Ben Bidstrup: Forestalling the inevitable?

DOES the announcement that the University of Queensland will close its fledgling physician assistant course — even before the first cohort of students has completed it — send the message of wrong place, wrong time; or is it a reflection of the hard times many universities are experiencing?

Or has the university bowed to the political climate that appears not to support physician assistants (PAs) especially in Queensland?

Many innovative solutions to the shortage in the medical workforce have been explored around the world. Australia seems particularly sensitive to this shortage.

One large group, the nursing sector, has established the nurse practitioner as one arm of the solution. Australia has increased the number of medical students in the past few years and they are now starting to flow from medical schools into the medical community. However, they need further training to deal with the wide variety of clinical areas with which they may be faced. There also seems to be a continuing reluctance for them to practise in areas that need them.

In much of the world, PAs are used to support the work of medical practitioners.

PAs are medically trained health care workers, acting in a supervised role, with a delineation of responsibilities set out by the supervising clinician.

In the US there are some 75 000 PAs in active practice. Australia currently has 17 PAs about to graduate and a further 23 accepted for the next course by the University of Queensland.

So, why is the medical profession feeling threatened by the introduction of PAs in Queensland?

Fewer than 50 PAs is unlikely to be an impediment to the teaching of medical students. With numerous complaints from the medical profession about overwork, inability of clinicians to teach and no time to undertake postgraduate education, especially for those in rural practices, PAs are but one potential group who can support the existing and future medical workforce to provide high-quality care.

Several pilot studies have been conducted in Australia. Queensland Health sponsored one such trial, and there was nothing but praise for the interaction of the PAs, from the US, with the whole medical process.

This pilot study reported that once an understanding of the role as a physician extender was understood, the concerns of the clinicians working with them were minimal. They interacted well with all health care providers, although the study was limited in scope.

Other concerns that have been raised about PAs relate to the lack of an accreditation process, which would ensure a minimum standard of training, a registration process, an ability to prescribe, professional indemnity and ongoing medical education.

With many examples of governance structures, scope of practice documentation and competency standards available, such as that produced by the Canadian PA group based on CanMEDS, the speedy development of these in Australia is a reasonable expectation.

The Australian Health Workforce Institute has embraced the concept of PAs. A framework for their incorporation into care delivery is imminent. All this takes time, and the cessation of the Queensland course seems premature.

What can we learn from the Queensland experience?

Appropriate staffing with a good understanding of the local health system is vital. Many overseas PAs will have no experience of the nuances of the Pharmaceutical Benefits Scheme, Medicare Australia, Medicare Benefits Schedule, GP clinics and hospital specialist practice as delivered in Australia.

State health departments have yet to fully embrace the concept of PAs, so access to public teaching hospitals is limited. This makes competition for teaching places a non-issue, as much of the in-patient teaching for PAs is provided in the private sector.

Interestingly, federal funds have been allocated to the private sector for education facilities, some of which is predicated on PA teaching. The established teaching experience can be taken up by the universities continuing with their programs, especially where the clinicians are committed to helping solve the workforce issues in Australia by these innovative means. Other alliances with rural medicine groups are being forged.

Will groups such as the Australian Medical Students’ Association and AMA Queensland be prepared to revisit their initial responses?

The defence forces have historically used suitably trained health personnel for frontline care, and it is from this that PAs originated. It is likely that defence is an area in which many PAs will be absorbed; not helping the population at large, but those charged with our security.

The future of medicine in Australia will include PAs. It is not a bold move, it is a progressive move. It is the next step.

“Change starts when someone sees the next step” — William Drayton

Associate Professor Ben Bidstrup is a Queensland cardiothoracic surgeon and involved in training of PAs in Australia. He has also had some experience with PAs in the US.

Posted 23 May 2011

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