Submission to Productivity Commission 
Health Workforce Study

Introducing physician assistant type practitioners 
to  
Australia

From
Teresa O’Connor
77 Christensen St
URRAWEEN Qld 4655

Contents

Physician assistant type practitioners	4	
Why introduce physician assistants to Queensland Health	4	
Part 1 The Physician Assistant in USA	5	
What is a physician assistant	5	
Definition	5	
History	6	
Education	7	
Regulation	7	
Supervision	7	
How physician assistants responded to workforce shortages in USA	8	
Rural response	8	
Primary care response	8	
Hospital based response	8	
The physician assistant current role in USA	9	
Risk factors	10	
Quality of care	10	
Acceptance by patients	11	
Cost comparisons	11	
Resistance from medical profession	12	
Flexibility of profession 	13	
Part 2 The physician assistant in Australia 	14	
How physician assistants could be used in Australia	14	
Indigenous health 	14	
Rural settings 	15	
Urban settings 	15	
Issues to consider	16	
Education	16	
Regulation	16	
Supervision	17	
Managing resistance and opposition	17	
Resistance from medical profession	18	
Opposition from nursing profession	18	
Differentiation of physician assistants and nurse practitioners	18	
Conclusion	20	
References	21	

Abbreviations

AAPA	American Academy of Physician Assistants	
ACP	American College of Physicians	
ACRRM	Australian College of Rural and Remote Medicine	
AIHW	Australian Institute of Health and Welfare	
ARC-PA	Accreditation Review Commission on Education for the Physician Assistant	
CARPA	Central Australian Rural Practitioners Association	
CRANA	Congress of Remote Area Nurses Australia	
CVP	Central venous pressure	
DH&A	Department of Health and Ageing	
GMC	General Medical Council	
GP	General practitioner	
KAMSC	Kimberley Aboriginal Medical Services Council	
NP	Nurse practitioner	
NRHA	National Rural Health Alliance	
PA	Physician assistant	
PAHx	Physician Assistant History Center	rs.  While the term ‘physician assistant’ is used throughout the document, another term more acceptable to the Australian context could be substituted. 

Part 1 – The physician assistant in USA
What is a physician assistant
This category of health care worker was specifically developed to address the medical shortage in the USA, particularly in rural and remote areas of the country. Its original focus was primary care but this has broadened into hospital work and a number of specialty areas. 

Definition
The physician assistant health profession arose in the United States of America. The definitions all highlight the fact that physician assistants work under the supervision of a physician. On its official website the American Association of Physician Assistants provides a detailed definition which states that a license (from a state authority) or credentials (from the federal constituency) is required and outlines the specific responsibilities physician assistants have and their relationship with physicians. This is the most comprehensive definition found.

Physician assistants are health care professionals licensed to practice medicine with physician supervision. PAs employed by the federal government are credentialed to practice. As part of their comprehensive responsibilities, PAs conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery, and in virtually all states can 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.3

The following definition shows how the physician assistant can undertake some of the roles previously only done by doctors.
Physician assistants are clinicians who are licensed throughout the United States to practice medicine in association with physicians. They perform many of the tasks previously done solely by their physician partners, including examination, diagnosis, and carrying out investigations, as well as treatment and prescribing. All physician assistants must be associated with a physician and must practice in an interdependent role, described as “negotiated performance autonomy”.4

The crucial points to take from these definitions are that physician assistants cannot practice in the USA without a license, need to be associated (either on site or at a distance) with a doctor, and can undertake the broad spectrum of health care including diagnosis, treatment and prevention. Physician assistants practice “within the medical model of care”.5

History
Duke University Medical Center is the birthplace of the physician assistant profession. In response to shortages of nursing and allied health professionals, the chairman of the Department of Medicine, Dr Eugene Stead Jr, proposed the development of a group of health care workers who could work in the clinical setting and relieve rural physicians who wanted to undertake continuing education. His ideas stemmed from experience during the Second World War when medical students had assisted in the running of a hospital at which he was working and doctors were educated within three years for use in the armed forces.6

The original proposal was for nurse clinicians to take on this role. However after the proposal was rejected three times by the National League of Nursing, who claimed that it was “perhaps dangerous for nurses to assume medical tasks”, veterans who had worked with the military medical corps were recruited into the program which was initially taught by a nurse and then by other health care professionals.6

After two years of study and practice three students, all former US Navy medics, graduated in 1967. Stead was looking for a solution to healthcare staff shortages and worked from the premise that 
a person with a high school education, a reasonable rate of learning, and a tolerance of the unavoidably irrational demands often made by sick people can learn to do well those things a doctor does each day. Under the wing of the doctor, such a physician’s assistant can collect clinical date, including history and physical examination, organize the material in a way which allows its use in diagnosis, and carry out any required therapeutic procedure which the doctor commonly uses.6

By 2001, there had been 52,716 graduates from PA programs and it was estimated that 45,120 of these were in employed as PAs at that time.7 In 2002, the Bureau of Labor estimated there were 63,000 PA jobs available with many PAs working in more than one job.8 

The physician assistant movement expanded to Canada in 1992 when senior medical technicians in the armed forces were authorised to use the PA title.9 In 2004 the Canadian Medical Association granted recognition of civilian physician assistants and at least one of the physician assistant training institutions in the USA is offering admission to Canadian applicants in 2006.10 

In Britain in 2003, two PAs from the USA were employed in a pilot program by one of the NHS trusts and one PA started work in a general practice in the Midlands where there had been a vacancy for a doctor for 18 months.11 Since then there has been a growing interest in this category of health professional. Birmingham Medical School has developed a pilot training program, as has Wolverhampton University, and other trusts have taken on PAs to work in accident and emergency departments.12 

Education
There are more than 130 PA education programs accredited by the Accreditation Review Commission on Education for the Physician Assistant13 in the USA. Sixty-eight (over fifty per cent) of the programs offered master’s degrees while the rest were either bachelor’s degrees or associate degrees.8 

Most programs insist on students having had some time in patient care prior to enrolling for PA studies. The average course takes two years, each of three semesters, of which up to twelve months can be clinical practice under supervision. In some universities the PA students take classes with medical students (e.g. University of New Mexico).  

Regulation
Between 1972 and 2000 all states legislated for the practice of physician assistants.14  The legislation that enables physician assistants to practice in each state is usually found within amendments to the Medical legislation of that state. 

Physician assistants are required to undertake 100 hours of continuing education and each 6 years complete the Physician Assistant National Recertifying Examination or a similar piece of assessment.15 

Supervision
All physician assistants must practice under the supervision of a doctor, though this can be at a distance. The original plan was that each PA would work with one doctor. However since then it has been agreed that the PA to doctor ratio can be 2:1 in some states up to 6:1 in California with the proviso that this ratio is decided at the practice level by the doctor.16

One of the mechanisms of supervision is the use of clinical protocols.17 These are standard treatment plans for common conditions. They provide detailed information about how to treat particular presentations of illness. 

How physician assistants responded to workforce shortages in USA
Rural response
The first PA program started as a response to workforce shortages in North Carolina.6 In 1969 the MEDEX Northwest physician assistant program was started at the School of Medicine, University of Washington, Seattle. This program was developed in response to primary care health professional shortages in the Northwest region of the USA, particularly the states of Washington, Alaska, Montana and Idaho, large states accounting for 23 per cent of the land mass of the USA but with only three per cent of the population.18 

The WAMI program, now WWAMI with the addition of Wyoming to the group, has designed health professional programs specifically aimed at keeping health professionals in these sparsely populated states. One of the strategies that WAMI adopted was to recruit health care personnel from the rural and underserved communities into their PA program.18 This seems to have paid off as the physician assistant graduates from the MEDEX Northwest program have mostly remained within the five state region (76%) while 24% have moved to other western or central states with only 4% of graduates moving to the heavily populated eastern states.19 

A survey of the geographical workplaces of physician assistants in the mid 1970s found that half of PAs were “working in communities of 50,000 persons or less” which the study equated with medically under serviced communities.20 This study concluded that the “MEDEX programs have been particularly effective in producing physician assistants who are providing general primary care services in smaller communities”.20 As PAs need to practice under the supervision, or in association, with a physician, they could only undertake practice in smaller communities if there was a physician willing to supervise them. This occurred with a PA working in a satellite service in a community supervised by a physician in the main service centre.21 By 2001 23% of the non-physician providers (PAs and NPs) worked in rural areas, while only 13% of doctors did.7 

Results that will be familiar to anyone associated with rural health in Australia were found by Singh when developing a predictive model of PA location. “Male gender, rural or small town background, early commitment to primary care and primary care choice of specialty were predictive of rural location.”22

Primary care response
There was a crisis in primary care in the USA during the late 1960s when health care was considered to be over specialised, difficult to access and poorly distributed geographically.21 In the mid 1970s 75 per cent of PAs were working in primary care settings,20 with a similar figure found in the mid 1980s also.23 By 2001 this figure had dropped to 50 per cent as the PA movement had responded to other health workforce needs9 and in 2003 44 per cent of  PAs reported that they worked in primary care.24      

Hospital based response
By the early 1980s there had been a significant shift of PAs into institutions, particularly public ones. There were three drivers of this shift, the first of which was a reduction in the number of foreign medical graduates due to more stringent entrance requirements. The second was the ability of PAs to adapt to a different clinical settings quickly and finally the recognition that PAs were cheaper than medical staff.21 

Hospitals found they could substitute about 50-75 per cent of a doctor’s work with one PA, with their broad based training enabling them to quickly function in a number of different clinical settings.21 PAs worked in medical, surgical and paediatric settings, including emergency care.  In one geriatric institution, the Beth Abraham Hospital in New York, “foreign medical graduate house officers were replaced by 10 physician assistants in 1979. There was a marked decreased in patient mortality on physician assistant-staffed wards when compared with the results before 1979.”21

One of the advantages of having PAs working in house officer positions was the continuity of service they offered. They were not rotated as junior medical staff were and “they get trained for a very specific role and stay with it.”25 “PAs in these positions function with a degree of skill and competence similar to that of first-year physician residents in the same position.”25 

By 2003 thirty-seven per cent of PAs reported that they worked in hospital settings. This was divided between emergency rooms (10%), inpatient units (9%), hospital outpatient units (8%) and operating theatres (7%).26 With the reduction in the hours of work hospital residents were allowed to work which came into effect on 1 July 2003 and limited resident hours to no more than 80 hours per week27 there was even more demand for the services of PAs to fill the gaps left in hospital services.28 

The physician assistant current role in USA
As can be seen from the previous discussion PAs work in a broad range of settings and fields of medicine. The role of physician assistants includes procedural/technical activities, direct patient care, administration, research and medical education. Besides directly caring for patients they also undertake patient education and health promotion.25

Those working in primary care fields cover family practice, paediatrics and women’s health. The places where they work include private practices with family medicine practitioners (equivalent to GPs), in their own practices associated with a supervising doctor who may be some distance away, in prison services, in walk-in clinics in poorly resourced areas, in hospital outpatients, and in occupational health positions.