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UNIVERSITIES around Australia are pressing ahead with physician assistant (PA) training programs, despite a “turf war” with the AMA, which says they will take scarce clinical placement and training positions away from trainee doctors.
The recruitment of trained PAs from overseas has also met some obstacles, with a pilot trial demonstrating initial difficulties with their introduction to the South Australian health care system. Outcomes of the trial are reported in the MJA. (1)
A question mark also remains over whether PAs will be approved as registered practitioners with the Australian Health Practitioner Regulation Agency, which would allow them to order radiology and pathology tests and prescribe medications.
The American Academy of Physician Assistants defines PAs as health professionals who are members of a medical team with supervising physicians. PAs deliver a broader range of medical and surgical services than nurse practitioners. They can conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery and prescribe medications.
In the United States, where there are more than 75 000 PAs, they work in primary care, hospital and ambulatory care settings including emergency departments, procedural medicine, the defence forces, and in metropolitan, rural and remote areas.
They are considered by some as a new hope to relieve the severe workforce shortage of doctors in Australia.
But in the SA trial of two US-trained PAs at Queen Elizabeth Hospital, their scope of practice was limited, full use of their prescribing licence was not allowed until 3 months into the trial, and their authority to order radiology tests was limited.
However, coauthor Professor Guy Maddern, head of surgery at the University of Adelaide, told MJA InSight that the PA role and its fit into the SA health system had since been evaluated by independent contractors, who found that it was effective and well received.
As a result, PAs could be considered a useful workforce solution in SA provided they were accepted as a registered profession, he said.
Professor Maddern, who is helping set up a 2-year PA masters course at the University of Adelaide, said PAs would not take jobs away from graduating doctors.
“The whole concept of the PA is not to be a doctor but to make the doctor you’ve got more productive,” he said.
They also would not make a big impact on clinical placements, he said. For example, the University of Adelaide would have about 25 PAs and 600‒700 medical students in clinical attachments at any one time.
However, the Adelaide PA course was unlikely to start next year unless PA registration was assured, Professor Maddern said.
The University of Queensland launched Australia’s first PA training program in 2009. James Cook University (JCU) in Queensland and Edith Cowan University (ECU) in Western Australia are also planning PA courses.
Professor Peter Brooks, director of the Australian Health Workforce Institute, who set up the University of Queensland course, said there was still a lot of turf warfare with doctors over PAs.
“But there is plenty of work for all of us,” he said. “We are going to have to recruit about half a million people to the health workforce in the next 10 years.”
Professor Brooks said the US experience showed that PAs who worked for GPs and specialists made more money for doctors because PAs enabled them to see more patients.
Fears that PAs would cut into clinical placements for trainee doctors were also ill founded, he said. “The trials in Queensland and SA suggested, in fact, that [experienced] PAs actually taught the nurses, doctors and medical students a lot of stuff and that is the experience of the US as well,” he said.
Mr Allan Forde, a US-trained PA educator appointed to help develop JCU’s program, said it was a condensed, accelerated medical education. PAs who completed the course would mainly work in rural, remote, tropical and Indigenous areas.
“There are a lot of situations in remote towns, especially, where there is too much work for one doctor and no relief for them as far as being on call … but there is not enough work for two doctors so it is a perfect situation for a PA,” Mr Forde said.
“PA proponents are hopeful about addressing two major barriers to practice: indemnity coverage and access to Medicare billing and the Pharmaceutical Benefits Scheme,” he said.
Associate Professor Moira Sim, postgraduate medicine coordinator at ECU, said they were aiming for 20 students in their first PA training cohort next year.
“The ageing population means that despite increased training of medical students, demand for workforce will outstrip supply,” she said. “We need new models of health care to meet these needs.”
AMA vice-president Dr Steve Hambleton said the AMA opposed the introduction of any new health care professional because of the enormous increase in the number of medical students who needed training and placements.
“There are some conceptual benefits in having a new health professional who is actually assisting or leveraging doctors’ skills but the timing is entirely wrong,” he said.
“Even senior, trained PAs, who are quite useful in the health system, will still take away clinical experience [from students].”
– Cathy Saunders
1. Med J Aust 2011; 194: 256-258
Posted 7 March 2011
A debate that compares the relative role and worth of PAs vs junior doctors neglects a very important factor: “junior doctor” is a stage, not a career choice. Through factors like length of training, Australia – like NZ and the UK – have an excess of junior doctors working in hospitals. The medical workforce in AUstralian hospitals is much more bottom-heavy than the US. The role of the junior doctor cannot be replaced if we still want to have senior doctors – as one has to go through the training. SO, the junior doctor starts by checking each patient with a senior doctor, but eventually becomes that senior doctor, training others. At the same time, the PA can become more and more experienced, but remains working in a supervised capacity. it appears that, because of the different workforce dynamics, Australia needs more supervisors – not more people requiring oversight.
@AnonDr : If you don’t understand the role of PA, please do not act like you do. I am a physician assistant, currently working in the US. I love what I do! We as professionals CHOSE to be PA’s. We are not wanting to be doctors and if we did I would have gone to medical school and became one. At the end of the day, this is all political and at the end of the day.. the patients are the ones who suffer. Poor medical students who are afraid they won’t get a job, b/c a PA who is already trained wants to provide healthcare to patients just as much as you do. I see patients, provide and H&P, diagnosis/treatment plan, and prescribe. Yes, I have a supervising physician, but he can be up to 150 miles away. I am not a junior doctor checking out each patient to my attending physician. I also perform benign cyst & skin cancer excisions twice per week, without any assistance. At the end of the day, PA’s are well capable, unfortunately the shortage in Australia will not improve at this rate. The integration of PA’s will possibly happen at some point. It will take many years for it to become accepted. But, eventually it will.
@USApa – you are clearly uneducated about what you appear to be stating as “facts”. 1) There is in fact not a workforce shortage of medical/nursing staff, it is just that no one wants to work out rural. 2)we will not eventually try to come and work in the US because it is more lucrative. This is an offhand comment designed to indirectly attack med students for wanting to protect their autonomy and future career prospects. 3) Do not attempt to elevate yourself by focusing on the fact that you put patient care first. In the end, patient care is looked after by nurses (who are at the coalface essentially) then primary care doctors and specialists. 4) Good luck trying to integrate into Australia when we will barely have enough room for doctors and our health budget has major cuts.
I have worked as a Dr for 2 years now and I had at one stage worked with PAs. Look, lets be honest, they are pretty much performing the exact same role as junior doctors, just with less years of training and less future career prospects. I am not saying they are not intelligent people, but I am saying that they are doing the exact same role as junior doctors. In any department, there isn’t much difference between an intern doctor and a PA in the public system. Only private specialists would ever suggest that out sourcing the history/examination/ordering tests/etc to a PA and not doing it themselves is a good idea. At which point I do think a PA taking a history in a private setting is a bit useless as we have nurses who can do that job more than well and we also have referral letters for the basic gist. Aside from this, taking a history and examining a patient is how junior doctors learn clinical knowledge and skills. You think we would be better off sitting around thinking?. How is a doctor meant to direct his clinical inquiry, ask appropriate questions and diagnose when he is relying on the history and exam of a PA to go off? It all seems a bit weird doesn’t it? Even in our specialist clinics the residents take the history/examine the pt and present to registrars who then may do the same again then present to the consultant. Why throw a PA in that chain as well? There is no need. All you PAs can pretend you are a separate occupation but your role is extremely close to what junior doctors do. Yes, you probably would do well with private specialists who can afford to pay you (as no specialist could afford to retain a doctor who will eventually wish to specialise themselves). I believe I sympathize for PAs in that they have essentially been baited with a pseudo-doctor degree but 10-15 years down the road when you are highly experienced but you will still remain a supervised, lower paid and essentially disenfranchised junior doctor. Nevertheless, this is a political turf war in that this is simply the phasing in of a cheaper medical workforce whom are not to be feared because they must be supervised by doctors but at the same time are ensuring that there are less positions/jobs/daily tasks whatever you want to call it for junior doctors. In the Australian health system you will impact on both medical students and on junior doctors if you manage to creep your way into the system. If you wanted to prescribe/order tests, examine patients, take a history and diagnose you should have done medicine. Stop pretending you chose not to, we all know that is rubbish. A PA course is ~3 years, a post-grad medical degree is 4 years. There would only be one logical reason why you would not chose the latter and that is of course if you couldn’t get in.
USApa – there is clearly a productive and lucrative role for you in your own country, but I’m not sure that would translate well here. If you are truly making “well over six figures”, then there are more cost-effective clinician roles here, including many community GPs. Many GPs have additional training in dermatology, but can also manage conditions through the spectrum. Of course no-one is always right in their diagnosis, but the more thorough and more intense medical training would give a practitioner a greater chance at a correct diagnosis, and management. IF that were not so, why not get rid of medical training altogether and just have PAs?
It is amazing how narrow-minded people can be!! I am a USA-trained PA, and have been working in clinical practice for the past 7 years. The goals of PAs are not to take physician jobs. We are proud to be PAs. If we wanted to be physicians we would have chosen that route in the first place. It is sad that a country which is clearly lacking healthcare professionals, is not open to the institution of PAs and the impact it could make on healthcare in this country. Who in the end suffers… patients! Everyone is trying to protect their best interest: job security, but no one has once talked of the impact on seeing patients quicker and the accessibility to healthcare this could create. Poor med students… you want to protect your clerkship. Many of you eventually try to come to the US and practice b/c it is more lucrative anyway. Physician’s misdiagnosis as well, sometimes too much, and the PA makes the right diagnosis. The truth is that no one is God and no one is perfect. It is sad that you would graduate a class of PAs and no job. Yes, I make well over 6 figures, but I work hard everyday in the specialty of dermatology. If I have a question, I ask my attending physician.. but otherwise I take care of patients. Patients come first and that is how it works. All this is very political, but unfortunate. The integration will happen at some point. The US is utilizing our role and we are growing in number. Hope Australia chooses to do the same sooner, than later.
Anything new will attract many detractors, particularly in a field such as medicine, where some doctors install themselves as demi-gods. By the same token, anything new (in the treatment and management of patients) must be very carefully assessed. Guy Maddern and others have explored the use of PAs, albeit with only a small sample, and their results so far suggest that PAs could serve as very valuable members of treatment teams.
My concern relates to the syllabus for PA students; noting that they are postgraduate courses. Would they be trained to be a jack-of-all-trades, but master of none, or would there be prescribed responsibilities for which they are trained?
I could envisage that a consensus of doctors, with a mind to alleviating some of their patient management chores and freeing up time to practise medicine, would identify the skills that they would want to be taught. Engage rational doctors in the process of training the sort of PA that they want. If you don’t speak up, you won’t be heard: but, if you squeal and rant like a politician you will be ignored.
Next year the tsunami of medical students will hit. From what I understand there won’t be enough jobs for them all. Perhaps the unemployed ones can apply for PA positions. They should have full prescribing and imaging requesting rights, more thorough training and will be cheaper than 100k per year!
The best answer may well lie between the opposing views. PAs trained in the teaching hospital environment then able to compete for positions, under medical supervision, remote and rural, private sector, and military to meets needs. To task delegate and not task subsidise would be responsible.
To have PAs employed in the public sector may well be competitive to training of medical students and seen by bureaucrats as a cheap short-term fix and do no-one any good.
I was lucky enough to be a senior medical officer working with two excellent PAs from the USA in Queensland in 2009. Like most, I had significant reservations before meeting and working with these exceptional health professionals. As a rural GP registrar in a busy hospital they certainly made me more productive but also challenged me clinically and improved the calibre of my practice. As a doctor still in training I certainly see the point of veiw of medical students who are already struggling with enormous class numbers, but when you are talking about classes of several hundred compared to classes of thirty to forty, how much difference will you really see? The big question? In the long run will Australian-trained PAs want to work in rural and remote areas any more than junior doctors currently want to? Unfortunatley, the answer is – probably not.
The use of physicians assistants or nurses to preassess patients fails to recognise the importance of the initial patient contact. This is similar to the way in which the importance of the emergency room physician is underemphasised in most hospital models. The idea is that the specialists at the top of the ladder make the important decisions and diagnoses. However, what often fails to be recognised is that if the initial contact fails, a desperately ill patient may be sent home and never even see a physician – for example the risk of misdiagnosing meningococcal meningitis as a headache in the first stages before the development of the classical rash and neck stiffness. An experienced PA may be able to pick this, but the inexperienced ones should always have their work checked by doctors anyway – which rather decreases their usefulness.
It’s all really a way of getting cheaper doctors, isn’t it?
Professor Maddern said “The whole concept of the PA is not to be a doctor but to make the doctor you’ve got more productive,” he said.
I have no doubt that this may be ultimately true, however, as a medical student who had enormous difficulty in achieving the required number of new born “catches” because we were told that the trainee nurses came first, I have serious doubts that medical student training will come before PA training. As with the midwifery nurses, I won’t be surprised if an “us and them” culture develops which puts medical students last in terms of learning opportunities in the wards and clinics.
And as for experienced PAs teaching medical students, I just have to laugh! Yeah, sure thing… just like the midwives spend time teaching the med students… hahaha!
I fail to understand what business case has been made for PAs.
In the Queensland trial they were paid in excess of $100K pa. It might work for the public system which seems to have plenty of money when it feels like it, but wages like this will be essentially unaffordable in General practice, who can currently barely afford a nurse.
So where will they go?
A physician’s skills is obviously diverse – involving that of an expert, an educator, a clinician, patient’s advocate and technical expertise amongst others. I cannot see how training another set of bodies, with essentially all the duties of a physician, is going to improve patient care. We should be training physicians to perform all physician duties. There are enough future surgeons here in training to assist and learn from their consultants. If other bodies want to train in medicine, such opportunities are available. These days, I urge caution in anything coming out of America. Its health care system and model is not optimal and hardly a model to emulate blindly.
Personally I favor and support physician assistants, but I have my reservations about whether they will go to the areas that are under served or need them. Like most medical, nursing and para-medical practitioners they will cluster around the major centres. At present many private specialists use physician assistants under the guise of practice nurses or administrative office staff who fill in histories, organise tests and perform minor medical type activities. In essence we do now recognise the need for help to do our work. Better though to have a physician assistant than an independent nurse practitioner (who wishes to compete or replace us), but will physician assistants go to the rural and remote regions? I doubt it. More likely they will be sucked up into places like the Gold Coast, Sunshine Coast and metropolitan Australia.
I’ve had one personal experience with a PA in USA. She took a fine history but her diagnosis recognition of the seriousness of the situation and management were gravely lacking. When I need a doctor I will never again settle for a PA.
In my view, there is little to fear from the introduction of PAs, but potentially a lot to gain. This can be recognised if we think about the importance of COGNITIVE skills in the practise of medicine. Why not allow technicians to take over many of the manual skills, allowing doctors to exercise the more specialised cognitive skills that distinguish us from other health care professionals.
Doctors are trained in great depth and precision, across all the health sciences and every aspect of the human organism. Although we later sub-specialise to some extent, we retain an intimate understanding of the human organism, and the logical processes of clinical decision-making. Personally, I would welcome someone carrying out the more basic skills in clinical care, so that I can both practice and teach the sophisticated cognitive components.