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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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