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Although there is a potential role for PAs within the Australian health care system, this must be accompanied by rigorous regulatory oversight and governance to monitor their impact.
Physician assistants (PAs) have been widely used in the US and now the UK, with approximately 4000 in the UK (referred to as physician associates) and in excess of 160 000 in the US. Comparatively, Australia has approximately 40 locally trained PAs. However, a plan to expand the role of PAs in Queensland has been met with ire by the RACGP and AMAQ, with doctors raising concerns about the devaluation of medical practitioners and potential reduced quality of care. PAs typically have an undergraduate health degree and an additional two years of PA training; this training is no longer offered in Australia. They are frequently employed in private practice or the emergency department setting, and the roles outlined for them include diagnosis, devising a treatment plan, prescribing medications and ordering investigations for patients. This article will evaluate the overseas experience and potential impacts of expansion of PAs in Australia.
The UK experience
The implementation of PAs in the UK has been described as “an unqualified mess”. Initially touted as a solution to workplace shortages with a role to assist doctors, PAs have instead begun acting as substitute doctors, practising largely autonomously and without a national regulatory framework. This has reduced clinical training opportunities for doctors-in-training, and created significant distress for trainee doctors. For example, 70% of surgeons-in-training reported a negative impact on their training from the use of PAs. Similarly, a survey of doctors found that 55% reported increased workload following the introduction of PAs. Furthermore, the general population is confused around the terminology, with many unable to distinguish between a PA and a doctor. This limits patient autonomy and choice.
There are also concerns that PAs are acting beyond their scope of practice, with resulting negative outcomes for patients. There have been several high profile deaths associated with the care provided by PAs, including a 30-year-old woman whose pulmonary embolus was twice dismissed as a sprain and anxiety by a PA. The British Medical Association (BMA) have called for PAs to stop diagnosing patients, with 9 in 10 doctors reporting that PAs are dangerous for patient safety. Despite these concerns, the UK is persisting with plans to expand the PA workforce to 10 000 by 2037 and introduce an apprentice model with untrained PAs joining the health care service. The BMA is strongly advocating for increased restrictions on the scope of practice of PAs to improve patient safety.
The US experience
Contrary to the UK, the role of the PA has been established in the US for approximately half a century. The PA role was developed in the US in the 1960s to address rural workforce shortages, using trained military medics. They now operate as semi-autonomous practitioners, with their scope of practice limited only by their supervising physician. In contrast to the UK and proposals in Australia, PAs in the US undergo independent accreditation by the National Commission on Certification of Physician Assistants, must complete ongoing medical education and be re-certified by completing an examination every six years. PAs must also be licensed in their local state. With doctors specialising straight out of medical school in the US, PAs largely fill a gap of generalist junior doctors that is absent in the US health care system.
In the US, PAs are generally acceptable to patients in primary practice, but the evidence for them is weak and mixed, with unclear financial benefits. Similarly, they have been identified to have innovative roles in emergency medicine, in wound care, patient flow and rural emergency department staffing, but lack of research on clinical outcomes, effectiveness and cost–benefit analysis limited recommendations around their use. However, other studies have found similar prescribing outcomes and clinical outcomes for patients comparing physician and PA prescribing and outcomes during hospital admissions, with PAs being generally acceptable to patients. While the American Medical Association acknowledges the role of PAs in supporting health care delivery, they are also opposed to scope of practice creep and proposals for increased autonomy including PAs practising without physician supervision.
Potential role in Australia
There is no doubt that there is a significant health care workforce shortage and geographic maldistribution in Australia, demanding innovative solutions and models of care to meet clinical demands. Some doctors would welcome the use of PAs to address excess clinical demands, and point to their relative success in the US system. However, there are multiple concerns related to the potential expansion of PA numbers in Australia.
Firstly, there are currently no university or educational institutions offering training for PAs in Australia. This means that most PAs will have completed training outside the Australian health care system, with inconsistent benchmarking of standards. It is unclear how their accreditation in Australia will be standardised to ensure a consistent standard of care. Furthermore, there is no clear regulatory oversight of PAs beyond the supervision of senior doctors. They are not registered with AHPRA, and are therefore not subject to the same level of scrutiny as other health care professionals. The continuing medical education requirement enforced in the US does not appear to apply in Australia, and the ongoing professional development requirements are unclear. This increases the risk to patient safety due to potentially outdated and poorly regulated practice.
There are also concerns about the impact of PAs on the doctor-in-training workforce, including competition for training opportunities and clinical supervision. The proposed pay structure for PAs, which exceeds the pay of a first, second or third year junior doctor in Queensland despite the stark difference in training, is likely to further aggrieve doctors-in-training. With such generous salaries, it is unclear how the introduction of PAs will be financially viable, with it being more economical to hire junior doctors than PAs. With 20% of doctors-in-training considering a career outside of medicine, health services should be directing resources to retain their existing workforce through strategies such as retention bonuses and targeting bullying and harassment, rather than introducing divisive PA positions that risk further alienating this cohort.
Conclusion
Current proposals around expanding PA numbers in Australia are fraught with uncertainty. While PAs are relatively well accepted in the US, there are a myriad of issues in their rollout in the UK with associated concerns for patient safety. Although there is a potential role for a PA within the Australian health care system, this must be accompanied by rigorous regulatory oversight and governance, strategies to minimise disadvantage to trainee doctors, and ongoing monitoring and evaluation of their impact. There is inadequate research and demonstrated benefit to support the expansion of PA numbers in their current form. This proposal represents a bandaid on a gaping workforce wound that requires strategies for recruitment, retention and support of the medical workforce rather than role substitution.
Dr Elise Witter is Psychiatry Registrar at Cairns Base Hospital and Health Service.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Are we at all following what is happening in the NHS, with poor health outcomes, workforce substitution and patient deaths? Fund more training spots, increase the medicare incentive and make GP a well remunerated/respected profession.
The introduction of PAs and AAs in the UK healthcare system has been catastrophic. There are numerous examples of patients coming to harm as a result of these unregulated ‘practitioners’ . I believe expansion of medical and nursing numbers is the only safe way forward. The cut price option of assistants will be quite expensive in the long term.
You are absolutely right and actually in ideal world they are not meant to triage, make decisions and I referred to in my previous note, I have bad experience with nurses placed into ED to review and admi5tt patients, this is not against nurses but as you referred to people should do what they are trained to do.
The idea of Physicians Assistants to practice in Australia. was aired several years. The proposal fell into obscurity for want of a meaningful purpose, issues of registration, and the lack of clarity on their legal relationship with registered nurses and with medical practitioners. Nurse practitioners succeeded in overcoming hurdles of resistance to become accepted as legitimate skilled providers in their domain of practice. Where is the public demand for physicians’ assistants identified?
Having retired from specialist Hand Surgery practice, I now work part-time as a Surgical Assistant. The surgeons I work with find me more useful than a medical student or even a registrar, as I can advise from experience on surgical approaches, anatomical variations etc; as well as the usual retractor holding and stitch cutting.
But such ‘assisting’ is done under the continuous direct supervision of the responsible surgeon, not acting autonomously. I don’t consult on awake patients, merely the anaesthetised. I don’t diagnose, refer, investigate nor prescribe. I require MDO cover at over $6,000pa, full AHPRA registration and thus CPD compliance (50 hrs pa to work around 500 hours). I am aware there is no high-level evidence that an experienced surgeon working in an entry-level role like Surgical Assistant actually benefits from CPD, but it is an excuse for tax-deductible conference travel.
Yet the mooted local ‘PA’ is a role better described as a ‘Physician Replacement’, someone who consults alone and makes decisions about clinical management, generating costs (e.g. imaging, prescribing) and risk. As with the CFMEU or Pharmacy Guild, a more militant Union representation will ensure that PAs accrue more salary raises, and better benefits, than doctors (try billing Medicare for your maternity/sick leave, and remember that when everyone else got Superannuation, Medicare didn’t get an identical percentage rise. Even the profligate Dr Chalmers didn’t offer a Medicare rebate hike when Super rose this year.)
With no clear plans for restriction of practice creep, and neither AHPRA oversight, CPD, College nor indemnity costs, the salaried PA becomes a more attractive career path than GP as it starts at a younger age, has less bureaucratic oversight, essentially does the same job, and Dr Witter has pointed out the already higher starting salary.
In the UK there is generalised mediocrity of healthcare, but if you ask US colleagues, the rich folk get real doctors (some prefer DO to MD trained) but the poor get more PAs.
I’m a GP.
Instead of role-substitution, how about more support with nursing and administrative tasks; that would streamline my efficiency.
We could all then do what we do best.
Is there a place for retired Doctors to work as Physician Assistants, thereby using an already trained person?
I was part of the discussion we had many years ago at the RACP level and item was put on the agenda by Queensland representative, The committee agreed and welcomed the proposal.
Going in the details may need more than one article but thanks to Dr Witter for raising it.
I strongly believe that PAs have a role in our system but needs to be very well adjusted and job specified to avoid the concerns highlighted in this article, which are all legitimate in my view.
My quick inputs are:
1. The major potential contribution to be in (procedural areas) whether medical or surgical disciplines. The current situation in many hospitals is that those disciplines have turned into procedural workshops NOT much clinical practice.
2. Such practice has double disadvantages; on one side these procedural colleagues are shouldering more on General/Internal Medicine to cover the clinical/outsides the procedure or post procedural patient’s journey. On the other side some procedural colleagues are actually losing their clinical skills and practicing more or less similar to the scope PAs, with my due respect, to the degree that orthopaedic patients are on physician’s bed card
3. Area of practice for PAs should be very carefully selected, monitored by rigorous supervision, auditing, CME, CPD and research so that re-assessment be based on evidence not just review based on personal feedback. PAs to always practice under continuous supervision by clinicians and patient be on bed card of a clinician.
4. For PAs to practice outside area of procedures which should be under continuous and ongoing supervision of a clinician, I don’t see the time is NOT right to involve them in triage in ED or unsupervised practice. I had a recent encounter where the hospital was using nurses to triage patients at the ED and I came up with negative feeling and addressed it to the medical in charge as (inappropriate and very risky). This may change with further experience but not at this stage.
I hope this will shade some light and happy to be involved in further discussions.
When I fly in a commercial jet I expect a properly trained and certified pilot at the controls. When I have an electrical problem I call a certified electrician to do the work. If I go to a General Practice in Australia I expect a fully trained and
certified Doctor to be in charge. I am quite happy for a properly qualified nurse to do work under the doctor’s supervision such as observations or dressing changes. But diagnosis and management is actually quite difficult-It took me 10 years of training to be competent in General Practice. This country is rich enough to train sufficient Doctors to care for the population and there are plenty of applicants. So no PAs
Governments at all levels need to step up and fund bridging courses for Allied Health/ PA’s etc to train as Doctors. We need to set and keep standards instead of further fracturing continuity of care and responsibility for patient outcomes.
Call a spade a spade.
I have often thought about how GP practices could solve their workforce issues. I have spent time in the US. UK and Canada working as a Clinical Nurse across various areas. Patients With chronic, long term issues are a group, that if managed better could free up GP and Physician time without taking anything from the GP or Physician roles. Most of the clinical observations, blood screens and other important invisible markers could be done and collated by the practice nurses, who would be in a position to triage access in a timely way patients at present can be waiting six weeks or much more while problems deteriorate due to absence of diagnosis and appropriate action.. My solutions do not involve creating another class of professional, they merely require a better system of patient access and assessment with an excellent coordination system.