The new curer

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Title:
The new curer anthropological perspectives in the training of physician's assistants
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vii, 195 leaves : ill. ; 28 cm.
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English
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Johnson, Thomas Malcolm, 1947-
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Physicians' assistants   ( lcsh )
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bibliography   ( marcgt )
theses   ( marcgt )
non-fiction   ( marcgt )

Notes

Thesis:
Thesis--University of Florida.
Bibliography:
Includes bibliographical references (leaves 187-194).
Statement of Responsibility:
by Thomas Malcolm Johnson.
General Note:
Typescript.
General Note:
Vita.

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University of Florida
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
aleph - 000166408
notis - AAT2789
oclc - 02824563
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lcc - R697.P45 J63 1975a
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AA00003937:00001

Full Text












THIE NEW CURER:
ANTHROPOLOGICAL PERSPECTIVES IN THE
TRAINING OF PHYSICIAN'S ASSISTANTS









BY

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


1975
























































Copyright 1975

By

Thomas Malcolm Johnson















ACKNOWLEDGMENTS


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

special thanks.

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


Acknowledgments.................................................. iii

Abstract........................ ............................... .. v

Introduction..................................................... 1

Part One Separation: The Cultural Background

Preface.................................................... 17

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

Preface..................................................... 135

Chapter 6. The Employment of Physician's Assistants....... 140

Chapter 7. The New Curer and the Dilemma of Role
Definition.................................... 160

Conclusions...................................................... 168

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


BY


Thomas Malcolm Johnson


June, 1975

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

models."

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

part.


vii.
















INTRODUCTION


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
the natives."



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

specialization.

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

follow.

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

instruction.

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

student culture.

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

socialization.

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

professional practitioner.

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

and patients.

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.
















PART ONE
SEPARATION: THE CULTURAL BACKGROUND



PREFACE



"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
necessary?"

"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

criteria.

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
been accepted.









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

transcripts.

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.















CHAPTER 1
BACKGROUND OF THE PHYSICIAN'S ASSISTANT
TRAINING PROGRAM



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

Welfare.

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

physician's assistants.

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

months.

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

assistant training.















CHAPTER 2
STUDENT BACKGROUNDS



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
newspaper."

"My brother sent me a clipping about the P.A. program
from the newspaper. .. at that time I was working as
an orderly."

"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
being wasted."

"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
interested."


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-

pletely opportunistically.

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

goal.

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

students.

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

then.

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

satisfying.

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.


Figure 1


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















Figure 2

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 ::
........o.* o...




















-I




















ESTP ESFP:: ENTP

--- 3.2.% :7.::: 6.5%


ESTJ ::::?: :::::: ENFJ ENTJ
ESTP ESFP ,.EP-- ENTP





















--.-..---'-'.-'--6.5%-
1^ ---- --:_-__ ... ........ ----i] 5-. : -:.-- ^^ :





























m Oo...............o
--P ::'SFPZ::"' 6.5T-
"i~i~i~i...:.........
. .


Quoted with permission from McCaulley and Morgan
Mary H. McCaulley and Margaret K. Morgan.
Figure 3


(1973:53). () 1973 by


Students in Art Education
(N = 31)


A









ISTJ INTJ
.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.
Figure 4


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)


Morgan.


by Margaret K.


Figure 5


University of Florida Freshmen
(N = 2,264)


43.


O 1973 by


V-


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.
Morg.an.
Figure 7
.. 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%













Figure 7


Medical Students


(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







Figure 8

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).
Morgan.
Figure 9


Q 1974 by Margaret K.


Students, Faculty, and Practitioners in
Nursing
(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%
.X. .


Quoted with permission from McCaulley (1974:111).
Morgan.
Figure 10


Q 1974 by Margaret K.


Physician's Assistants:
Composite From Three Schools


(N = 102)





47.


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





48.


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

their feelings.

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

care.

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

P.A. program.

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."
















1.
ESTJ (11.7%)
GENERAL PRACTICE
general practice 1.46
pediatrics 1.19
internal medicine .68
PSYCHIATRY

3.
ENFP (11.7%)
PSYCHIATRY
pediatrics 1.23
internal medicine .98
general practice .73
ANESTHESIOLOGY

5.
ENTJ (9.8%)
NEUROLOGY
internal medicine 1.35
general practice .72
pediatrics .72
OBSTETRICS-GYNECOLOGY

7.
INFP (7.8%)


PSYCHIATRY
internal medicine
general practice
pediatrics
PEDIATRICS


1.12
.79
.66


ESFJ (11.7%)
PEDIATRICS
pediatrics 1.51
general practice 1.16
internal medicine 1.03
PSYCHIATRY

4.
ISTJ (9.8%)
PATHOLOGY
general practice 1.16
internal medicine .99
pediatrics .75
PSYCHIATRY

6.
ISFJ (7.8%)
ANESTHESIOLOGY
pediatrics 1.43
general practice 1.13
internal medicine .81
PATHOLOGY

8.
ENFJ (5.8%)


PSYCHIATRY
pediatrics
general practice
internal medicine
NEUROLOGY


1.16
.99
.83


Figure 11

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
know them."

"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
patients' vanity."

"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.















PART TWO
TRANSITION: THE STUDENT SUBCULTURE


PREFACE


". .. 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
last winter?"









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

liminal period.

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

medical center.

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

college faculty.

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,





64.



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.
















CHAPTER 3
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

feelings:


"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
intolerable administration."

'"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
inspection."
Signed,
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

typical:


"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
up."

"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
in lab."

"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
would fold."

"They must just be nervous about the test later
this week."









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
doing!' unbelievable."


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

activities.

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
mouth open."


Anatomy was also intimidating because of the amount of work the

instructor expected:


"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
knowing some."

"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
you."

"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

load:


"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

learn.









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:


"Bad surgery!"

"Bad technique!"


Similarly, if a group just couldn't find what they were looking for,

the most frequent comment was:


"Bad cadaver!"


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

other professionals.

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
communicate."

"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

approach:


"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
learn it."

"I'm really tired of the stereotyped lecture method
of education."

"We're going to have to get used to the idea that some
of the curriculum is not pertinent and even downright
ridiculous."

"I had not expected that curriculum would be this
concentrated."

"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
somewhere!'"










"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

perspectives.

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-

been-there-before" attitude:


"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
class.


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- --

.946@ 9090


Clique A


Extensive Interaction
Frequent Interaction
Moderate Interaction


Clique B |


^6 \

**-i, ... -
* ---- .: -_ ?
I,~- mI IILLI I~I


Q ..



* *
* .



* *
O 5
*4
4 a

9

*


I ; /. '


* S

0%0
.4 a
-... I

0 0* *m^ "
y s .4'*



** ..: -.I
0* -
00 0% *

p ;EI* U.
*


% S
F2 20 .3


0


Figure 12
Interaction Network of Physician's Assistant Class


: E'O


Clique C


* El

**L
r.


0









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





















































Figure 13

Cliques in Physician's Assistant Class Superimposed
on Myers-Briggs Personality Type Table