paeav17n2.qxp 60 2006 Vol 17 No 2 | The Journal of Physician Assistant Education The PPrraaccttiiccaannttee:: Puerto Rico Physician Assistant Prototype Justine Strand, MPH, PA-C, Duke University Medical Center, Durham, North Carolina PA HISTORY INTRODUCTION Physician assistants (PAs) have achieved enabling legislation in all 50 states and almost all US territories, with the notable exception of Puerto Rico and American Samoa. (An attempt at passage of legislation authorizing PA practice in Puerto Rico was unsuccessful in 2000.1) Given that Puerto Rico is one of the last places in America to enact PA enabling legislation, it is surprising to learn that Puerto Rico had a PA prototype, the practicante, in the 19th and early 20th centuries. The practi- cante was discontinued in 1931 when the Puerto Rican legislature passed a new law regulating the practice of medicine. The Commonwealth of Puerto Rico is part of the Greater Antilles island chain in the Northwestern Caribbean. Christopher Columbus claimed the island for Spain in 1493, and it was under Spanish rule until it was ceded to the United States at the end of the Spanish American War in 1899. The island is 100 miles long and 35 miles across, and has 3,500 square miles of land and 750 miles of rugged coastline. A steep mountain range, the Cordillera Central, bisects the island from east to west.2 As recently as the second half of the 20th century, Puerto Rico had many isolated areas that were difficult to reach because of a lack of roads. Trujillo-Pagan observes that in the 19th and early 20th centuries “… physicians rarely set foot in rural areas. They saw rural, interior mountainous regions as inaccessible … these rural areas and the people who lived within them carried conta- gious diseases they felt ill-equipped to control.”3 Care of the poor in rural areas thus fell to another type of health care provider, who worked under the auspices of physicians—the practicante. On May 29, 1866, the Royal Subdelegation of Medicine, which regulated the practice of medicine in Puerto Rico under the authority of the Spanish government, authorized the profession of practicante.4 The practicante is a forerunner to the modern PA. A two-volume manual for practicantes published in Spain in 1951 covers a broad range of medi- cine, including anatomy, physiology, diagnosis and treatment, suturing wounds, and setting fractures.5 Practicantes were typically located in rural and isolated areas, while licensed physicians usually practiced in more populous urban centers. Practicantes were classified as either minor or major, and surgical or medical, and the major practicantes had responsibility for supervision of those classified as minor. Practican- tes’ duties included bloodletting (accepted medical practice in the 19th century), pulling teeth, minor sur- gery, and care of the acutely ill. Care of the sick was historically pluralistic in Puerto Rico, and was delivered by a variety of nonphysician and nontraditional practitioners, including comadronas and parteras (midwives), curanderos (folk healers), and curiosos (people who found medi- cine interesting and dabbled in it). This feature publishes articles on all aspects of PA history. Much of the material comes from the PA History Center, which is dedicated to the study of the history and legacy of the physician assistant profes- sion. Additional information can be found on the Society for the Preservation of Physician Assistant History at http:// pahx.org. Authors desiring to contribute to PA History should forward submissions to: Reginald Carter, PhD, PA Physician Assistant History Center 1121 Slater Road Durham, NC 27703 Phone: 919-941-9325 Fax: 919-479-9726 Email: pahx@mc.duke.edu Feature Editor’s Note: Feldshers, barefoot doctors, and frontier nurses are often cited as examples of prototypical physician assistants. But there is another, not previously men- tioned in the literature—the practicante. Exported from Spain to Puerto Rico, the practicante was used to extend physi- cian health care services in the com- monwealth from the mid-1800s into the 1940s. It is ironic that the last place in the US and its territories to enact enabling legislation for PAs was the first place in the Western hemisphere to legitimize and use a PA-like provider. — Reginald Carter, PhD, PA Justine Strand can be reached at justine.strand@duke.edu 61The Journal of Physician Assistant Education | 2006 Vol 17 No 2 The role of the practicante was adopted from Spanish tradition, as were (obviously) many of the customs and practices in the Spanish-speaking new world. The practicante was supervised by a physician or surgeon (or in some cases by major practi- cantes), and occupied a position we would describe as “midlevel” today. Costa Mandry notes that “the profes- sion of practicantes in Puerto Rico began as a consequence of the lack of physicians, the great number of patients under their [physicians’] care and the need for a person who could provide services urgently in [their absence].”6 A subtype of physician, called the municipal physician, was charged with caring for the poor in towns and villages and also had public health responsibilities for controlling epi- demics and providing for vaccination of the populace. Each was aided, by edict, by five practicantes.7 Municipal physicians were loosely defined and may not have had formal medical training. (It should be noted that this was not unusual in those days; until Abraham Flexner’s report on the scandalous state of American medical education in 1910, many mainland US physicians had for all practical purposes purchased their diplomas). Problems with access to care, com- bined with epidemics of cholera, bubonic plague, and the aftermaths of hurricanes, led to desperation on the part of government and the need to allow anyone who was willing to help to provide medical care. For example, curiosos and curanderos were authorized to vaccinate and pre- scribe in 1855, during a cholera epi- demic.3 This set the stage for formal- izing the role of the practicante through regulation by the Subdelegation of Medicine in 1866. A beloved figure in Puerto Rican history of the mid-1800s, physician Ramón Emeterio Betances, utilized a practicante. Betances received his medical training in France and later became a leader in the Puerto Rican independence movement. He was exiled on several occasions because of his opposition to slavery and his political activism against Spanish authority. Though born into a wealthy family, he cared for the med- ically underserved; history docu- ments his care for the poor people of Mayagüez during the cholera epidem- ic of 1855. On September 23, 1868, several hundred of his compatriots occupied the town of Lares, declared Puerto Rico independent, and set up a provisional government. The Spanish quelled this revolutionary spark, but the shouted motto of their revolution, “Puerto Rico Libre!” (Free Puerto Rico!) became known as the Grito de Lares (Cry of Lares) and remains the rallying cry for Puerto Rican independence. Betances’ prac- ticante, Juan B. Ventura, is listed in Spanish colonial regulatory records and noted in historical records as “el compañero de Betances (Betances’s associate).”7 Arana-Soto provides documenta- tion of the duties of the major practi- cante of surgery: “It is your obliga- tion to treat the sick and injured as soon as they arrive at the Hospital, and if the [level of injury] requires it, involving the surgeon by notifying him of the diagnosis and treatment you have provided.”7 The practi- cantes’ manual speaks to role social- ization: “In all your activities, obedi- ence, respect and submission to the physician will be the basis of profes- sional regard, but in no case should this become servility or adulation, because the only real servitude we all owe in our profession is to the sick.” The manual goes on to assert: “The auxiliary mission requires a decided spirit of collaboration between physi- cians and their helpers for the bene- fit of the sick.”5 The practicante continued to exist after the US government took over regulation of medicine in 1899 but was eliminated in 1931 when the Puerto Rico legislature passed a new law regulating the practice of medi- cine and did not include practi- cantes. In 1945 a law establishing a role of “surgical technical auxiliary” (surgical technician) was created, which subsumed some aspects of the practicante’s scope of practice.6 Despite their loss of legal status, some practicantes continued to pro- vide health services, particularly in rural areas. In 1942, when a proposal to expand training for public health in Puerto Rico was being debated, pub- lic health director Myron Wegman suggested that practicantes should undergo formal training through the new school. He wrote: “At present these men are looked down upon because of the inferior nature of their work. We must, however, recog- nize the actualities of the situation. They carry and will continue to carry a large part of the burden of medical care of the people. They are fre- quently criticized for practices beyond their ability but no attempt seems to be made to supervise or instruct them. Training would serve the double purpose of making them effective within their legitimate sphere of activity as well as making clear the danger of doing things for which they have no training.” Dr. Wegman’s suggestion was not adopted, and the practicante remained without legal standing in Puerto Rico.8 The practicante has a place in history alongside Russia’s feldshers and China’s barefoot doctors. As Perry and Breitner noted in 1982: “The ‘discovery’ in the United States that appropriately trained nonphysi- cians are perfectly capable of diag- nosing and treating common medical problems had been previously recog- The Practicante: Puerto Rico Physician Assistant Prototype 62 2006 Vol 17 No 2 | The Journal of Physician Assistant Education The Practicante: Puerto Rico Physician Assistant Prototype nized in both Russia and China.”9 A similar discovery was made in Spain and exported to Puerto Rico, where the practicante was utilized extensive- ly until legally discontinued in 1931. Perhaps it is time for history to come full circle and enable today’s physi- cian assistant to contribute to health care in the Commonwealth of Puerto Rico. ACKNOWLEDGEMENT The author would like to thank Nicole Trujillo-Pagan, PhD, for her assistance in the preparation of this article. REFERENCES 1. Gardenhire R. American Academy of Physician Assistants. Letter to Sen. Kenneth McClintock, Request to sponsor enabling legislation for PAs in Puerto Rico in 2006 legisla- tive session. 2005. 2. Peffer R. Puerto Rico. 2nd ed. Haw- thorn, Vic: Lonely Planet Publications; 2002. 3. Trujillo-Pagan NE. Health beyond prescription: a post-colonial history of Puerto Rican medicine at the turn of the twentieth century. DAI. 2003;64(06A):298. 4. Costa-Mandry OG. Report on establish- ment of an accredited medical school at the University of Puerto Rico. Río Piedras, PR: University of Puerto Rico; 1944. 5. Box María-Cospedal A. Manual teóri- co-práctico para practicantes, matronas y enfermeras. 3rd ed. Madrid: Instituto Editorial Reus; 1951. 6. Costa Mandry O. Apuntes para la historia de la medicina en Puerto Rico: breve reseña histórica de las ciencias de la salud. San Juan, PR: Departamento de Salud, Estado Libre Asociado de Puerto Rico; 1971. 7. Arana-Soto S. Historia de la medicina puertorriquena hasta 1898. San Juan de Puerto Rico; 1974. 8. Ramirez de Arellano AB. Education for public health in Puerto Rico: 1940-1942. P R Health Sci J. Dec 1991;10(3):157-164. 9. Perry HB, Breitner B. Physician assis- tants: their contribution to health care. New York, NY: Human Sciences Press; 1982.