Research Paper no. 24 2007–08
Health workforce: a case for physician
assistants?
Dr Rhonda
Jolly
Social Policy Section
25 March 2008
- Health workforce shortages are a global phenomenon. Dealing
with these shortages requires a multi dimensional strategy that
some developed countries have recognised may need to include the
introduction of new health professionals. These professionals
supplement the work of medical practitioners in dealing with
changing population health needs.
- One such complementary practitioner, the physician assistant,
has made significant contributions to the United States health
system for over forty years. In the United States, physician
assistants have proven to be an efficient and cost effective means
to deliver health care and demand for their services is
growing.
- Other developed and developing nations have either adapted the
United States physician assistant model to suit their health system
or have shown interest in the model.
- In Australia, debate is still underway concerning the merits of
alternative practitioners. Primarily, this debate centres on
whether these practitioners constitute a threat to the quality and
safety of health care.
- This paper outlines the development of the physician assistant
model in the United States, Britain and Canada and considers the
possible application of the model to the Australian health
system.
- The paper concludes there is potential to adapt this model to
suit the Australian health system so that quality of care and
safety in the delivery of services is not compromised.
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Contents
Executive summary
Introduction
Physician assistants origin
Physician assistants
in the United States
Definition, education
and practice
Definition
Education
Practice
Benefits of physician
assistants
Support and criticism
The future
Transferring the
physician assistant concept into other health systems
Britain
Workforce
shortages
Physician assistant trial
Collaboration and recommendation
National standards
Criticism
Future prospects
Canada
Australia: a role for
physician assistants?
Support
Resistance
The task substitution debate
The state of play
Possibilities for Australia based on overseas experience
Conclusion
Appendix A: the global applicability of
physician assistants
Appendix B: Physician assistant education
programs in selected countries
Endnotes
Introduction
According to the World Health Organisation (WHO), a conservative
estimate is that there are over 59 million health workers world
wide. These workers are spread unevenly between countries and the
ratio of health workers to population is greater in developed
nations. WHO predicts that there will be a global shortage of more
than four million doctors, nurses, midwives and other health
workers over the next decade.[1]
In Australia, despite the fact that the health workforce has
been growing at nearly double the rate of the Australian
population, shortages in a number of workforce areas have been
evident for some time. These are particularly obvious in general
practice, dentistry, nursing and key allied health areas.[2]
Factors such as a reduction in the average number of hours
health professionals choose to work, ageing of the health workforce
and the feminisation of some previously male-dominated professions,
have contributed to the phenomenon. In some areas, including aged
and disability care, demand has also outstripped supply.
In 2005, the Australian Medical Workforce Advisory Committee
considered that there would be a shortage of between 800 and 1300
general practitioner graduates by 2013.[3] In a 2006 research report for the
Council of Deans of Nursing and Midwifery Australia and New
Zealand, Barbara Preston predicted there would also be a shortage
of around 470 registered nursing graduates a year by 2010 despite
increases in nursing training numbers.[4]
Various attempts have been made to resolve the health workforce
shortage problem in Australia. Since the mid 1990s these have
included the extensive use of the services of overseas trained
doctors and nurses, resulting in what has been criticised as an
over reliance on the services of overseas trained doctors.[5] More recently, attempts
have included substantial increases in student numbers for nursing,
medicine and some allied health courses.[6]
However, there are structural pressures on demand and supply
that increasing student numbers and importing health workers alone
are not likely to address. A changing mix of disease burdens,
rising expectations of patients, ageing of the population and
technological advances, have contributed to shortages and led to a
mismatch between workforce demand and supply. As a result, like
other developed nations, Australia has begun to examine the
possibility of implementing new models of care and workforce
practices into health planning to accommodate and utilise the wider
range of treatment possibilities .[7]
This paper considers one such model which involves the
introduction of a type of medical assistant , usually referred to
as a physician assistant, who can supplement the services of
doctors by undertaking routine and less complex care at both
primary and tertiary care levels.[8]
Assistants in one form or another have been supplementing the
services of doctors at least since the seventeenth century in
Europe.[9] One group
of assistants, called feldshers, was first introduced into the
Russian Army by Peter the Great (1672 1725).
By the early twentieth century feldshers provided much of the
medical care received by the rural population in Russia. Russian
doctors however, were critical of these assistants who, they
argued, lacked adequate training and provided inferior medical
services. Despite the disdain Russian doctors held for feldshers,
the medical profession rejected any proposals to improve their
training, fearing that better trained, but cheaper assistants would
replace many doctors.[10] By the 1970s, there were over 500 000 feldshers
practising in Russia, mostly in isolated areas.[11]
Other medical assistants called loblolly boys were also used in
the British and United States navies from the early 1800s as aides
to surgeons.[12]
Their duties were:
to do anything and everything that was required
from sweeping and washing the deck and saying 'amen' to the
chaplain, down to cleaning the guns and helping the surgeon to make
pills and plasters and to mix medicine.[13]
The loblolly boy evolved into the modern navy corpsman (or sick
bay attendant).[14]
One view of the Physician Assistant
Source: BMJ Careers[15]
While military surgeons throughout the world have been using
medical assistants since the mid 1800s, civilian physician
assistants were only introduced in the United States in the 1960s
to provide medical care in places where there were obvious
shortages of medical practitioners.
In the 1960s, the American health system not only faced a mal
distribution of the medical workforce, it also experienced an
actual shortage of medical practitioners. Initially, in order to
address this situation, new medical schools were opened and class
sizes for medical students were increased, general practice was
promoted as a medical specialty and special programs were created
to deliver medical services to under serviced areas.[16]
However, medical practitioner shortages were accompanied by
rapidly rising medical costs and increased public demands for
better access to health services and improved care. So in order to
contain costs, the United States Government was forced to consider
other workforce solutions. One of these involved developing and
using alternative, cost effective, non physician health
workers.[17]
Eugene Stead of Duke University[18] developed one such option for a new
class of health workers who were eventually labelled physician
assistants. Stead at first envisaged that the new health workers
would be nurses with expanded clinical skills, but his proposal to
develop an advanced nursing program was rejected by the American
National League of Nursing.[19]
This rejection led Stead to consider training ex military
corpsmen as generalist assistant[s], whose training and skill
development were adequate to serve as a platform for further
education and further skill development by the physician employer
.[20]
Stead s first class of three physician assistants graduated in
1965. Soon after, other university medical schools adopted similar
programs.
At first, these programs were mostly privately funded, but under
legislation such as the Health Manpower Act of 1970, the United
States government provided some funding for physician assistant
(and nurse practitioner) training to stimulate recruitment of
underrepresented minorities and deployment to rural areas. In 2008
this funding was (US) $2 million.[21]
Physician assistants are generally
defined as non autonomous health professionals who are licensed to
practice medicine under the supervision of medical
practitioners.
The definition given by the American Academy of Physician
Assistants is:
Physician assistants are health care
professionals licensed, or in the case of those employed by the
federal government they are credentialed, to practice medicine with
physician supervision. As part of their comprehensive
responsibilities, PAs [physician assistants] conduct physical
exams, diagnose and treat illnesses, order and interpret tests,
counsel on preventive health care, assist in surgery, and write
prescriptions. Within the physician-PA relationship, physician
assistants exercise autonomy in medical decision making and provide
a broad range of diagnostic and therapeutic services. A PA's
practice may also include education, research, and administrative
services. [22]
Physician assistant training is provided through tertiary
programs which are accredited to a national American
standard.[23]
Admission requirements to individual training programs vary, but in
many cases there is a pre requisite requirement of two years
university study and experience in a health related field.
The physician assistant curriculum[24] resembles a shortened form of
traditional medical education, and emphasises a primary care,
generalist approach .[25] Unlike undergraduate medicine training however,
physician assistant courses are usually only about two years in
duration.
In 2008, there are 139 United States education programs for
physician assistants accredited or provisionally accredited by the
Physician Assistant Education Association. More than 90 of these
programs offer the option of a master s degree, while the rest
offer either a bachelor s degree or an associate degree. In
addition, all programs grant a certificate, which is required to
sit for the national certification examination[26]
Practice
Physician Assistants are required to adhere to a set of
professional competencies. These include:
the effective and appropriate application of
medical knowledge, interpersonal and communication skills, patient
care, professionalism, practice-based learning and improvement,
systems-based practice, as well as an unwavering commitment to
continual learning, professional growth and the physician-PA
[physician assistant] team, for the benefit of patients and the
larger community being served.[27]
To practice, physician assistants need to be registered in the
state in which they wish to work.[28] As noted in the definition of a physician
assistant, in compliance with conditions attached to their
registration, physician assistants are able to perform, under
supervision, many of the tasks previously only the prerogative of
doctors.
What constitutes supervision for physician assistants is
dependent on the state in which they practice, the settings of
their practices and the services they offer.[29] But generally rules for
supervision:
convey the idea that direction of the medical
practice of the physician assistant is provided and assured by
supervising physicians, but that this does not necessarily require
the physical presence of a supervising physician at the place where
services are rendered. It is imperative, however, that the
[physician assistant] and a supervising physician are or can be in
contact with each other by telecommunication.[30]
In all American states physician assistants have prescribing
rights, but these are subject to limitations.[31] For example, in the State of
Florida they are prevented from prescribing controlled substances,
anti-psychotics, general anaesthetics, radiographic contrast
materiels, and parenteral injectables except for insulin and
epinephrine. Similarly, in general practice, they are able to write
prescriptions only for medications within the scope of the practice
of their supervising doctors.[32]
As part of their licence conditions registered physician
assistants need to undertake 100 hours of continuing medical
education (CME) every two years and to sit for recertification
every six years.
Physician assistants work across a number of medical practices
and locations. As the table below shows these are extensive and
include general practice and hospitals, where they specialise in
areas including surgery, neurosurgery, orthopaedics, pathology,
dermatology, endocrinology, urology, obstetrics-gynaecology,
ophthalmology, gastroenterology and rheumatology.
Source: National Commission on Certification of
Physician Assistants[33]
In 2007 there were approximately 70 000 physician
assistants in the United States and approximately 5500 more
physician assistants graduate each year. The United States
Department of Labor ranks the occupation of physician assistant as
one of the fastest growing in the country.[34]
While the first physician assistants were all male, in 2002 the
majority of physician assistant students were women.[35] Seventy per cent of applicants for physician assistant
programs are white.[36]
Research on physician assistants has been carried out in the
United States since the 1970s. Although a considerable amount of
this research is dated, its findings are consistently positive
about the benefits physician assistants have delivered to the
United States health system.
A number of studies have concluded that the quality of care
provided by physician assistants is equal to that provided by
doctors in comparable situations.[37] One evaluation of over 40 000 patient
satisfaction surveys for example showed that patients were equally
satisfied with care delivered by doctors, physician assistants and
nurse practitioners.[38]
Another study undertaken in April 2007 on behalf of the American
Academy of Physician Assistants, noted that over 80 per cent of
respondents were happy to consult a physician assistant for a
routine health visit if their doctor was not available. Of people
previously treated by a physician assistant, 90 per cent were happy
to see a physician assistant again.[39] One explanation for this high
approval rate is perhaps, as some evidence suggests, that many
people prefer the more holistic care delivered by physician
assistants.[40]
Some research has indicated that physician assistants and nurse
practitioners are more likely than doctors to establish practices
in rural locations and in other areas where there is an overall
shortage of health professionals.[41] Forty two percent of physician assistants work in
communities with less than 50 000 population and ten per cent
of those work in communities with less than 10 000
people.[42]
Any claim that physician assistants are the definitive solution
to rural workforce shortages must be tempered, however, by
arguments such as those advanced by Dr Robert Bowman, a researcher
from the University of Nebraska Medical Center (sic) in the United
States. Bowman considers that because United States health policy
has failed to recognise the value of the services of physician
assistants and nurse practitioners in providing solutions to
workforce shortages in rural areas a trend has emerged for these
professionals to locate to major medical centres as the centres
take advantage of the versatility and cost savings the professions
offer.[43]
Economic studies suggest that physician assistants deliver cost
effective service. One comparison of the productivity of physician
assistants and physicians[44] in a number of medical fields, including general
practice, revealed that physician assistants generally saw ten per
cent more patients than doctors.[45]
Importantly also, in terms of the delivery of quality services
and in the context of a litigious American health system, studies
have also found that there appears to be no increased liability
cases as a result of using physician assistants in all settings and
all types of medical practice.[46] Some anecdotal evidence indicates in fact that
physician assistants can reduce the risk of malpractice claims by
improving communication between patients and healthcare
providers.[47]
Other research has found that physician assistants, in rural and
solo practices particularly, increase productivity in terms of the
number of patients seen. At the same time, they alleviate the
workload and improve the income of doctors that employ them;
thereby delivering a safer and more effective health
workforce.[48]
Still other studies suggest that where physician assistants see
the same types of patients, most of the time, it was more
beneficial financially to employ these health professionals than to
employ more doctors.[49] This claim must necessarily be qualified by noting that
doctors continue to see more difficult, complex and time consuming
cases. At the same time, however, the fact that physician
assistants are available probably assists doctors to have adequate
time to attend to such cases.[50]
Promoting the study of physician assistant courses to Native
Americans (American Indians), Alaskan natives and native Hawaiians
has been recognised as a potential strategy for delivering benefits
to indigenous communities. Like Aboriginal and Torres Strait
Islander people, Native Americans make up only a small proportion
of the American population.[51] However, also like Aboriginal and Torres Strait
Islander people, this group is more likely to suffer from chronic
disease and to die younger than its white counterparts.[52] A number of
institutions run programs particularly targeted to Native
Americans. Study under the Arizona School of Health Sciences Native
American Physician Assistant Track program for example leads to the
award of a master s degree and involves additional indigenous
orientation components.[53] The University of Washington Medex program actively
recruits Alaskan natives working as community health aides to enter
the Seattle program and return to their communities.[54]
The American Academy of Physician Assistants notes that the
American Medical Association, the American College of Surgeons, the
American Academy of Family Physicians, the American College of
Physicians and other national medical organisations in America
support the physician assistant profession by actively supporting a
physician assistant certifying commission and an accrediting
agency.[55]
According to some academics, this support is due to the
interdependent relationship physician assistants and doctors enjoy.
Within this relationship, doctors and physician assistants are
functional teams[56] and physician assistants negotiate what has been
labelled performance autonomy .[57] What this means effectively is that physician
assistants have a degree of professional independence, within a
relationship of trust and mutual respect they share with their
supervising doctors.
There is some indication that this was not always the case.
Initially, both nurse practitioner and physician assistant models
were criticised by the medical profession in America as a second
tier of medical care .[58]
It appears doctors were initially reluctant to transfer
responsibility to physician assistants, despite the fact that the
profession was created partly as a response to the excessive
workload doctors faced.[59] One assessment makes the point that state and local
medical societies feared the physician assistant concept and
hindered development of the profession through their control of
state licensing laws.[60]
The nursing profession also criticised physician assistants.
Nurses argued that the development of the discipline was an attempt
by the American Medical Association to sabotage recognition of
nurses as independent and professional associates of
doctors.[61]
Further criticism of physician assistants is based on the
argument that there is no actual need for any type of alternative
medical practitioner within the health systems of developed
nations. This argument contends that while such professionals may
represent a valuable resource in developing countries where the
advanced skills of doctors are not essential (or available) to the
delivery of basic health care, in developed countries the same
claim cannot be justified. According to this view, alternative
practitioners are simply a hasty solution to medical workforce
shortages which could be more effectively resolved by other means.
In the American case, for example, the argument continues:
policies in the 1970s were based on an
unwillingness to impose social obligations on the physician (e.g.,
location in areas of need) and to train adequate numbers of primary
care doctors.[62]
It could be argued that this approach is condescending in that
it assumes the health of people in developing countries is less
important than the care of those in developed nations. It is also
questionable to what extent so called social obligations could be
imposed on medical practitioners in the predominantly private
sector driven American health system.
The
existence of a largely privately financed health sector is most
likely one important reason why the introduction of a physician
assistant profession has been successful in America.[63] This may be because
there is an inherent flexibility in the United States system which
marries well with policy devised to deliver quick responses to
health demands. In the 1960s, therefore, introducing alternative
health practitioners into the system was not only feasible, but
considered crucial in supplementing the services provided by
medical practitioners and in ensuring the financial well-being of
the system.
Commentators on the American health system have argued there
was, and continues to be, a need to contain escalating costs
associated with public assistance schemes for the poor, elderly and
disabled and the treatment of chronic conditions associated with an
ageing population.[64] As the American health system relied on competition as
the principal lever to deliver efficiencies, this made the
employment of alternative health practitioners, such as physician
assistants, an attractive way to deliver more cost-effective
services.[65] These
less costly services then helped compensate for escalating health
costs.
Nevertheless, Professor Roderick Hooker, a long-term researcher
and commentator on the physician assistant profession, is convinced
that despite the innate flexibility of its health system and the
influx of alternative practitioners this has not been enough to
satisfy America s medical needs. Professor Hooker believes this
situation is likely to worsen as the numbers of American medical
graduates remain static.[66] This is likely to be further compounded if a trend for
graduating doctors not to select general practice as a career
continues and if the number of international medical graduates
entering the United States declines.[67]
The situation is compounded by the growth in numbers of older
patients and the rise in chronic diseases as well as changes in the
work patterns of medical practitioners. In addition, it is
possible, as some researchers predict, that economic expansion will
place additional pressure on the American health system.[68]
Hooker concludes that the shortage of physicians will mean that
physician assistants and nurse practitioners may be the only
resource available in the near future .[69] But it appears even
one source of alternative practitioners is in decline, as the
numbers of nurse practitioner graduates diminish.[70] In contrast, however, the number
of physician assistants is increasing.[71] The (American) Department of Labor
agrees that one reason for this growth is an increasing emphasis on
cost containment in the health system.[72]
Taking the cost containment premise as a starting point, it may
be concluded that physician assistants will continue to play an
important role in the delivery of health care in America.
Therefore, they will play a substantial role in providing services
where the underlying health system ethics are that consumers should
have freedom of choice about the value they place on their health
and what they are prepared to pay for protection against sickness
or accident. In this context, vertically integrated prepaid group
practices, such as health maintenance organizations (HMOs), which
offer insurance and health care, in seeking to minimise costs to
consumers (and at the same time maximise organisational profits),
are likely to employ more physician assistants.[73]
Similarly, there may be an increasing potential for the services
of physician assistants to be used more often through telemedicine
consultations. As telemedicine develops further using
post-operative television and vital monitoring protocols, physician
assistants could be employed to determine if health care needs to
be taken to the level of medical intervention. Employing more
physician assistants to undertake these tasks is not only likely to
be cost effective, but it may enhance patient care in rural and
remote areas by providing services where there may have been none
previously.
In addition, as the supply of medical practitioners declines,
physician assistants in hospital settings may be able to take on a
greater workload in areas such as teaching. They have already been
called upon to fill gaps in care, which have resulted from an
80-hour week cap placed on the working hours of medical residents
introduced in 2003.[74]
There is provision in the American system to cater for the needs
of the poor and the elderly through the Medicare and Medicaid
programs.[75] But
there is considerable criticism of the cost of these
programs.[76] As
the Medicare rebate for physician assistants is 85 per cent of the
prevailing fee paid to doctors (although some clinic visits may be
reimbursed fully if certain conditions are met),[77] there is also scope for the
greater use of the services of physician assistants as a cost
saving measure under these programs.[78]
While the American physician assistant model was developed to
serve the needs of a particular system, Christine Legler has argued
that it can be easily adopted to accommodate the health needs of
other systems.[80]
As the table below illustrates, some nations have begun to
embrace the physician assistant model while others, including
Australia, are investigating the possibilities whereby it can be
adapted to suit local conditions.
Source: Journal of Physician Assistant Education[81]
Britain
In 2001, the British National Health Service (NHS), like the
United States health system in the 1960s, faced serious health
workforce shortages. While the NHS had already begun to train more
doctors, it was recognised this strategy needed to be supplemented
if a potential workforce crisis were to be averted.[82]
One option was to introduce alternative practitioners, such as
physician assistants, into the system. But it was recognised that
there were obvious difficulties to be overcome in integrating this
group of practitioners into the British health system. These
included adapting a dependent practice model into a system where
health worker practice was based on a principle of regulation of
autonomous practitioners.[83]
Concerns were raised also that because physician assistants
delivered the same sorts of medical services as doctors they would
not contribute to a reduction in unnecessary duplication of tasks ,
nor would they improve the transfer of care between services
[84] in the British
system. Similarly, questions were raised about whether substantial
training savings could be gained for the NHS. Some academics argued
that there would be little significant difference in the cost of
training physician assistants and undergraduate doctors for
example.[85]
Additionally, it was argued that antagonism between physician
assistants and other professions, particularly nursing, would be
inevitable and that this would outweigh any benefits to be gained
from the new workforce.[86]
The conclusion, from this perspective, was that:
Other initiatives aimed at reducing
professional barriers and mixing skills may be more effective in
solving the problems in primary and secondary care [than
introducing physician assistants]. It would be a shame to respond
to the impending shortfall in medical staff by creating a mini
medic and losing the chance to tackle simultaneously the barriers
to expanded practice and to seamless care. The best aspects of the
US physician assistant system could be incorporated into new
initiatives, both locally and nationally, but a comprehensive
national programme to train and employ US-style physician
assistants may not be the answer.[87]
In reply, a number of critics of this view argued that there was
a clear need for a broadly based, new healthcare professional who
could contribute to holistic, patient-centred care in both primary
and secondary care settings in the British health system. These
critics considered that dismissing an American style health
professional as inappropriate for Britain failed to appreciate the
scale of the problem the NHS faced in providing effective primary
medical care.[88]
It could be argued equally that it failed to focus on similarities
in the situations faced by both health systems and potentially to
capitalise on the experience gained in the American case.
The proportion of general practitioners in the British health
workforce has been falling for years. In 2002, only around a third
of doctors in the NHS were general practitioners and research into
medical student work preferences indicated, as Lambert and
colleagues had found in the United States case, this situation was
likely to compound into the future.[89] Traditional strategies, such as
increasing places at medical school and offering doctors financial
incentives, either to enter general practice or delay retirement,
many believed were seriously flawed. More radical solutions, like
introducing new types of health workers, were needed. Moreover,
some research had indicated that general practitioners would
consider alternative health professionals a welcome addition to
health care teams. [90]
As a consequence of the health workforce crisis, and in response
to the commitment by the NHS to modernising the health system to
make it more responsive to the expectations and needs of
patients,[91] in
2003, two general practices in an under serviced urban area in
England employed American trained physician assistants on a trial
basis. A further 12 physician assistants were employed in 2004 in
primary and secondary care settings.
Results from these trials suggested that any concerns about
transferring the physician assistant model were unfounded. While
there were some initial difficulties for the American trained
physician assistants in familiarising themselves with the British
system, the problems did not appear to be insurmountable. On the
contrary, it appeared the introduction of physician assistants had
had a positive impact on the delivery of better patient-centred
health care in the under serviced areas, a key goal of the
modernised NHS policy.[92]
In achieving this aim, it was found that the physician
assistants reduced the workload of other members of general
practice teams in which they worked. Supervisory relationship
arrangements worked well and patients appeared satisfied with
consulting arrangements. Indeed, the main reported concern of
patients was that they were required to wait after a consultation
for prescriptions to be written by a doctor, as physician
assistants did not have prescribing rights.[93]
There was some variation in cost effectiveness reported from the
trials, due to factors such as longer consultation times undertaken
by physician assistants in comparison with doctors. Overall, this
was balanced by an increase in the capacity of the areas of medical
practitioner shortage to service the needs of their
patients.[94]
The physician assistant trial confirmed that some specific
integration issues needed to be resolved. Primarily, these related
to defining how supervision would apply in a British context,
solving the regulatory issue in relation to the type of practice
physician assistants could engage in (as noted above) and
addressing limitations on prescribing.[95]
Despite the success of the trial, there was continued resistance
from one sector of the medical profession on the grounds that
physician assistants were a fast-track, cut-price alternative
solution to medical workforce shortages that would ultimately
undermine patient care. This group was adamant that pseudo-doctors
should not be entitled to diagnose and treat patients.[96] Doctors who had
participated in the trial on the other hand argued that physician
assistants provided complementary, not replacement medical
service.[97]
The British Medical Association s (BMA) response to the
physician assistant trials was restrained. However, it accepted
there was potential for physician assistants to ease workload
pressure on doctors. At the same time it stressed that patients
must be consistently made aware that these practitioners were not
doctors.[98]
Furthermore, the BMA voiced a number of concerns about what it
saw were possible future impacts on doctors and
doctors-in-training. It was concerned that medical students and
doctors-in-training would have to compete for the same education
and training opportunities as physician assistants; that possible
extra training requirements for doctors would add to the work
pressures of medical practitioners and that there was an unstated
intention to expand the physician assistant role to the detriment
of the medical profession in the future.[99]
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British Medical
Association:
Summary of concerns
about the introduction of physician assistants
- less training and less accumulated debt as a result of the
period required to gain a medical degree may make the career of
physician assistant an attractive option to the detriment of
medicine
- if physician assistants were similarly qualified to doctors in
training, the NHS may increasingly seek to employ them to undertake
work traditionally undertaken by doctors in training
- doctor training better prepares practitioners for the
unexpected in patient care
- physician assistants may not have sufficient training and
breadth of medical knowledge to recognise the limits of their
expertise and consequently, they may jeopardise patient safety
- physician assistants may not have the necessary training to
apply skills and knowledge in a patient centred way
- any prescribing rights given to physician assistants should be
limited and should be subject to clear guidelines.[100]
|
In September 2006, following a public consultation process, the
Royal College of Physicians and the Royal College of General
Practitioners, in partnership with the National Practitioner
Programme (the Collaborative Group) released a competence and
curriculum framework proposal that it intended should apply to
physician assistants working in Britain. The Collaborative Group
recommended a framework, rather than a set curriculum for physician
assistant study. This was intended to provide higher education
institutions leeway to design programs that took into account local
circumstances, while at the same time remaining within national
criteria requirements.[101]
While the Collaborative Group acknowledged criticisms of the
physician assistant trials, it observed that the development of new
medical roles was often contentious, with perceived threats to the
training, role and status of existing healthcare professionals, and
the need to safeguard standards of patient care .[102] But it also pointed out that
as new professions did develop there was an accompanying need to
define the role and scope of practice and the standards for
education and assessment in order to ensure that practice is to a
uniformly high standard .[103] This was particularly so given that an
increasing number of American-trained physician assistants had
found employment in England, Wales and Scotland since 2004.
As some higher education institutes had also begun to develop
their own courses for physician assistants in response to employer
demands, introducing regulation of training and registration for
the profession was equally critical to ensure public
safety.[104] In
this context, the Collaborative Group expected that its framework
would provide guidelines for new physician assistant training
programs to produce:
professionals who have the knowledge, skills
and professional behaviours to function as Physician Assistants
(and to have their qualification nationally and, potentially,
internationally recognised) and the personal and intellectual
attributes necessary for lifelong professional development.[105]
The Collaborative Group recommended the introduction across
Britain of national training, registration and monitoring standards
for physician assistants (see box below). It proposed that
physician assistant students would undertake a 90 weeks degree
program consisting of both theory and clinical placement
components. On completion of this degree, students would then
undergo a theoretical and clinical learning assessment which was to
be set by a national examination board. In addition to this
assessment, however, individual learning institutions would be free
to impose further assessment requirements. Core subjects of a
physician assistant degree, including health policy and ethics,
would be validated by a professional body established for that
purpose.
Upon graduation, students would undergo a 12 month internship
before they would be eligible for registration. They would be
required to undertake continuing professional development to retain
registration and to sit a re-accreditation examination every five
years.[106]
In keeping with the concept of autonomous practice that applies
to other health professionals in Britain, each physician assistant
would be responsible for his/her own practice and subject to the
requirements of a regulatory organisation. However, because of the
dependent nature of their practice, supervisory doctors would be
required to accept overall professional responsibility and would
determine the scope of duties and responsibilities of the physician
assistants practising under their supervision.[107] In addressing the apparent
anomaly in these latter requirements, the Collaborative Group
observed:
Physician Assistants work under the supervision
of doctors throughout their professional lives. Although this may
appear to contrast with autonomous practice in nursing and other
health professions, it should be remembered that all health
professions, including doctors, remain professionally and
managerially accountable to others throughout their working lives
despite being independent, clinically autonomous practitioners.
[108]
Criticism of the proposed framework for physician assistants
appeared mostly to be motivated by a desire to protect professional
turfs . The British Medical Students Association Journal, for
example, argued that those who chose to study physician assistant
courses would suffer. This was because these students may otherwise
have entered medicine and by choosing the physician assistant
profession they would be condemned to a career of reduced status,
pay and career prospects.[109]
|
British physician
assistant: competence and curriculum framework model definition and
role
Definition:
A new healthcare professional who, while not a doctor, works to
the medical model, with the attitudes, skills and knowledge base to
deliver holistic care and treatment within the general medical
and/or general practice team under defined levels of
supervision.
The role of the physician
assistant is to:
- Formulate and document a detailed differential diagnosis,
having taken a history and completed a physical examination
- develop a comprehensive patient management plan in light of the
individual characteristics, background and circumstances of the
patient
- maintain and deliver the clinical management of the patient on
behalf of the supervising physician while the patient travels
through a complete episode of care
- perform diagnostic and therapeutic procedures and prescribe
medications (subject to the necessary legislation) and
- request and interpret diagnostic studies and undertake patient
education, counselling and health promotion.
|
Source: (United Kingdom) Department of
Health[110]
The Association of Advanced Nursing Practice Educators (AANPE)
was one of a number of groups that argued the work of physician
assistants was already undertaken by existing professions in this
case by nurse practitioners.[111] The AANPE considered that rather than improving
health care, physician assistants could destabilise and undermine
the extensive work in progress by other professions in establishing
new advanced clinical roles .[112]
In the view of Jim Parle, Nick Ross and William Doe, from the
University of Birmingham Medical School existing professional roles
in Britain served health care delivery well in the past. [113] These academics
argue however that the combination of many factors has generated
new demands for a more flexible health workforce and that physician
assistants can provide one viable solution to these
demands.[114]
Physician assistants in the view of these academics can deliver
significant advantages in areas such as shorter patient waiting
times, stability for doctors in rotation posts and the maintenance
of generic medical knowledge.[115]
Dr Ricky Bhabutta, who is involved in extension of the British
physician assistant project into Scotland,[116] can see a time when physician
assistants will be employed, not only in Britain, but throughout
Europe.[117] One
prediction is that as early as 2010 there will be up to 200
students per annum training across Britain and there will be up to
300 British trained physician assistants in practice.[118]
Physician assistant courses commenced in England for physician
assistant postgraduate diplomas in 2004 and the first graduates
entered physician assistant roles in 2006. The University of
Birmingham offers a course open to graduates with a degree in Life
Sciences including biology, biochemistry, medical sciences, nursing
and physiotherapy.[119]
Canada
While physician assistants had been employed by the Canadian
Defence Force for over 30 years, it was not until 2005 that a
conference was convened to discuss how an expanded role for the
profession could assist in addressing the health workforce
shortages that were being experienced throughout Canada.[120]
At that time, the defence force employed approximately 130
physician assistants and trained about 20 each year under a program
accredited by the Canadian Medical Association. Trainees accepted
into the defence force program were required to have a medical
assistant[121] or
paramedical[122]
background. Defence Force physician assistants received two years
training twelve months theoretical instruction followed by a year
of clinical rotations and station based examinations. The clinical
rotations were provided in civilian hospitals and general
practice.[123]
Although the Canadian Medical Association had approved physician
assistant as a designated health care profession in 2003, outside
the defence forces opportunities for physician assistants to work
in Canada were limited.[124] Manitoba was the only province to employ physician
assistants, (known in the province as clinical assistants), and
this was generally only in medical and surgical specialties.
Participants in the 2005 Canadian conference agreed that there
was potential to make greater use of the services physician
assistants. This was considered particularly to be the case for
remote communities and towns that have one or two physicians and
face retention problems because of onerous on-call duties .[125]
In May 2006, Ontario enacted legislation to introduce a pilot
program, which involves physician assistants in its health human
resources strategy, HealthForceOntario. After consultation with
stakeholders, the selection of six demonstration hospital sites and
the development of competency profiles and scope of practice
statements, a two year pilot project began in 2008. The project has
the intentions of addressing health workforce shortages in high
demand areas, such as emergency departments, community health
centres, and hospital services and defining what specific roles and
responsibilities physician assistants may be able to undertake
within the Canadian health system.[126]
The Ontario project has capitalised on the United States and
British experience in developing its competency profiles and scope
of practice statements.[127] A broad coalition of stakeholders oversees the project
and an extensive evaluation project will assess the outcomes of
care and satisfaction of all participants (that is, patients,
doctors, nurses, and the physician assistants).
HealthForceOntario has also undertaken to introduce a four-month
conversion course for overseas trained doctors (OTDs) to train as
physician assistants. The rationale behind this initiative has been
that there are insufficient medical residency positions available
for OTDs in Ontario and that the competencies of these doctors
appear to compare to those expected of physician assistants. All
OTDs considered for the initiative are expected to have passed
medical examinations required of all medical graduates as well as a
clinical examination. Successful candidates from this program will
commence practice in 2008.[128]
In 2008, three civilian physician assistant programs will be
added to the Canadian Defence Force program and a fourth is
expected in 2009. Provinces such as Nova Scotia, Alberta and
British Columbia are observing the Ontario and Manitoba activity
and considering their own options.
Queensland academic Laurent Frossard and his colleagues consider
the quick timeframe from conception to trail in Ontario has been
due to several factors. These include:
the development of strong partnerships and
collaborative relationships; support from other health professions
and experts in the field; high acceptance of overseas trained PAs
participating in pilot projects; completion of a PA competencies
document; and significant government investment in the PA
initiative.[129]
Frossard also makes the pertinent point that the establishment
of a Steering Committee to guide development, implementation and
evaluation of the Ontario pilot was able to allay concerns
expressed by other health professions about the introduction of a
new and unregulated health worker.[130]
Anticipating need the
case of the Netherlands
Physician assistants have also been introduced in other
countries. In 2004 for example the Netherlands inaugurated
physician assistant programs at four universities and as a result,
in 2008, there are over 200 graduates employed in the Dutch health
system. Most of these graduates are working in hospitals, but a few
are deployed in general practice.
Interestingly, as one study has observed, while the Netherlands
does not have a shortage of doctors at this time, it has elected to
introduce physician assistants in anticipation of increasing
medical demands it calculates will result from the ageing of its
population.[131]
|
Australia: a role for
physician assistants?
Like its counterparts, Australia faces health workforce
shortages. These have become particularly evident in the medical
workforce beginning in 1990s. Since that time various attempts have
been made to address the shortage of doctors, both in the short and
longer terms. Strategies are also in place to attempt to address
nursing shortages, although little appears to have been done to
address shortages in the allied health workforces, such as
physiotherapy and pharmacy.[132]
The evident cycles in Australian medical workforce supply
policy, with periodic shifts between phases of containment and
growth , have intersected with questions about whether a numbers
policy alone can resolve either specific medical, or general health
workforce supply issues, however.[133] As a result, discussions of how the
health workforce crisis in Australia should be addressed have begun
to focus on strategies that may be able to supplement plans that
simply advocate the supply of more of one kind of health worker or
another.
In 2004, key stakeholders in the health care sector agreed to a
National Health Workforce Strategic Framework (NHWSF). One of the
principles of the framework was that a complementary realignment of
existing health workforce roles, or the creation of new workforce
roles, may be necessary to make optimal use of the existing health
workforce and to ensure better health outcomes. [134]
In its 2005 inquiry into the health workforce, the Productivity
Commission not only endorsed this view but added that there were
various opportunities for more significant workforce innovation,
including broadening scopes of practice and major job redesign that
had either not been adequately evaluated or even
considered.[135]
The Productivity Commission in effect endorsed a multi-faceted
solution to workforce solutions, recommending the establishment of
national registration standards for example to increase the
efficiency of the existing health workforce as well as improvements
in the coordination of education and training regimes.[136]
Professor Peter Brooks of the University of Queensland is
similarly of the opinion that no single strategy will solve the
problem of health workforce shortages.[137] Brooks is an advocate of health
workforce solutions that are achieved through combining new ways of
delivery with new models of practice. He argues that governments,
administrations and professions alike must consider how the roles
of all current health professionals can be extended and how new
professionals, such as physician assistants, can be integrated into
the health delivery system .[138]
In 2005 and 2006, two Australian health conferences supported
what has been labelled a groundswell of feeling in support of
investigating new options for the health system to develop
partnerships to break down the professional silos, and create a
range of new health practitioners who can deliver care in a
patient-friendly fashion .[139] A Medical Delegation Conference in Mt Isa in
December 2006 in particular cited physician assistants as a
possible and viable option with which to begin this process noting
that the health care system should optimally utilise existing
health professional groups as well as explore new classes of health
professional to best meet the long-term growing needs of the whole
community . [140]
Findings from the Mt Isa Conference stressed, however, that
national, flexible models and sets of competencies for physician
assistants needed to be developed and put in place before this
could occur. In addition, the Conference concluded that any models
should reflect the specific needs of the health system and that
they should be able to demonstrate that safe and effective care
would not be compromised similar conclusions to those earlier
reached in Britain and Canada.[141]
The Australian Medical Association (AMA), like its overseas
counterparts, has been restrained in its initial response to the
suggestion that alternative practitioners could play a valuable
role in the delivery of health care. In its reply to the
Productivity Commission report on the health workforce, the AMA
criticised recommendations for task substitution . It claimed that
proposals made by the Commission would lead to poorer patient
outcomes and that the Commission s agenda was based on budgetary
considerations. It noted:
Far too often, the AMA has witnessed
governments talking about delivering better health outcomes through
reform when what they are really on about is limiting access to
costly services for budgetary reasons. It would seem that doctors
are now seen as so costly that other health providers should screen
patients to limit access. The actions governments take speak far
louder than the things they say. It is, of course, the fate of
governments to grapple with those vexing questions of how much tax
to extract and where to spend the revenue. However, if the decision
is to lower health outcomes for budgetary reasons, then there must
be open and honest engagement with the patients and the electorate.
If governments are not prepared to meet patient expectations re
quality and access, they should say so clearly.[142]
In effect, it could be argued that the AMA saw the Productivity
Commission s recommendations as a threat, rather than an
opportunity. One physician argues that behind such claims about the
safety of patients perhaps lurks the specter (sic) of self interest
whereby:
Physicians want to maintain control of care and
the financial rewards that come with it. They don t want to be
undercut in the market by less costly providers.[143]
Another commentator is less critical, believing that such
concern, couched in terms of safety and quality, may actually be
more about the break down of the exclusivity of medical knowledge
and skills , rather than simply about control or financial
considerations.[144]
Objections to the idea of the introduction of physician
assistants have also been voiced by the Australian Medical Students
Association (AMSA). AMSA considers the introduction of what it
labels a hybrid medical practitioner will threaten the quality of
patient care and jeopardise clinical training places for medical
students. Echoing the concerns raised by the British Medical
Association it argues:
Doctors occupy a unique and important role in
the Australian healthcare system, however this role is coming under
increasing threat by the prospect of task substitution AMSA
believes that Physician Assistants (PA) are an inappropriate
measure to address current workforce shortages in the Australian
healthcare system. AMSA believes that their training will undermine
and diminish the available resources for medical students and
junior doctors. Reducing training opportunities may have a negative
impact on the level of clinical experience for Australia s future
medical workforce and hence compromise patient safety.[145]
In addition, AMSA does not see physician assistants as a
long-term solution to medical workforce shortages and argues
resources for the training of physician assistants would be better
invested in medical education and greater administrative
support.[146]
Some sectors of the nursing profession may similarly resist any
move to introduce physician assistants. In its response to the
Productivity Commission inquiry the Australian Nursing Federation
noted its disappointment with suggestions that a doctor-nurse
hybrid could be introduced in Australia, but it has not as yet made
any substantial objections.[147] These may come, however, from nurse
practitioners. Indeed, nurse practitioners may possibly feel
threatened by the physician assistant profession because they too
have yet to make a significant impression on the Australian health
system, with less than 250 registered to practise across Australia
in June 2007.[148]
It may be that the future of the physician assistant profession
in Australia is dependent on the outcome of the debate about the
benefits of so called task substitution .[149] In favour of task substitution it
is argued that:
The exclusivity of medical knowledge and skill
is being broken down. Interprofessional learning is now commonplace
in medical education and seems likely to increase. Professional
boundaries are being blurred as more and more things that were once
the sole domain of doctors are being undertaken by other health
care professionals. None of us works alone any longer, but in
multidisciplinary teams in which we depend upon the expertise of
others. This is not a diminution of medicine, but a strengthening
of health care. We must acknowledge that, more than ever before,
knowledge is available to patients and the public.[150]
It is also strongly argued that there is no evidence to suggest
that task substitution will compromise health outcomes. Indeed, as
has been shown in the American and British cases, there is evidence
to suggest the opposite. Supporters of task substitution do not see
it as the definitive solution to health workforce shortages but as
one of a number of interconnected options. Other solutions include
improving health outcomes through more efficient use of technology
and by emphasising prevention and health promotion.
In terms of retaining health workers and providing them with
graduated career paths, it is argued further that task substitution
can have positive repercussions by encouraging a workforce that
displays competencies that cross professional boundaries and by
providing multiple entry points to health careers.[151]
Another perspective in this debate is that rather than
considering task substitution, workforce reforms should be
structured around synergising the different skills of health
professionals, rather than substitution. This approach it is argued
would have more capacity to extend medical services with efficiency
gains, but without the potential loss of safety or fragmentation of
care .[152]
Encouraging other health professionals to undertake the work of
doctors is counterproductive according to this view, as it is
likely to increase workforce shortages in other health
areas.[153] It is
therefore effectively a poor allocation of limited resources
because it expects health workers to undertake roles for which they
are not adequately trained and in which they are not
expert.[154]
Back to top
Examples of potential or current task substitution in
Australian health system:
|
Task*
|
Traditional
professional
|
Substitute
professional/assistant
|
|
|
Anaesthesia
|
Anaesthetist
|
Nurse anaesthetist
|
|
Clerking of new hospital
patients
|
Hospital medical
officer
|
Nurse
|
|
Closure of wound
|
Surgeon
|
Nurse
|
|
Foot care
|
Podiatrist
|
Foot care assistant
|
|
Foot surgery
|
Orthopaedic surgeon
|
Podiatric surgeon
|
|
Laryngoscopy/Naso-endoscopy
|
ENT surgeon
|
Speech
pathologist/Nurse
|
|
Maternity care
|
Obstetrician
|
Midwife or GP
|
|
Mobilisation
assistance
|
Physiotherapist
|
Physiotherapy
assistant
|
|
Patient management
|
Medical practitioner
|
Nurse practitioner
|
|
Plain X-ray
|
Medical imaging
technologist
|
X-ray assistant
|
|
Refraction
|
Optometrist
|
Orthoptist
|
|
Reporting pathology
|
Pathologist
|
Scientist
|
|
Reporting X-rays
|
Radiologist
|
Medical imaging
technologist
|
|
*
Performance of the substituted tasks will generally require
additional training and clear protocols, and will also depend on
the complexity of the condition and the comorbities of the
patient
|
Source: Duckett[155]
Following from this is the claim that task substitution does not
fully take account of patient preferences and expectations about
care. From this perspective, patients will want and expect to see a
doctor , not a lesser trained practitioner to ensure they receive
the best available care. The view, albeit in relation to a specific
instance, can be summarised in the words of Richard Clarke,
President of the Australian Society of Anaesthetists:
Enthusiastic amateurs will not be, nor can they
be expected to be, as skilled in the rare but crucially important
area of patient rescue from either a surgical or an anaesthesia
crisis. The question that needs to be answered by the proponents of
task substitution in anaesthesia is: Would YOU [emphasis in
original] want to have a non-medical anaesthetist or a medical
anaesthetist provide anaesthesia care to you, your children or your
ageing unwell parent?[156]
The Howard Government (1996 2007) showed little enthusiasm for
the Productivity Commission s recommendations concerning the
exploration of alternative health workforce solutions. Its primary
strategy following from the Commission s recommendations was to
increase the numbers of medical and nursing students and in the
2007 election campaign it promised a further increase in student
places.[157] The
Australian Labor Party similarly promised to increase nursing
places.[158]
While it did not directly commit to additional strategies apart
from increasing places for existing health workers, it has noted
that the health system of the future needs to focus on providing
more health services in the one place .[159] This may indicate that in
Government it may be open to re-consideration of traditional health
workforce policies.
To date, Queensland appears to be the only state seriously
considering physician assistants as a health workforce option in
the near future. In 2005, the Queensland government announced that
it was exploring how to use the potential of different health
practitioners better.[160] It was also considering how to use the services of new
practitioners, including physician assistants, as part of an
overall strategy to address health workforce shortages in the
state.[161]
In October 2007, Professor Dennis Pashen, Director of the Mt Isa
Centre for Rural and Remote Health, reported that a pilot program
was about to commence in North West Queensland.[162] A number of other reports have
suggested commencement of a phsyican assistant trial was imminent.
However, it appears these announcements may be premature as
Queensland Health is in the preliminary assessment phase of the
pilot program which is likely to involve employment of a small
number of experienced physician assistants from the United States
for a period of 12 months to 18 months at a number of pilot
sites.[163]
Sites chosen for the Queensland trial will need to demonstrate
that as well as clincial need, they have capacity to provide
appropriate supervision and workloads commensurate with the
education, skills and competency of experienced physician
assistants.[164]
While no special regulatory processes will accompany the pilot,
standards of education and training, proficiency, ethics and
conduct will be monitored and physician assistants will be required
to hold licences to practice in the United States and to be
certified by the United States National Commission on Certification
of Physician Assistants (NCCPA).[165]
According to Queensland Health:
The pilot will be evaluated to determine
whether the role [of physican assistant] would be accepted by the
Queensland community and whether, in social and cultural terms, the
role fits within the health workforce in Queensland and whether the
role may increase the workforce pool by attracting a different
cohort into health
If it is determined through the pilot that the
role has applicability for Queensland, further consideration will
need to be given to how the role should be developed and
implemented to ensure that the introduction of trainee Physician
Assistants does not impact negatively on the training opportunities
for other health professions. The development of training programs
would also need to be informed by industry workforce needs and
ensure that the qualifications of Australian trained Physician
Assistants are recognised internationally.
Perhaps in anticipation of the outcomes of the Queensland trial,
the University of Queensland and James Cook University have also
formed a consortium to develop a physician assistant program to
train Australian students. The first course at the University of
Queensland is expected to be a two year post-graduate program. Some
discussions have been undertaken with Queensland Health about
placements for graduates of the course.
The Australian military has expressed interest in the
development of the physician assistant profession also. Professor
Niki Ellis, Director of the Centre for Military and Veterans'
Health at the University of Queensland, notes this is because of
the potential career options the profession may be able to offer
existing military medics once they are discharged from the
services.[166]
Possibilities for Australia based
on overseas experience
As has been demonstrated in other health systems, one of the
advantages in developing the role of physician assistant is the
flexibility it can bring to a health system. Physician assistants
have been employed in the United States to assist in the delivery
of care to rural and remote areas and underserved inner city
communities for over four decades. They also assist in the hospital
system, particularly in roles similar to those undertaken by junior
doctors. Physician assistants are being employed successfully in
the Netherlands and it appears that they may also become an
integral part of the British and Canadian health systems.[167] In addition, a
number of countries employ non-physician clinicians .[168] Countries such as
Brazil, Estonia, Thailand and Paua New Guinea are in the process of
developing and establishing formal affiliation agreements with the
United States for physician assistant rotation trial
programs.[169]
There would appear to be potential for physician assistants to
undertake similar roles in the Australian health system. For rural
and remote communities where it has proven difficult to attract
doctors to practice initially and also to retain medical services,
physician assistants could make a significant contribution. This
could include providing doctors with relief from professional
isolation and constant on call duty. It could also possibly
involve, if not the elimination, at least a reduction in the need
for doctors to obtain the services of locums.[170]
Moreover, the introduction of physician assistants has the
potential to address some of the concerns that have been expressed
about the lack of consistency in standards under which temporary
resident overseas trained doctors (OTDs) practise in rural and
remote areas.[171] As one study has pointed out, there is no formal
assessment of the level of theoretical and clinical skills of OTDs
before they are granted conditional approval to work in designated
areas of need. OTDs who apply to work in Australia on a temporary
basis only have to satisfy prospective employers that they hold a
medical degree and that they have the skills relevant to the task
the employer wishes them to fulfil.[172] In contrast, physician assistants
would be trained to Australian standards in Australian
institutions. They would also be subject to rigorous supervisory
conditions and continuing education requirements in order to retain
registration based on a nationally approved curriculum, most likely
developed in consultation with Australia medical colleges.
Importantly, in addition, physician assistants would not be
approved to practise independently and their practice would be
limited to mirror that of their supervisors.
Significantly, as Teresa O Connor from the School of Public
Health at James Cook University suggests, physician assistants
could be employed in rural and remote (as well as urban) Indigenous
communities. O Connor points out that employing Indigenous health
workers has already proven successful in these communities.
Furthermore, the role of the Indigenous health worker has expanded
from that of a basic nursing assistant to encompass a greater role
in health education, chronic disease management and some clinical
services, such as immunisation.[173] Expanding the skills of Indigenous health
workers in this way in O Connor s view, could address the high turn
over of clinical staff in remote health services , such a move
could ensure better continuity of care for Indigenous people. It
could also increase the participation of these communities in their
own health provision.[174]
Physician assistants could also work in both rural and
metropolitan hospitals delivering a range of services similar to
those they now provide in Canada and the United States. This could
help to relieve the workloads of doctors, particularly those of
junior doctors, and consequently, contribute to better patient
outcomes.[175]
It is debateable whether recent government commitments to
increase the numbers of doctors and nurses will adequately improve
health workforce supply in Australia. It may be that in the case of
doctors, training strategies will only serve to replace those
doctors due to retire and compensate for changes in the working
practices, such as shorter working hours, of the next generation of
doctors.[176]
Similarly, the nursing workforce is ageing and it is increasingly
being called upon to undertake more complex tasks, often without
accompanying recognition of its skills. Attempts to increase the
numbers of nurses may not therefore effectively relieve shortages,
unless they are accompanied by complementary actions, such as
increasing remuneration and improving the status of the nursing
profession.
This is not to say that improving the supply of existing
practitioners should be discounted as a health workforce strategy.
As noted throughout this paper, however, this strategy may be one
facet of a multi-dimensional approach to addressing health
workforce shortages. Another may be expanding the roles of existing
health workers and introducing new types of workers.[177]
There are concerns that quality and safety of care will be
compromised by the introduction of new, less qualified health care
workers. However, as noted earlier in this paper, the United States
and British experience has indicated to the contrary that health
outcomes can be improved, both in primary and secondary care, when
alternative practitioners supplement the work of
doctors. Recent trials in Britain also suggest that quality of care
for patients has been enhanced and workloads of medical
practitioners alleviated as a result of the employment of physician
assistants.
Evidence that introducing another type of practitioner, whose
practice is based on a medical model, into the health system will
result in shortages in other health workforce areas appears
inconclusive. In the United States, the physician assistant
profession is one of the fastest growing professions, and at the
same time there has been a consistent decline in medical students
choosing general practice for many years. But as this decline
predated the introduction of physician assistants, it could be
argued that only the existence of the physician assistant (and
nurse practitioner) profession has ensured that health services
shortages in certain areas are not worse.
That there has been objection raised to the introduction of
physician assistants in Australia is not surprising, given this has
been common to the experience of other countries. Some in the
medical profession see physician assistants as a threat from a
number of perspectives. Because physician assistants are trained on
a medical care model, there are fears that funding may be diverted
away from medical student and doctors in training programs to
support physician assistant courses. There is also concern that
medical exclusivity will be lost if another profession trained on a
medical model is introduced. Or in other words, that the medical
profession will be less central to the delivery of health services
than in the past and will lose status.
The overseas experience, however, highlights the opportunities
that the introduction of a new profession can deliver. One such
opportunity could be that the existence of competent nursing and
other professionals who are able to deal with routine care will
ease the work load on doctors and allow them to use their skills
more effectively treating more complex conditions. The existence of
physician assistant generalists may also provide general
practitioners with more opportunities to subspecialise in certain
types of care, for example, in sports medicine, palliative care,
skin cancer, mental health, sexual health or diabetes care.
This view is supported by Brendan Murphy, Chief Executive
Officer of Austin Health and Chair of the Victorian Health Service
Management Innovation Council. New health professionals, in Murphy
s opinion, can protect and justify improved income and working
conditions for medical staff, as they take on a broader supervisory
role .[178] As
Murphy notes, an evolution in medical practice in the public
hospital setting has meant that doctors are not motivated to spend
their time doing routine clinical work. They seek complex case
work, collegiality and continuing medical education and exposure to
teaching and research experiences. Role delegation and some
substitution could help therefore to increase satisfaction for
practitioners by allowing them time to undertake these
tasks.[179]
Murphy considers that existing and projected vacancies and
continued reduction in working hours mean that it is inconceivable
that existing doctors will be displaced. He concludes that the best
protection for the medical profession is to ensure that the [new,
alternative practitioner] roles are established in a
delegation/partnership manner, with a key requirement for medical
practitioner involvement .[180]
Under such a model, physician assistants in the hospital
environment may be able to provide more stability of treatment for
patients. They may also provide a counterpoint to the trend towards
increasing specialisation by bringing generalist skills and
flexibility into hospitals and by fulfilling generalist roles in
sub speciality settings.[181]
As health workforce shortages have become apparent worldwide,
the demand for the services of doctors, nurses and allied health
workers has escalated. The rise in chronic disease and the ageing
of the population ensure that this need will not disappear. But in
addition to these trends, more medical specialisation to keep pace
with medical advances and improved technologies and changes in work
practices have compounded the need for more health workers and more
skilled workers.
Just as the problems which have contributed to health workforce
shortages are complex, so their solutions will need to be multi
dimensional. Overseas experience suggests that introducing
physician assistants to supplement the work of doctors in a variety
of situations as well as complement the skills mix of primary and
secondary health care teams provides one dimension of the remedy.
Physician assistants have proven both cost effective and efficient
in the American health care system for decades. Recent trials in
Canada and Britain suggest they will be no less an addition to
these health systems; both patients and practitioners have recorded
satisfaction with the services delivered by these health
professionals. Given that Australia is experiencing similar health
workforce shortages and that it is faced with similar health needs
as Britain, Canada and the United States, it may be that it will
also experience comparable health benefits from the introduction of
physician assistants as part of a future multi dimensional health
strategy.
Source: http://www.paeaonline.org/iac/Global%20app.pdf
Source: R. Hooker, K. Hogen and E. Leeker, The
globalization of the physician assistant profession , Journal
of Physician Assistant Education, Volume 18, No 3, 2007,
http://www.paeaonline.org/perspective/100711.pdf
Endnotes
[116]. In 2006, twelve physician assistants
were employed on contract for two years in the Scottish NHS in
general practice, acute and emergency medicine. J. Buchan, F. O'May
and J. Ball, 'New
role, new country: Introducing US physician assistants to
Scotland',
Human
Resources For Health, 5 (4), 2007, pp. 13 20.
[132]. Australian Health Workforce Advisory Committee,
The Australian allied health workforce. an overview of
workforce planning issues, March 2006, http://www.health.nsw.gov.au/amwac/ahwac/pdf/allied_health.pdf,
accessed 21 November 2007.
[133]. C. Joyce, J. McNeil and J. Stoelwinder, More
doctors, but not enough: Australian medical workforce supply 2001
2012, Medical Journal of Australia, 184 (9), 1 May 2006,
http://parlinfoweb.parl.net/parlinfo/Repository1/Library/Jrnart/X6IJ60.pd.f,
accessed 21 November 2007.
[144]. N.
Ellis, L. Robinson and P. Brooks, Task substitution: Where to from
here? , Medical Journal of Australia, Vol. 185, No. 1,
2006, p. 18.
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