It’s 2 a.m. in Bicknell, Utah, and Elmo Taylor PA’78 hears someone knocking on his door.

Opening it, he finds a man standing before him, slightly drunk, bleeding from his forehead. The man claims that he has just been in a fight.

“He was too big to fit on my kitchen table,” remembers Taylor, “so he laid down on my living room floor and I began suturing his forehead.” With Taylor’s Labrador retriever keeping a watchful eye on the patient—and the patient just as carefully eyeing the dog—Taylor finished the procedure in the stillness of his sleeping house. The suturing having had a sobering effect on the patient, Taylor was able to send him on his way (and to learn later that the “fight” was actually a rollover). “And sitting there with my dog, that was when I thought, Well, I guess this is what rural medicine is all about,” Taylor recalls.

Almost 200 miles to the north, a man enters the Fourth Street Clinic in Salt Lake City, yelling, “I need my TB medicine or I’m going to die!”

The physician assistant on duty, Peter Chapa PA’95 MSPH’95, discovers that the agitated patient had been under treatment for tuberculosis in another city—and that, in addition to the TB medication, he needs housing, treatment for alcoholism, and counseling. Quickly.

Working from a hierarchy of greatest needs, Chapa and others at the clinic coordinate with social-service organizations to get the patient his TB medication, a bed in a respite care facility, a space in an Alcoholics Anonymous program, and, eventually, a spot in a state-administered Directly Observed Therapy (DOT) program in a shelter.

Today, and several fortunate vacancies later, the patient works, keeps his appointments, takes his medication—and, Chapa adds, “has friends—people who care about him.” Chapa himself continues to spend each day at the clinic seeing new faces, “each presenting with unique challenges.”

When it comes to PAs—physician assistants—Chapa and Taylor, graduates of the Utah Physician Assistant Program (UPAP) at the U, are, well, a little unusual. Taylor was named national “Rural PA of the Year” in 1989 and Chapa was named national “Inner-city PA of the Year” in 2001. But what they do—quite well—is what most PAs do. They are on the front lines of health care: the first and sometimes only person that most patients encounter, the general practitioner who sees every patient and every ailment, the point of entry to a sometimes inhospitable health-care system.

“During the course of a day, I may see 20 to 30 patients, and every one of them is different,” Taylor says. “I never know what’s going to be behind that door when I open it.” Chapa agrees. “I take patients one at a time,” he says, “and I always have to be on my toes.”

Direct patient care is the cornerstone of the University’s PA program, which is currently in its 30th year of operation. “Our basic premise is ‘service to the underserved,’” says Don Pedersen PhD’88, director of the program. “Seventy-five percent of our graduates are in primary care, and 40 percent are in communities of 10,000 or less.” And, he points out, most of those PAs stay in their practices for a long time. “They don’t want to move into administrative ranks; they feel they’ve really made a commitment to patients.”

PAs at the U complete an intensive two-year graduate program in the School of Medicine. Like other PAs, they are licensed to practice medicine with a supervising physician; they are, in Pedersen’s view, “an extension of a doctor’s practice.” In most states, including Utah, they can prescribe medicine.

Both Chapa and Taylor clearly enjoy the one-on-one interaction with patients. Chapa, who had worked as an emergency medical technician and a laboratory medical technician prior to enrolling at the U, says, “I liked the medical part of being a med tech, but I didn’t like being stuck in a lab all day.” Even-tempered and nonjudgmental, Chapa is a crucial link for homeless patients whose everyday world is far different from the institutional world of health care.

“I started in homeless health care 12 years ago,” Chapa says. “I knew I wanted to work with low-income people. It’s where there’s the greatest need for, but the least access to, health care. Working with the homeless was more challenging than I thought it would be at first. These people are living on the streets, malnourished, often substance abusers, and have psycho-social issues. So the health-care issues are complicated by so many other issues.”

Observing Chapa’s waiting patients—tired looking and sometimes bundled in several layers of clothing, wearing everything they have on their backs—it’s clear that he is often their sole portal to many needed services. To care for his patients, who see him for everything from respiratory ailments and the flu to complications from diabetes, hypertension, and liver disease, the seemingly unflappable Chapa has had to construct a dual life. “When I first started, it was overwhelming. But now I try not to be frustrated by the things I can’t do and by the things the patients can’t comply with. When I go home, I try to leave it all behind.”

Like Chapa, and like most who enroll in the PA program, Taylor had prior health-care experience. “My first training was in the military. I was an Army medic and did a tour in Vietnam,” he says. “It was horrendous.” A member of the National Guard, Taylor is still a medical officer for an artillery unit.

Today, Taylor practices at the Westside Medical Clinic in Clinton, Utah, but for 11 years, he served the 2,000 people in Wayne County, Utah (including the 350 people in Bicknell), taking care of “everything from emergency childbirth to gunshot wounds.” (In fact, the first baby he delivered, he says, “was a breech baby in the back of an ambulance.”) It’s still the interaction with patients that draws him to his work. “The most gratifying part of my job now is the continuity of care,” he says. “I’ve seen people since they were little kids, and now they bring their own kids in.” In fact, the affable Taylor says that in Bicknell, he was almost too available to the community. “I had a lot of sidewalk consultations, people stopping me at church or in the grocery store to ask about a medical problem. I was essentially on call 24 hours a day, seven days a week”—not surprising, since his supervising physician was in Richfield, 60 miles away, and visited Bicknell only once a week.

The need for health care in rural communities was central to the creation of the physician assistant program in Utah. With a shortage of primary-care physicians in the late ’60s, C. Hilmon Castle, M.D., and William Wilson created the Utah Physician Assistant Program and its precursor, the Utah Medex Project.

Thirty years later, UPAP has graduated 700 PA practitioners; it’s the only PA program in the state and one of only a few in the region. Nationally, there are 129 accredited programs, and more than 40,000 people—including Chapa and Taylor—were in clinical practice as PAs at the beginning of 2001. A recent national report on PAs showed that solo physicians who utilize PAs significantly increase the number of patients seen, decrease patient waiting time, and spend more time with patients answering questions and providing preventive care. It’s no wonder that “physician assistant” is listed as one of the top 10 fastest-growing occupations, according to the U.S. Department of Labor, with a projected growth of 48 percent from 1998 to 2008.

As front-line practitioners, PAs also grapple with one of the biggest impediments to health-care access: money. Though both Chapa and Taylor see improvements in the system—Chapa in the better facility in which his clinic is housed and Taylor in the numbers of people being reached—they both worry about the costs of basic ser-vices.

“We have the best health-care system available,” Taylor points out, “but can we finance it? Nowadays, with managed care, things are so insurance driven. If a company changes its insurance carrier, then patients are displaced, and that can be hard.” At the Fourth Street Clinic, where 95 percent of the services are free to eligible patients, “we can only provide as many services as are funded,” Chapa says. “Most of our funding comes from federal grant money, and we get some state money, along with donations.” Even meeting the most basic needs of the homeless patients—shelter, food, and clothing—can be difficult if the social-service funding isn’t available.

Witnessing Chapa and Taylor at work in their clinics is a reminder of the importance of those fundamentals. For parents with a sick child, the elderly suffering chronic pain, or the homeless who are habitually ignored, interaction with a knowledgeable, caring human being surely expedites recovery. As Chapa points out, “I think a little kindness goes a long way.”

—Theresa Desmond is editor of Continuum.