaction with administration, which
were seen by Becker and Geer as guiding medical student behavior in
academic activity as much as did the expectations of faculty. Simi-
larly, in the physician's assistant training program, student group
perspectives or attitudes strongly conditioned the amount and direction
of effort put forth by students.
In a sense, the exemption examinations provided the first student
contact with curriculum and faculty, and the perspectives generated with
regard to this contact prove interesting. Since they had relatively low
previous class assignments and little contact with faculty, this examina-
tion and the perspectives from which students viewed the examination were
precedent-setting. The examination consisted of 300 terms, prefixes,
suffixes, and abbreviations to define, and was considered exceedingly
difficult by the students. Passing the exam and exemption from medical
terminology required a grade of 80%. Many students just went down the
list of items and, after counting more than 20% that they could not
answer, handed in the papers and left. As these students filed out of
the room, there were some attempts to get everyone to leave:
"Come on, we're all in the same boat!"
"We might as well all take this course together."
Comments made by the students indicated that they felt the examination
itself was really difficult, and they wondered if the entire program
would be as difficult. Of greater interest, however, is the fact that
the medical terminology instructor from the community college also
expressed to the students the feeling that the exam was difficult. This
led the students to feel that the examination had been made up by the
head program administrator/physician, and that it represented the type
of work they would be expected to perform throughout the program:
"Boy, that test was hard! I can see we're in for
it in this program!"
"Yeah! Did you hear that the test was made up by
the head of the program?"
"Sure, but I also heard that he took the exam himself
and only made 70%."
"Look, everybody is in the same boat, so there is no
reason to get upset about all of us doing badly on
this test or any other test."
"We all have the same amount to learn .. ."
Thus, as with the first contact by students with administration through
registration, the examination in Medical Terminology served not only as
a harbinger of future work in the program, but also as a catalyst for
the initial development of student-group perspectives toward the
academic aspects of training.
A major impetus toward student grouping and the development of
group perspectives toward the training period was provided by the
anatomy class. The anatomy instructor, both explicitly and implicitly,
demanded that students work together. In the former case:
"Individual students in the medical sciences rarely
are successful study together."
"In working with the cadavers you must work in teams
one person should read the dissection manual
while the other dissects."
Implicitly, however, the anatomy instructor was even more of a factor
in the formation of group perspectives. His demeanor was often
purposefully authoritatian and he was enormously intimidating to stu-
dents. In the early part of the first quarter, for example, trans-
parencies were projected on the wall (tissue types, cell structure,
anatomical planes, organ systems, etc.) and students were randomly asked
questions about the slides. These transparencies were changed so rap-
idly that students complained they had a ". difficult time trying to
guess an answer, let alone think logically." Also, student answers were
never exactly acceptable. Some comments from the anatomy instructor:
"Sure, that's the upper lip, but we don't say 'upper
lip' we say 'superior labium'."
"No! No! not tibia! Left tibia."
"Listen, you'd better answer quickly on these slides!
When someone asks you a question during clinical rounds,
you'd better say something fast they don't care if
you're right or wrong, just don't stand there with your
Anatomy was also intimidating because of the amount of work the
"In dissection, memorize everything you see as you go."
"Nobody is going to flunk anatomy for not knowing an
esoteric point, but nobody will get an 'A' without
"I'm going to give you a certain amount of work to do,
and if you have to stay up all night working on your
cadaver, then that's exactly what you will do. At the
very least, I expect you to be in the cadaver lab every
other night of the week, and I'll be there to check on
"I know it's only the first week of the course but I'm
assigning two weeks of reading now you'll have a
hard time keeping up, believe me!"
Thus, in addition to the amount of work and the fact that dissection is
tremendously time-consuming, the general demeanor of the anatomy
instructor served to promote esprit de corps among the students, based
on a feeling of collective persecution. No students, even the best
academically, could avoid the pressures brought to bear upon the stu-
dent group by anatomy.
In many respects, chemistry and physiology were almost as demand-
ing as anatomy in terms of their academic rigor and the effect that this
had on students. Student discussions during the quarter almost always
equated these subjects in terms of difficulty. The chemistry and physi-
ology instructors, however, offered encouragement and went back over
points when asked, whereas, in anatomy, students were expected to "get
a lot more on their own." Nevertheless, anatomy, chemistry, and physi-
ology were of the greatest academic concern to students.
If the coursework in anatomy, chemistry, and physiology was the
greatest source of anxiety to students, it was also the source of great-
est satisfaction. This was the type of work they had expected to do
before entering the program. These courses are factual and practically
oriented, involve careful attention to detail and memorization, and have
a manual component as well. It has already been noted that the anatomy
instructor was extremely demanding of students: he gave little direct
advice on dissection ("You can read the dissection manual, can't you?"),
and, instead, devoted time in lab to clinical anecdotes or commentary
on the relative merits of dissection being done. In anatomy there
was clearly much more to learn than the students could assimilate, yet
the instructor acted as if they should "learn everything." Perhaps
it is more nearly accurate to say that he didn't tell them what to
study, or what not to study.
The perspectives generated in the student group with respect to
work in anatomy serve to illustrate not only student interest in the
course but also their solutions with regard to dealing with the work
"Really, learning what is expected is not hard, once
you've figured out what is expected."
"I bet the anatomy instructor isn't as tough on the
inside as he is outwardly he's probably more
than willing to help students if he is approached
in the right way."
"I'd rather be a little behind in anatomy than way
behind in medical terminology at least here
in anatomy we can more or less set our own pace and
work when we want to."
"Sure, the anatomy professor gets on our nerves, but
I don't think we should jump to conclusions before we
really get a chance to see if his techniques for
learning really work."
"Hey, we don't have to worry about how much dissection
we've done. We're keeping up with everyone else."
Students spent a great deal of time debating exactly what would have to
be learned, and how fast they could dissect. In general, they came to
feel that, if everyone studied at about the same level of specificity,
the instructor would have to realize that they had done the best they
could; if they all did badly, obviously his expectations were just too
high. The interesting thing about the debates about what to study, how-
ever, is the fact that students were forced to think and talk about the
material to be considered, a process which actually seemed to help them
As a group, the class had interesting ways of encouraging conform-
ity with respect to the amount of work done in lab, and the amount to be
learned. If one group of students on a particular cadaver (four stu-
dents worked on each) were dissecting "too fast," people from other
cadavers would walk over and say:
"You're going too fast to learn all the details .
now you've cut so much you'll have destroyed important
stuff you need to know."
If a group was working too slowly, and was spending too much time "with
details," students from other cadavers would walk over and say:
"You're spending so much time with details that you'll
never finish dissection you'll be here all night."
In this manner, student interchange served as a "leveling mechanism":
a method by which the group regulated the amount of work done and the
level at which material is learned. Additionally, mistakes were
rationalized. If a group went too fast, and couldn't find something,
students often commented:
Similarly, if a group just couldn't find what they were looking for,
the most frequent comment was:
If the student group was uncertain about what to study, or what
would be on the next examination, a student who seemed to have the most
rapport with the instructor would be designated to "go talk to the
instructor," and an elaborate system of communication about what was
discussed got the information back to all the students, at least to all
the students who were conforming to group standards.
Although less demanding academically, the two classes which were
the source of greatest controversy were BE and HF: the two core courses
taken by all health and related professions students. Physician's
assistant students had their own sections of these two classes, which
met on alternating days, immediately after anatomy class. The stated
purpose of "HF," Introduction to the Health Related Fields, was to
assist the student in gaining a better understanding of the health care
delivery system in the United States today and his role as an allied
health professional within that system, and to help the student become
familiar with the whole range of social factors in health care. The
purpose of "BE," The Individual in a Changing Environment, was not
clearly delineated, but seemed to involve getting the students to exam-
ine their own beliefs and feelings as they progressed through the pro-
gram, thus understanding better their own biases and shortcomings in
order that they might communicate more successfully with patients and
To test knowledge of social factors in medicine, students in
HF were required to take a diagnostic examination (on which they gener-
ally did poorly) and complete reading assignments outside of class.
Classes were supposed to be devoted to lectures and discussion about a
variety of topics: patient-practitioner roles, communication in thera-
peutic relationships, socio-historical perspectives in health,
the health team, medical care delivery centers, the community framework,
and psycho-social factors in health care. Despite the class outline,
however, discussion seldom conformed to plan and the instructor became
increasingly frustrated at her inability to structure the class activi-
ties or gain the cooperation of students. Student attitudes toward the
class were almost uniformly negative:
"We've been in this class for three weeks now and we may
not yet know where the course is going."
"I just dread coming to this class for 75 minutes five
times a week to listen to the same stuff week after week."
"This course is just another little box in the curriculum,
and I resent being forced into these little boxes."
A similar "curriculum box" which the students resented having to
attend was "BE". The only requirement for this class was to keep a
journal or diary of personal observations in the program. Classes were
largely unstructured and given over to discussion of what happened to be
bothering the students on a given day; role-playing, in which students
acted out the parts of patients and practitioners; discussions of com-
munication theory; and an occasional yoga session. The instructor, a
psychologist/counselor, consciously attempted to avoid the "pressure
approach" of anatomy and chemistry, and admitted that the unstructured
approach tends to make students a little paranoid. Whatever the reason,
students exhibited negative feelings toward BE:
"Since BE is mostly letting off steam, why is it
necessary to be here all the time?"
"BE is forced interaction if you don't feel
like interacting, you shouldn't have to."
"It seems to me that the grade in this course is based
on communication, and I just don't want to be forced to
"If there is no need to communicate, you just grope and
grope and that's what this class has been doing."
"Perhaps this class is superfluous because everybody
already gets to know each other outside of class."
"This course is nothing but group therapy."
Much as they did in anatomy, students exhibited adaptive behavior,
consonant with these perspectives, to deal with HP and BE. In the for-
mer, students encouraged discussion to roam far afield from the topics
to be discussed with little constraint from the instructor. Once the
students decided that the HF instructor was "sympathetic" to their
workload in other courses, they asked for class to be cancelled before
examinations or simply missed class to study. During most class periods
of both BE and HF, one-third to one-half of the students were ignoring
the discussion in progress and studying another subject. Students were
also overtly hostile to what was being presented in class. At one point,
the HF instructor actually brought in an outside arbitrator to try to
help "solve the problems." At times, students were creative with their
solutions, encouraging work or observation in a clinical setting as a
class project instead of so many lectures. This idea was adopted and
proved successful. In BE, where the instructor encouraged an even more
unstructured classroom atmosphere, students responded by turning classes
into enormous "gripe sessions," by studying other subjects in class, and
by cutting class altogether. In some cases students would get together
beforehand and decide how to "sabotage" class for the day so that they
could study, or not have to confront the scheduled subject matter.
In terms of faculty and curriculum, then, the student group in
the first year was confronted with a wide divergence in terms of both
substance and style, and perspectives generated within the student
group were equally divergent. The students generally viewed anatomy,
chemistry, physiology, medical science, and practical laboratories as
necessary and relevant (although difficult); medical terminology as a
bore and a bother (although necessary); and BE and HF as worthless and
a waste of time.
Many factors seem to contribute to the differential attitudes
toward courses and faculty, and, particularly, the negative attitudes
toward BE and HF. It has already been noted that the nature of the
subject matter covered in BE and HF was more theoretical and less
practically oriented than in other courses. Most physician's assistant
students have practical backgrounds and are not attuned to a theoretical
"You can read all the theory you want and sit here and
throw things back and forth across the room, but you'll
never learn anything unless you just go out and do it."
"I think we're dissatisfied with these courses because
we have not yet had a chance to play PA to put on a
white coat and a spiffy name plate and see patients."
In addition, these two courses met immediately after anatomy, and just
before chemistry. Essentially, this meant that courses requiring a
different type of mental activity were sandwiched in b- ,Teen courses
which required a mentality that the students were better prepared and
more inclined to operate with, and which seemed far more relevant to
their training. Therefore, while the original student perspective about
HF and BE was that these courses would be fun and a good change from
anatomy, the later perspective was that they were a waste of time which
could be better spent on anatomy, or preparing for chemistry.
In addition, during the first orientation meeting, the program
administrator had said, in effect, that BE and HF were courses required
by the community college and that students, while they might not like it,
had to "put up" with them. It is possible that such attitudes of pro-
gram administrators unwittingly influence student perspectives. Often,
people toward the top of an organization set the pattern for relations
in the organization more by the way they act than by written policies.
The formation of these group perspectives, however, may not be due as
much to the personalities of higher executives as it is to the overall
pattern of organization: students may have perceived the community
college component of the program, as typified by BE and HF, as extrane-
ous and irrelevant when compared with the university college of medicine
component. Nevertheless, personalities came into play when the HF and
BE instructors tried to reduce student anxiety about workloads in
anatomy and chemistry by altering their own courses; thereby reinforcing
the priorities already set by students.
Ultimately, it is perhaps most accurate to see the student per-
spectives and disputes with instructors as elements of the process of
adaptation to the program environment, and of students seeking to create
an environment in which they themselves have some exclusive control.
The exclusivity of the student group is perhaps best illustrated by the
reaction of the students toward BE and the BE instructor, who attempted
not to confront students, but to work with them even to the point of
"helping them to know each other better," and "to break down barriers
between themselves." Students, both consciously and unconsciously,
seemed to be confused by, and to reject, this whole approach as a
usurpation of the functions of the student group and as a distortion
of the distinction between student and nonstudent:
"Perhaps the class is superfluous because we already
get to know each other outside of class. If there
is no need to communicate you just grope and grope
and that's not what class should be used for."
The adaptive nature of student perspectives toward faculty and curricu-
lum is revealed in the most common complaints expressed by students:
"There is too much to learn and not enough time to
"I'm really tired of the stereotyped lecture method
"We're going to have to get used to the idea that some
of the curriculum is not pertinent and even downright
"I had not expected that curriculum would be this
"There is so much to do in so little time."
"Learning what is expected isn't hard, once you've
figured out what is expected."
"The biggest adjustment I've had to make so far is
learning to tolerate the outmoded lecture method of
instruction for nine months."
"Faculty can't agree on what is important .I feel
like the kid who was given a shovel in a room full of
manure after an hour or so he was found to still
be shoveling furiously asked why, he replied,
'With all this manure, there must be a pony in here
"The cause of the greatest hostility in the program
is the course load."
Each of these comments reveals a generalized feeling of confrontation
with curriculum and faculty which corresponds closely to the feelings
toward administrators discussed previously. When students are con-
fronted with more work than they can possibly handle, such as in
anatomy or medical science, or work that is quite difficult, such as
chemistry or physiology, it is clear that they themselves choose,
within limits, not only how much work to do, but also in what direction
to exert their energies. In addition, when students are confronted
with material or work they consider irrelevant, such as in BE or HF,
they will attempt to ignore, slightly alter, or radically alter the
conduct of the courses to suit their own interests. It is also clear
that the low priority given to BE and HF by the students may have been
unwittingly furthered by the administrative structure of the program
environment, comments by administrators, and other elements peripheral
to both course content and student interest. Whatever the case, these
student perspectives serve to give the student group a sense of solidar-
ity and of covert self-determination, in a situation of liminality and
of confrontation with nonstudent elements in the program environment.
Associations of classmates with more advanced students were
important elements of the program environment. As is the case with
other cultures or subcultures, elements of the student culture of the
physician's assistant program are "passed on" or transmitted from one
class of students to the next. While it is clear that sources of stress
in the program environment, such as administration, faculty, and
curriculum, serve to promote the formation of distinctive group per-
spectives and attitudes, older students often provide an important
source of support which also promotes the formation of group
Perhaps the earliest interclass student contact occurred at a
party given by a program administrator during the first week of class.
At this party, clusters of four or five students abounded; usually,
these clusters were made up of one or two second-year students, and the
remainder first-year neophytes. Second-year students were animated,
anecdotal, and were scaring the new students with a sort of smug "I've-
"Just wait, the first year will seem like hell,
and you'll love it when it's over!"
"Yeah, the second year will be much easier;
we're looking forward to it."
"I'm over the hill now!"
"I've gotten all the bad stuff behind me!"
In addition, however, these older students were also providing helpful
hints: what to study, extra books needed, buying used books, what
courses will be hard and which will be easy, faculty members, social
activities, work with patients, and future employment. The second-year
students continually impressed upon the new student several points:
Administration of the program is "screwed up."
Chemistry is really hard.
Students should develop a spirit of camaraderie
and cooperate with each other as much as possible.
Study groups should be utilized.
Class officers should be elected spokesmen
for the group are needed.
Seeing patients is a lot more fun than sitting in
In this manner, many seeds of the student perspectives to emerge later
are sown by upperclassmen.
In future years, the two classes of students would be more
separate, but, by virtue of the fact that vast curriculum changes were
made after the first year of the program, interclass contact was, for
one year, unnaturally high. In fact, students in the two classes had
some coursework in common, and members of the advanced class often
assisted new students by offering overt advice and assistance during
the year, and by covertly serving as "role models" for new students.
The new students, for example, could better know what to expect when
they start clinical rotations, simply because the advanced students
were already doing clinical work and supplying many anecdotes, hints,
and suggestions to the new students. It was clear that a great deal
of loyalty exists among students, even cutting across class lines.
Whereas faculty interest in the program of study and professional
development was regarded by students with great skepticism, or even
rejected (as was observed previously with the BE instructor), student
interest in other students became a crucial element in the organization
of the student group.
A useful method for viewing the ties between students, the
structural organization of the student group, and the sentiments
among students towards each other is a network analysis (Whitten and
Wolfe 1973). Network analysis can reveal the organization of a group
based on the systematic ordering of social relations, and offers the
feature that the network revealed is "grounded" in the observations of
real behavior, though assuming very little in the beginning about the
nature of that behavior (Aronson 1970:221). In addition to observa-
tion, members of the first-year class were asked on a questionnaire to
name the three other students with whom they spend the most time, the
activities engaged in, and the average number of hours spent with them.
Figure 12 reveals a partial network of the class based on these data.
The general organizational features of the class studied, as revealed
in Figure 12, can be seen as three tightly knit cliques, a female
isolate, and a cadre of other individuals who interact with less
frequency and exclusivity with a number of people. In addition,
although not included in Figure 12, several students reported signifi-
cant interaction with a certain member of the advanced class. This
student is the only connection between the two classes which has an
extracurricular basis. Other than this one individual, the two classes
can be seen as fairly discrete entities.
Sentiments of mutual affection are an important element of the
student culture, and can be seen as an outgrowth of student interaction
or group organization. It has already been noted that one source of
student group cohesion is the shared perspective of students as "we"
and other elements of the program environment as "they." Homans (1950:
121) has noted that friendliness within a group tends to be dependent
upon, or at least accompanied by, some degree of hostility toward
"outsiders" and, in this manner, students feel a sense of unity and
- m- --
Clique B |
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* ---- .: -_ ?
I,~- mI IILLI I~I
I ; /. '
0 0* *m^ "
y s .4'*
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00 0% *
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F2 20 .3
Interaction Network of Physician's Assistant Class
comradeship based on antagonism toward administration and faculty. In
addition, warmth of feeling among group members can be seen to heighten
as they successfully confront sources of stress or danger from the
environment such as tests (Homans 1950:117). Some student sentiments,
however, are products of group structure, of organization or interaction
within the student group.
By virtue of the fact that they were in class together, all mem-
bers of the student group had daily, face-to-face contact with each
other. In fact, classroom activity was the greatest source of student
contact: working on cadaver teams is a particular example of such
interaction. Typically, persons who interact frequently with one
another tend to like one another and, further, if interaction between
members of a group is frequent as they are forced to associate by an
external nonstudentt) system, sentiments of liking will grow between
them, and these sentiments will lead to further interactions, over and
above those demanded by the system of which the group is a part (Homans
1950:111-113). Thus, students who interacted frequently in class
activities, or because of proximity of seating in classes, often
studied together as well. If classroom activities provided the most
important impetus for student interaction and group organization, study
sessions out of class were the second most important. While much of
student group organization is a direct result of the exigencies of con-
fronting the academic system, P.A. students, brought into proximity by
coursework, tended also to develop friendships involving activities
which were entirely extracurricular such as golf, fishing, etc.
"Some of the people I consider 'best' friends are
people I spend little class time with, but still,
it varies so much from quarter to quarter, week
to week, and also depends on the stage the rela-
tionship is in."
"After getting to know people in class, I've
started to spend a lot of time with them outside
of class I really like the other students."
Turning attention again to Figure 12, although sentiments
between all students were prevalent during the course of study, it is
clear that interaction was not uniform throughout the class. Small
subgroups, or cliques, were an important aspect of the student group
organization; certain subgroups of students interacted much more
frequently with one another than they did with outsiders. It has
already been noted that this more-frequent interaction can be caused
by factors in the academic environment, but it is also true that these
individuals who interact more frequently are in general more similar
in their activities. Clique A worked together often in class and out
of class, had similar outlooks on the program itself ("a healthy
irreverence for things in white coats"), commuted to class together,
and often spent leisure hours together. Clique B and C also were fairly
exclusive in their associations. The remainder of the individuals in
class can best be termed as loosely-knit cadre of friends and associ-
ates who spent less time together outside of class, whose friendships
were more generalized, and whose mutual interests generally involved
studies. Many of these students, although they often interacted with
members of Clique A, resented the exclusivity and personalities of
some members of Cliques B and C.
These groupings, then, exhibited distinctive styles of behavior
with respect to both academic and nonacademic activity, and attitudes
toward these activities. Interesting is the fact that these cliques
can be differentiated by personality type: it is hypothesized that
people who are more like one another tend to interact more frequently
(Homans 1950:111). Figure 13 superimposes the clique networks on a
Myers-Briggs Personality Type Table (see Chapter 2), and illustrates
that clique composition tends to comform to personality types. An
especially interesting individual is labeled #6: early in the program
he associated almost exclusively with #5 and #4 (with whom he worked
most closely in classes), but, later, almost exclusively with #1, #2,
#3, and #7 (whom he more nearly matches in personality type). Thus, it
appears that in addition to structural factors, personality factors
also affect the mechanisms of social elaboration.
It is clear, now, that there existed internal subgroups within
the student group, conditioned in part by the external academic factors
and in part by internal personality factors. This differentiation had
important ramifications for the student culture. In Turner's conception
of liminality, liminal persons are ideally equal (Turner 1964:9), and
it is true that, in the class of P.A. students, there was little differ-
entiation of roles. Yet, there existed a certain degree of social
ranking. Within the P.A. class, there was a general agreement, as
revealed informally and by questionnaire responses, that students #14
and #1 were the best P.A. students, and that #1 would be the most
successful P.A. The classic study of the "Bank Wiring Room" (Mayo 1933;
Roethlisberger and Dickson 1939) indicates that a person's rank in a
Cliques in Physician's Assistant Class Superimposed
on Myers-Briggs Personality Type Table