Seat, Voice, Standard: A Leadership Framework

Matt Bell, DMSc, PA-C, CAQ-HM

Chief PA| Chief AI Officer| Process Improvement Specialist| Western North Carolina VA Health Care System

A decision is being made about Physician Associates.

The people in the room are thoughtful and well-intentioned. They are working through how PAs will be deployed, supported, and evaluated, and what role they should have in the larger system of care. The conversation is careful because everyone wants to get it right. One thing is missing from the room, though: an actual PA.

For much of our profession’s history, that was not unusual. PAs were trusted at the bedside and often nearly invisible in the organizational chart above it. When you are absent from the room where your profession is being discussed, you are not a participant; you are an agenda item.

I have spent much of my career watching that change from inside the system and learning from the people who helped make it possible. I also saw this transition directly when I was part of the initial Lead PA structure at a prior VA facility and later at my current one. That experience helped shape how I think about leadership, because the most durable gains do not come simply from being respected individually. They come when representation becomes influence, and influence becomes structure.

I have come to describe that leadership arc in three words: seat, voice, standard. A seat gives a profession presence, and a voice gives it influence. However, standard gives influence a way to survive turnover.

That sequence matters. It is not only a VA story; it is a leadership lesson for doctoral PAs working in hospitals, universities, health systems, professional organizations, government, technology, policy, and every other setting where decisions are made before a PA is invited into the room.

A note before I go further: this is a personal reflection drawn from my own professional perspective and from public sources. The views expressed here are my own. The internal deliberations of any specific institution are not mine to share, and I will focus on the leadership pattern rather than on inside details or precise chronology.

How New All of This Is

It helps to remember how young the PA profession is. The profession began in the mid-1960s, when Dr. Eugene Stead at Duke University assembled the first PA class from former military corpsmen. The first PAs graduated in 1967, and several went directly to the Durham VA. The VA became the first employer of PAs in the country and remains one of the largest employers of PAs today. ¹

So, PAs have delivered care in the federal system for more than half a century but delivering care and shaping the decisions about that care are different things. The second often lagged behind the first, and that lag is where the leadership lesson lives.

Seat: You Cannot Lead from the Hallway

The first stage of any leadership arc is almost embarrassingly basic: be in the room.

You do not have to run the meeting at first, win every argument, or even have the final version of your proposal. But when the profession is absent from the room where decisions are made, it does not shape its future; it allows it to be shaped by others.

For many decades within the VA, PAs were often absent from higher-level decision-making tables. That began to change as some “unofficial” PA leaders pushed for formal representation in national, network, and facility-level conversations. One important milestone was the appointment of a PA representing senior advisory structures within the VA. One seat may sound small, but in leadership terms, it was not small at all. It created visibility, access, and the possibility of influence.

The lesson is unglamorous but absolute: representation precedes influence. You cannot advocate from the hallway. The first victory is not always a policy, a title, or a raise. Sometimes the first victory is a chair at the table where those things are decided.

Leaders who understand this do not spend all their early capital trying to impress. They spend it making sure the profession has a permanent place in the room.

Voice: A Chair Is Not Yet Influence

A seat is necessary, but it is not sufficient. Plenty of people occupy important chairs and change very little. The second stage is turning presence into voice.

For VA PAs, this meant moving beyond isolated representation toward coordinated advocacy. The public evidence of this shift is shown in VHA Directive 1063, issued in 2013, which established a national framework for PA utilization across the Veterans Health Administration. ² The directive addressed individualized scopes of practice, collaboration, prescribing, competency assessment, PA utilization, and Lead PA responsibilities. It gave a clearer structure to how PAs could practice and how PA leadership could function across the system.

The directive matters, but the larger leadership lesson matters even more. Presence became more meaningful when PA leaders could speak with clarity, coordination, and mission alignment. Over time, PA leaders across facilities and networks were no longer functioning only as isolated local advocates. They were able to compare what worked, learn from one another, support common priorities, and speak with a more unified message.

A lone voice in a large system is easy to delay, dilute, or ignore, while a coordinated voice is much harder to dismiss. Two lessons live inside that. First, a coalition will almost always beat a collection of gifted soloists, because influence compounds when voices align. Second, voice has to be earned with substance. The PA leaders who are taken seriously are the ones who arrive with data, solutions, and a clear explanation of how a proposed change helps patients, teams, and the mission.

Advocacy built only around professional frustration has limits. Advocacy built around access, quality, safety, and service travels much further. That is not a rhetorical trick; it is the truth. Leadership becomes legitimate when it is tied to the mission.

Standard: Build It to Outlast You

Here is the stage many leaders skip.

A seat can vanish when a supportive supervisor leaves. A voice can fade when a charismatic advocate retires. A local practice can disappear when the person who protected it moves on. The only way to make a gain durable is to build it into standards: roles, policies, offices, directives, position descriptions, expectations, and repeatable processes.

This is where leadership becomes more than personal influence; it becomes institutional memory.

For PAs in the federal system, this standardization developed over time through national policy, PA leadership structures, and the continued maturation of the VA Office of Physician Assistant Services. ³ These structures matter because they help define PA practice, support consistent expectations, and make leadership roles more reproducible across the system.

This is why institutional scaffolding matters. Not because bureaucracy is inspiring (it usually is not), but because structure is how a hard-won advance becomes the default the next generation inherits. The truest test of leadership is not how much gets done while you are sitting in the chair; it is how much keeps happening after you leave it.

That is the part I have seen most clearly in my own career. Being part of early Lead PA structures taught me that informal influence is useful, but fragile. Durable leadership requires a role someone else can step into, a process someone else can follow, and a standard someone else can defend. If what you build cannot survive your departure, you have not finished leading yet.

Why This Is More Than a VA Story

It would be easy to read this only as VA history, but that reading is too small.

Seat, voice, and standard are not unique to federal healthcare. They describe what building leadership from the margins looks like in almost any setting. The same pattern applies when a university has no PA on its faculty senate, when a hospital board discusses APP workforce issues without an APP leader present, when a company designs clinical technology without a clinician in the room, or when a professional organization wants PA participation but has not built a real pathway for PA influence. The setting changes; however, the sequence does not.

Doctoral PAs are walking into these rooms right now, whether in clinical leadership, education, research, policy, informatics, operations, entrepreneurship, or emerging areas such as artificial intelligence. In many of those rooms, the PA role is still being defined.

That creates both risk and opportunity. The risk is that decisions will be made around us, and the opportunity is that doctoral PAs are unusually well-positioned to help build the next structures of influence.

What It Means for the Doctoral PA

So, a few things I would offer to any doctoral PA with an ambition to lead.

Do not wait for the title. Nearly every meaningful leadership gain begins with someone behaving like a leader before anyone formally names them one. The doctorate, the credential, and the role all help, but leadership begins as a behavior, not a badge.

Get in the room before your proposal is perfect. Presence is the prerequisite for everything else. Spend some of your early influence securing a permanent seat for those who come after you, not just a hearing for yourself.

Build coalitions, not monuments. The temptation, especially for accomplished people, is to become the singular voice. The more durable move is to align voices. A profession that speaks together is far harder to overlook than a profession made up of impressive soloists.

Anchor everything to the mission. The advocacy that lasts is rarely about professional status alone. It is about access, quality, safety, workforce stability, education, and care for the people we serve. That is what makes leadership credible.

Institutionalize your wins. If a process depends entirely on your memory, your relationships, or your persistence, it is not yet built. Write it down, put it in the structure, create the role, and define the standard. Make the next person’s path easier than yours was.

The Next Door

In a remarkably short span, the PA profession moved from absence to representation to influence to more formal standards of practice and leadership. That is a real achievement, and it is worth honoring the people who made it possible, many of whom did the work quietly and without any recognition.

But the work is not finished. New rooms are forming all the time: in governance, education, technology, policy, workforce design, clinical operations, and health system strategy. In each of those rooms, PAs will either be present or absent. We will either be participants or agenda items.

The doors are more open now than they once were, but doors do not stay open on their own. The arc that carried the profession this far, seat, then voice, then standard, is the same arc that will carry it into whatever comes next. Our job is to keep walking it with purpose, and to hold the door for the people coming up behind us.

The views expressed in this article are strictly those of the author and do not represent the Department of Veterans Affairs or the U.S. government.

References:

1. Department of Veterans Affairs, Office of Physician Assistant Services. Historical Outlook: Physician Assistant. Veterans Health Administration. Accessed June 20, 2026. https://www.patientcare.va.gov/PATIENTCARE/PA/Historical_Physician_Assistant.asp

2. Department of Veterans Affairs, Veterans Health Administration. VHA Directive 1063: Utilization of Physician Assistants (PA). Published December 24, 2013. Accessed June 20, 2026. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2958

3. Department of Veterans Affairs, Office of Physician Assistant Services. Office of Physician Assistant Services. Veterans Health Administration. Accessed June 20, 2026. https://www.patientcare.va.gov/PA/