INTERVIEW TOPIC LOG

0:39 Early life and education, attending NCCU 3:40 Early research and lab work, time spent in Air Force 6:04 Transition from early medical school to enrollment in PA program 8:12 Impact of Civil Rights Era, lack of diversity in Duke PA program 10:51 Newness of PA position and belittling from pateints 13:44 Opportunity for growth at Lincoln Community Health clinic 14:44 Start of role as Director of Minority Affairs and beginning of recruiting at HBCUs 17:47 Addressing Black community concerns about recruiting students to be PAs instead of doctors 20:22 Educating students about PA requirements and training 22:58 Overcoming intimidation of Duke reputation in recruiting 24:10 Positive relationship with HBCUs 25:47 PA history and emphasis on diversity 29:22 Eliminating bias in teaching and admissions processes 32:46 American Academy of Physician Assistants African Heritage Caucus founding, Black Duke leadership 35:20 Project Access and recruitment 37:11 Misconceptions and value of PA role, the need to “sell the role” 40:06 Early work with Lincoln Community Health Center, underserved patient care 44:06 Recruiting with fewer resources, recruiting online 46:46 Increasing diversity in PA Program leadership, importance of no longer being the only Black faculty member 49:34 Lack of regret in choosing PA role, joy in son’s success

FULL TRANSCRIPT

Caroline Overton 0:04 My name is Caroline Overton, the date is March 13, 2024, and we're interviewing in Durham, North Carolina, in the Duke Physician's Assistant Program building. And I'm interviewing Lovest Alexander [Jr.], for the Agents of Change Oral History project. And thank you so much for being here with us. So to start off, What was your early life like? Who were your early influences? Lovest Alexander 0:39 That is a good question. I grew up in Warren County- and that's about 60 miles north of here- in a small town called Wise, North Carolina and went to public school there. I grew up in- I guess you would call it Jim Crow days, of which there was segregation in that area. And I went to an all Black elementary school, middle school, and high school. And I was also an athlete, and played three sports, and also maintain a pretty decent academic GPA. And I graduated third in my class. CO 1:52 And my understanding of is you went into the military after school? LA 2:00 After leaving high school, I enrolled at North Carolina Central University, which is an HBCU school. And I majored in pre-med. I was a biology and chemistry major. And at that time, I wanted to go into medicine. And what inspired me about going into medicine when I was a junior in high school, there was a teacher who I guess saw something in me that I was fascinated with science, other than sports. And she motivated me and talked to me about going into a- enrolling in a summer program [name?] at North Carolina Central which was founded by the National Science Foundation. And so I went into that program and there's where I really- my interest in medicine started. But I still love sports. And at one time I was thinking about majoring in sports education, but I changed my mind and- before I went to college- and I continued in pre-med. I finished pre-med, and I got- my first job was at Duke out of school as a research assistant in the Department of Immunology and Microbiology here at Duke. And I only worked there for about six months, and then I later went on to work at the US Department of Agriculture Forest Service. And that was during the Vietnam War that I was about to be drafted [into]. So I elected to join the Air Force. And fortunate enough, I was placed in a- my assignment was I was a medical laboratory specialist in the Air Force, initially in a hospital and clinic in upstate New York- Newburgh, New York. And later I was sent to Wheelus Air Force Base, Tripoli, Libya, which is in North Africa. Wheelus was the largest base overseas for Air Force at that time because it was a training facility for our pilots to come in and bomb out there on the desert during the Vietnam War. So I stayed there 15 months. And after that tour, I was sent to Brooks Air Force Base Aerospace Medical Division, in which I later was doing research. We did research until I got out. When I was released from the Air Force, I came back to my US- my job at the National Institute of Health that was at the- [Break for 30 seconds] Yes, I worked for the National Institute of Health [Division of] Environmental Health Services at Research Triangle Park. And that was right- then I applied to medical school. And- because that was always my goal- and I was admitted to medical school at the University of North Carolina. I did interview at Duke, and I was put on a waiting list, but I didn't get in. But right before- and so I entered medical school. And I had- My wife was- I had a two year old son- about a year and 11 month old son during the time that I entered medical school. And some months prior to entering medical school, my wife became ill. And she got sick on a- she was a teacher here in Durham County- and she got sick on a Friday, and she died on a Tuesday. So I was left with a two year old son to take care of, and I guess it's kind of rough to take care of a son when you're in medical school. Two years old. My mother took my son, and she was just retired from teaching, but I didn't want my mother to take care of my son. So I stayed in medical school a couple of years at Carolina. And so I decided that I probably needed to take a different route of my desire to be in medicine. And so I came over to the dark blue side and entered PA school in '76- about a year so after- a year after I got out of medical school. CO 8:07 What were your feelings about Duke like at the time? LA 8:12 It was- My feelings at Duke at the time were kind of mixed, in the sense that that was in the early '70s, and we had gone through a lot. While I was overseas, Martin Luther King was killed. It was during the Civil Rights- and also John F. Kennedy, and- no, Robert Kennedy, not John F., Robert Kennedy. And the country was in a lot of turmoil at that time. So when I came back, things were kind of- they were a little bit different than when I left. And a lot of things happened while I was overseas, really, in Africa- North Africa- when I was in the military. Because the night- the day that Martin Luther King was assassinated, we had a riot on base. There was an uprising. And I was working in the hospital. And I had to report to the hospital because we thought we were gonna have a lot of patients at that time. It was kind of scary. But we did- Things quieted down. But when I came to Duke initially, when I entered PA school in early '70s- I was in 11th class here- I was only Black in my class out of 40 students. But I was determined. I- well, quite naturally, I'd been in medical school two years- and I asked the director [Dr. Reginald D. Carter] did I have to go through the first year? Because most of the courses I had already done and passed. Anatomy, physiology, microbiology, and all of that I had taken at UNC. And so he said, "Yeah, you have to go through it just like anybody else," you know? But there was no problem with that. CO 10:31 What had your feelings been about the idea of becoming a PA instead of a doctor- I'm sorry. To rephrase that, what were your feelings about the prospect of becoming a PA instead of a doctor early on? Or your impression early on of the Physician Assistant Program? LA 10:51 It was actually my mother, who was very intuitive, in that- And she was a visionary. And prior to going to medical school, she said, "You know, they have this new program at Duke called 'Physician Associate Program.' And you might want to look into that." And I looked at her and said, "No, Mom, I'm going to medical school." I always tell my students this: "Always listen to your mother. Because your mother's right." And so I ended up being a PA. So she knew from the beginning, I guess, [laughter] that I might end up being a PA, I don't know. Actually, when I got out of PA school, being that I was in- there were less than 10,000 PAs practicing in the United States- and so I was in one of the early classes. Because the program started in '65, and I finished in '78, because I was in 11th class. But things were pretty [pause] gray about PAs, and most of the patients didn't know who we were, and what we could do, and that type of thing. And they said, "Oh, you assist the doctor." I said, "Yes, in a sense, but we work collaboratively together. And the physician is usually our supervisor, but we do things autonomously ourselves." So we had to sell the profession. So it was a lot of selling of the profession at the beginning. People- patients didn't know who we were, and what we could do. And sometimes a patient would refuse seeing us. I've had patients who said "No, I want- I came in to see the physician, not a PA." And then the physician would get upset and have to go and explain to the patient who we were. And so the physicians really helped us sell the profession at the beginning, which was a good thing. CO 13:22 What was diversity at the time like for physician assistants? You mentioned being the only Black student out of 40 in your class. Was there a much emphasis at all on diversity at the time within Duke administration or efforts to work on inclusivity? LA 13:44 Well, after working as a PA, initially I worked at Lincoln Community Health Center prior to coming to Duke. And then I worked in internal medicine at Duke. And I was working in the outpatient clinic in which residents- medical residents- would see their patients. And many of the residents had very complicated patients- patients who are underserved and that type of thing. And I worked in a clinic in diabetes and hypertension. And so, I was kind of working with them collaboratively trying to- because they would only see patients one day a week. But I saw these patients every day. I was there every week. So I became interested in teaching aspect and so I came to the director of the PA program at that time [Dr. Reginald Carter] and asked him that I would like to join the faculty here, because I was doing some teaching. Anyway, I was precepting some students, and he said, 'I have a good job for you.' He said, 'I would like for you to join the faculty, but I would like for you to be over the minority affairs for the program.' So he, the director, hired me initially- Dr. Carter- as Director of Minority Affairs. And so that's when- so I asked him, "Why did-" He said "Because we need to do something about diversity in our program." And so I developed a program in which I started recruiting from HBCU schools. So I made a list of HBCU schools in the country and in Durham- I mean in North Carolina- and I started out recruiting from those particular schools initially. And then I broadened it to schools that had- like UNC, and Duke, and East Carolina, or Wake Forest, and other schools- that also had African American students. I start recruiting at those schools too. So that's where it has come- where it started. It started in the beginning at HBCU schools, and then I've gone over to other schools, but majority schools. CO 16:44 Was the decision to start at HBCUs at all impacted by your own attendance of an HBCU? LA 16:50 Yes, absolutely. Because I knew a lot about HBCU schools. And I've recruited at every HBCU school in North Carolina, and many of the HBCU schools in Virginia, and some HBCU schools in Georgia, and HBCU schools in D.C., Howard. CO 17:20 And you've mentioned before [in PA History Society oral history interview] that there are certain concerns that some students or administrators that HBCUs feel about veering students into PA programs as opposed to medical schools. How do you assuage those fears or go about navigating those conversations? LA 17:47 Well, we have to sell the profession. And many of the leaders- Black leaders- in the medical profession thought that we were selling the Black students out by emphasizing the Physician Assistant/Associate Program instead of emphasizing medical school. And so I remember vividly the president of National Medical Association (NMA) had a table once at the beach- one of the beach meetings that they were having- and he walked by my table, and he said, "Duke Physician Assistant Program." He said, "That's what you're down here doing?" I said, "Yes, sir." He say, "You should be recruiting for a medical school, not PA school." He said- So I looked at him, and I said, "Well, we need- there is a shortage of individuals of color in all aspects of health. So I'm just- a PA is just one part of it." But at the time, they thought that we were selling the Black people out by emphasizing PA education instead of medical education. And that was a hard sell, in a sense, because the students in undergraduate school were aspiring to be physicians. I guess, science professors and their health advisors were telling them that, "You should go to medical school, not PA school." Because they didn't know anything about PA education, and they didn't know anything about what PAs could do. But that has changed over the years, and it's more difficult to get in PA school than again in medical school now. CO 20:13 What have been some of the other challenges in recruiting students at the HBCUs? LA 20:22 Other challenges? Well, I had to- the requirements of getting into PA school were slightly different in this sense of individuals had to have some healthcare experience or patient care experience prior to matriculating into a PA program. And so, if you're talking to a student in undergraduate school- usually if they coming in right out of undergraduate school, they don't have that. So they would always ask me, "How can I get that patient care experience or healthcare experience prior to matriculation?" And, I just tell them about different things that they could get into, like EMT, become a nursing assistant, becoming some other profession prior to going into PA school. And the reason for this is that PA school is only two years here at Duke, but the average PA school is around 27 months. So it's a shorter process of learning. And you out- Once you pass your certification exam, you start practicing. So that's kind of scary to some people. Because you know, you're talking about two years, and you're out practicing, as opposed to four years in medical school, and internship, and residency, and now practicing by yourself. But medical students do start practicing and after medical school. They do an internship, or they do a residency, but they are practicing. But they are practicing as a resident, so that's a difference. So I had to sell that to the health providers and the health advisors about that concept. CO 22:45 What do you find students views of Duke are, usually, when you're recruiting at the HBCUs? Is that at all a barrier? LA 22:58 That's a good question. And yes, because they are frightened at Duke. Duke has a name. And when you start talking about coming to Duke, for any type of education, they say, "Well, I can't get into Duke.' They usually- And I usually tell them that, "Yes, you can. If you have the qualifications, you can get in." Because we have a holistic approach to education, admissions. A holistic approach and not just- We don't [just] look at GPAs and just one aspect of your training, your knowledge base. We don't just look at what you made on the GREs. What've you been doing? We look at the entire applicant. CO 23:56 What is it like to- having attended an HBCU yourself- [go] to HBCUs for recruiting to Duke as a representative of Duke? LA 24:10 It's a good thing. They are glad to see me. I have a relationship with North Carolina Century University. I've had it over the last- I guess 30 something years. And I have been fortunate enough to recruit a sizable amount of individuals from that school. And from other schools too, HBCU schools from North Carolina, A&T State University, Bennett College, Virginia State University, Virginia Union, Shaw University, St. Augustine University- that's having some problems- but we have had students to come from those individual schools also. CO 25:17 And how have you seen the Physician Assistant Program at Duke change- Beyond- I'm sorry, to rephrase it a bit- beyond just the recruitment, have there been other changes to the Physician Assistant Program to encourage more diversity and inclusion that you've been involved in? LA 25:43 At present? CO 25:44 Or in the past few years. LA 25:47 Well, absolutely. That's why I was hired. I think I was the first faculty member in PAEA [Physician Assistant Education Association] that was hired, specifically, for diversity. That's all the PA programs in the country. And I was the first one that was hard initially for recruitment, and diversity and inclusion. There are some other programs- about two or three other programs- that have faculty members who specifically concentrate on diversity and inclusion. And most of the programs now- just over the 200 and something programs that are listed in the United States that we have- have some type of diversity, equity, inclusion in their program. They emphasize that. So they have seen it. I've spoken at PAEA meetings about our accomplishments and some of the challenges that we've had. But over the years, with Dr. Carter, seeing, having that vision- And Dr. Stead [Eugene A. Stead Jr.]. I was fortunate enough- Dr. Stead, who started the PA profession at Duke. You know the PA profession was started at Duke? And by Dr. Stead, who was an internist, and he was over there Department of Medicine. I was fortunate enough to have a lot of conversation with him every year that he would come and talk to us about- And he was very much interested in diversity and in diversifying the profession. Because it started with military corpsman. He had a vision that PAs- We had started up because there was a shortage of physicians during the time. And so that's why the profession was set up for it to be two years, so you can get people out quickly so they can go out and start practicing in areas of need. And people who are- There are some areas in North Carolina, as we speak, some counties that don't have healthcare providers, in some rural areas, you know, remote areas. So that's why the profession was set up that way, so that we could go out and fill the gaps that are out there. But we are now- I have the opportunity to work with our Division Chief and Director of the PA Program at present [Dr. Jacqueline S. Barnett], who is very, very much in front of the- everybody's voice. Diversity is concerned because she is very much attuned to it. And she emphasizes that. CO 29:11 What have some of those other initiatives been? LA 29:14 What's that? CO 29:15 What have some of those other initiatives been for diversity and inclusion been, beyond just the recruiting? LA 29:22 Well, we trying to have diversity, inclusion, and inject it into our teaching of our courses. That we will emphasize that in all of our teaching, and instructional types of things, in cases- case presentations. And anytime someone comes in and gives a lecture, that they will think about that in their lectures- of emphasizing diversity and inclusion in their lectures of when you're talking about patients. And alleviating biases. Because at one time, we had quite a few biases in case presentations. Of presenting like, "You have a 25 year old African American woman." That's not necessary. And when you're giving a case presentation, obviously it's not some disease that's specifically for African Americans. Instead of saying that, you could say, "A 25 year old female, who is here for such and such and such." You don't have to emphasize race or ethnicity in your presentation. And we're trying to eliminate those biases and things of that nature in our teaching and across the board in everything that we do. In admissions, we have blinded a lot of the things that we have been having before. We don't look at schools that the individuals are from, initially. We have an admissions committee, but when we're getting ready to interview, we blind that information out so that the interviewers don't know what school they came from- they know what area they came from, but- because that's a bias in itself. Because you might have an applicant from North Carolina Central University, and most people will say, "Well, that must be a-," you know. They look on that. Their education might not be [as] up to par as a person from the University of North Carolina or, you know, some other school- Harvard, or Yale, or Hopkins. Where if you blind that, if you take that out, you're only talking about a person who is from such a such a place, and you're not putting things in that are biases. CO 32:26 With the American Academy of Physician Assistants African Heritage Caucus, what was it- What was the lead up to founding that? Or the decision process behind it? LA 32:46 During the time back in the early '70s and '80s, the academy- AAPA [American Academy] of Physician Assistants]- the academy was only focusing on- It was very white across the board, no diversity, whether it was Asian, whatever. It was very Caucasian driven. So we felt that we needed to have our voice heard, and more individuals of color were coming into the profession. So we decided that we, in order to groom a leadership or to instill leadership in the academy, is to have our own individuals as a caucus. There were other individuals who had caucuses. There was the Veterans Caucus there were the caucus of religion, different religions, and there was some with other things. We felt that, as a group, that if we were to get together, that that would represent things that we were interested in, as far as recruitment, and mentoring, and that type of thing. So we got together as a group, and many of us- the founders. I'm one of the founders, and some of my colleagues. And they are three other individuals who graduated from Duke who are founders also on that panel. Joyce is one of them, Joyce Nichols. Prentiss Harrison is one of them. Prentiss Harrison was the first Black to finish PA school. And he graduated here in the second class. Joyce graduated in '70. She was the first female, but Prentiss was the first African American. CO 35:14 What have been some of the challenges and successes for the caucus over the years? LA 35:20 One thing is leadership, sustained leadership. Because it's all volunteer. And anytime we go to a national meeting, we always do Project Access. Project Access is a vehicle in which a group of us, when we're visiting a city, we find a school or some venue that we can go out and sell the profession, talk about the PA profession. And we started this with AAPA back in the '70s. Ironically, we did Project Access yesterday, at Northern High School here in Durham with the first year students who- I went with the first year students to the new high school in Northern Durham, and we presented at a class. And we took different things, like an ultrasound. And they were able to look at ear modules and the eyes. And we took x-rays. And that type of thing for the students to look at. And they, we had a PowerPoint presentation from our diversity chair in the class, first year class. And it was a very good group of students yesterday afternoon. CO 36:51 You've mentioned a lot over time that a lot of what you have to do is "selling the profession." Does that get frustrating over time? What is it like being in a place where that that ends up being an aspect with so much emphasis? LA 37:11 That is. It was frustrating at the beginning. Because no one knew who you were. They said "PA, you must assist the doctors, and what else can you do? The doctor says, 'I need a prescription pad, so you go get it for him." So people had that concept, that we were just there to help the physician. And they failed to realize that we could diagnose, treat, do minor surgery, do physical examination, take a comprehensive history and physicals, order laboratory tests, and interpret laboratory tests, and that type of thing. 80% of things that you see in outpatient basis can be handled by a PA. So that only leaves about 20% for the physician that might be a little bit complicated. PAs now work in all specialties in medicine. Some concentrate, but the program was set up for primary care here. It's primary care driven. But it can be- Many of our graduates go out into other areas. PA education is the- PA profession is the only profession now that a person can go from one specialty to another specialty without going back being trained. So we can- If you're a PA, and you graduate, and you start working in primary care and all of a sudden you said, "Well, I think I want to work in pediatrics," [or] "I think I want to work in orthopedics, get me a job in orthopedics." Well you can do that. It might be maybe six or seven months of onboarding to get you up to speed in orthopedics. But you can go and start working in orthopedics from primary care, or from pediatrics, come from OBGYN, or from, you know, some other specialty. CO 39:46 If you don't mind me circling back a little bit, you had mentioned that early on in your career, you worked at Lincoln. And I was wondering if that had any impact on your activism today, or on your drive to become involved in diversity efforts? LA 40:06 Oh, absolutely. Because initially when I came out, my first job was at North Carolina Central University in Student Health. So I worked there for a while. And I found out that, being that I had loans from medical school [laughter], and in order for me to satisfy, to pay that money back, I had to work in an underserved area. And North Carolina Central University was not an underserved area, working in student health. So I got a job at Lincoln, and that was. It satisfied that to pay back the loans. Because I was working in underserved area. So I was supervisor of an outpatient clinic. It was in Braggtown. I was the PA supervisor in that clinic. I did that for about a year and a half. And at that time, Lincoln built another facility, and so it closed that clinic. And it closed the clinic at Rougemont, Bahama [Road], the two outpatient clinics. And [Lincoln] brought everything in house to one specific clinic. Later, they have gone back out. You know, what goes around, comes around. So they still have those outpatient clinics. So at that time, that's when I came over to Duke. Because they closed the clinic that I was working in. And that's when I started Duke [inaudible] too, in internal medicine. But when I started at Duke, I started working in outpatient clinic, like I said, with their residence clinic. And that clinic was designated as an underserved clinic. So I was able to pay off my student loans- people didn't realize that- by working at Duke. And that was something I looked into because all of the patients that were in there were Medicare, Medicaid. A lot of Medicaid patients and Medicare patients. CO 42:26 What do you- I'm sorry, to rephrase it- What do you think the- How do you think it affected you going forward, having worked in an area that was considered underserved? LA 42:43 I loved the clinic at Lincoln because it was underserved. And it was probably one of the best experiences in my career by working there. Because the people were just so lovely, and they were so appreciative of my services there. And I just loved getting up every day going to work to see these individuals because I felt that I was making a difference in their life. Because these people were in a- I was in a project area. I was in a public housing area. They made one of the facilities a clinic, and I was right there in public housing clinic. So I was right there with them all day in a public housing clinic, and it was it was a beautiful experience. CO 43:47 And I was wondering too what have been some of the biggest changes that you've seen over time with diversity and recruitment with the Physician Assistant Program at Duke LA 44:06 Some of the larger changes that I've seen- Initially I had [pause] monies or resources, more than I have now. That has kind of dried up. Things a little bit more- Some of those dollars are gone. I had a larger budget when I started out as far as recruiting, and some of that has dissipated. Which is things that we have to do. We have to prioritize things a little bit differently. But one good thing that we have, we have social media. And that has made a difference in our recruitment. Because we do quite a bit of recruiting and through- We do some doing Facebook recruiting. We've got a session coming up this week. And we have a lot of Zoom recruitings with different universities. We don't have to go there. We can just do a Zoom. A meeting with- I had one Monday night at University of Virginia, Pre-PA Club. I guess there were maybe 12 or 15 people on that that we talked to, that society. And wasn't very diverse, but still it was- we're able to disseminate information about the PA program here. Everybody wants to do to talk to them because it's one of the top programs in the country- number one program as present- and everybody wants to see what Duke pair requirements are in that type of thing, and what we're doing? CO 46:35 What do you envision or hope for going forwards for diversity with the Physician Assistant Program? LA 46:46 Well, our director at present and division chief has done a tremendous job with diversity here. In that, for a long period of time, I was the only Black faculty member, for many, many, many, many years [laughter]. And now we have- oh, gosh, quite a few people of color on the faculty. That has changed. And also our division chief and director of the program is African American, African American female, Dr Jackie Barnett. She came from D.C., Maryland. She worked in that area at GW [George Washington University], and for many years in education. And so she has a tremendous background in diversity. And also, her husband is an educator at GW in diversity, also. He's over the public health program there. So we have been able to change the climate here at Duke. And it's good to see that we have more people of color on the faculty other than myself. And they're able to do more things, that I don't have to be the sole person, now. I'm not the sole person at the table. Because back in the past, I was the only person, and I spoke up, and sometimes I felt like I was out on an island, talking to people about diversity, and there wasn't too much interest in it, other than what I was doing. They were interested, being that you only one, you can't make- but when you have colleagues around you that are- have the same philosophy that you have about diversity, it makes a lot of difference. CO 49:27 That makes sense. And was there anything else you wanted to add that we didn't ask you about already? LA 49:34 That's a good question, and I always ask that when I see my applicants. "Is there anything that you can-" [laughing]. Other than, Duke is going in the right direction right now, as far as the PA program. I'm proud of the program. If I had to do it all over again- although I started out going into medicine, but I ended up being a PA- if I had to do it all over again, I would be a PA. And I think that that was the best fit for me. And this just so happened that mine was due to a tragedy in my life that I didn't expect. You don't expect a 28 year old woman dying in three days of pneumonia and influenza. So that was tragic. But my son, who was two years old at that time, is now 54. And he is a fine young man. And he's very- He works for the Department of Defense. He works for NSA. He is an engineer, a mechanical engineer. He has a master's in mechanical engineering. And he's very much so in leadership at that position. He makes more money than I've ever made [laughter]. So he's successful. And he's in a GS grade, but he's way up into GS grade. He's one of the top GS grades in government. So I think that with that, he gave me a grandson. And so with that, I don't think that by sacrificing my education at that time- I look at him, that he has been successful. CO 52:04 Oh, thank you so much. LA 52:25 Hi, I'm lovest Alexander Jr. I am Associate Professor in the Department of Family Medicine and community health in the Division of PA studies. And I have been a faculty member at Duke for over 40 years, and an employee at Duke for over 40 years.