Issue 18 / 23 May 2011

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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13 thoughts on “Ben Bidstrup: Forestalling the inevitable?

  1. woolly says:

    I’m responsible for supervising the actions of many junior doctors in our emergency department, and find that incredibly challenging already. Why would I also want to be responsible for supervising and managing the actions of people who are NOT fully fledged doctors with limited knowledge and skills ?

  2. Ian Haywood says:

    I think the debate exposes key differences between American and Australian medicine at the junior levels.
    Basically, Australia already has PAs: only we call them HMOs. The qualification is different, being medical graduates, but the pay, duties and level of responsibility are very similar. American resident doctors start at a higher level of pay and responsibilty (closer to Australian registrars), so what we call the HMO role can be filled by PAs/NPs.
    Therefore I think the disinterested response of the state health departments is very logical, they already have skilled and cheap medical workforce, PAs won’t save them a dollar, and if they are rolled out beyond a few dozen, will lead to embarrassing headlines about unemployed junior doctors.

  3. Alan Dinehart, MD says:

    A PA is considered an extension of the physicians hand. In a rural situation, it allows the physician to extend care to a much larger area. Obviously mandating IMGs to the bush for 10 years isn’t working to solve the shortage. If patient care is really the goal, than PAs are inevitable. If keeping medicine a closed door shop, medicine will ultimately fail.

  4. Anon says:

    I dont have any basic objection to PA’s but should be done in discussiona nd collaboration with doctors. The way practice nurses are going to be working without supervision except with “collaboration aggreements with doctors” inspires no confidence of the health authorities.
    Good medicine is very difficult as most doctors will attest. If the population want to try PA’s, NP’s and alternative medical practitioners in isolation then good luck to them and got help us all.
    As a wise old doctor commented when asked why a prescription was such a complex issue (and warranted a fee) to be told – 5 % was doing what you know, and 95% knowing what to do.

  5. Max King says:

    Ben Bidstrup’s article provides a nicely potted view of the case for PAs. The literature is overwhelmingly positive about this enlightened concept. It is not a fanciful idea that has emerged from the addled mind of an opium eater, but a tried and true adjunct to medical practice that has blossomed over the last 50 years.
    Clearly Alan Dinehart is a realist and a pragmatist.

  6. dr jay says:

    I have been working in EDs for the last 20 years and am one of the higher paid docs. It’s rare that suture trays, plasters are set up anymore …. I would look at any initiative that made me more efficient, eg, my assistant to set up for my sutures and other procedures – would make me more efficient certainly. Maybe they should be bonded to the doctor not the system….

  7. jenni says:

    Pilot studies/trials of the few PAs in Australia were of short duration. Not surprisingly the results published were favourable. The ‘Hawthorne effect’ makes it highly likely participants in the study would display positive attributes. Assumptions quickly follow, such as that PAs might relieve the medical and other workforce shortages in rural and remote areas.
    A proliferation of health practitioners, each claiming aspects of client care and treatment, blurs the boundaries of who is responsible/accountable for what. The relationships between various health professionals remains unclear (eg, between Registered Nurses and PAs). The lack of a specific PA knowlede base in Australia and lack of legal status adds to the confusion

  8. Greg Coffey says:

    In the US, PAs are actually bonded to the doctor, not the system, the doctor is responsible for their actions, and if they don’t perform well the relationship is terminated, leaving the PA to look for a different sponsor. PAs have varied roles, including performing routine general practice tasks in rural areas, taking first call after hours, admitting patients and performing early diagnostic work-up, and generally making the rural doctor’s life a lot more comfortable.
    There are hundreds of doctors in remote areas in Australia who would find their workload lightened and work practice enhanced if allowed to employ a PA, provided services were able to be rebated by insurers. A logical extension of reduced on-call load for the solo country doctor is increased retention of the medical workforce in rural communities.
    A useful adjunct to the survey above could include a question such as: “Is your view the result of actual contact with PAs, or merely uninformed speculation?”

  9. Ben Bidstrup says:

    Greg Coffey has hit the nail on the head. In the main, the PAs will be the direct responsibility of a doctor. The public health system has many issues, and PAs may not fit into that area just yet, despite the resounding success of the trial held in Queensland. He asks the question about contact with PAs. I am in contact with them daily. They are all looking for a way to use their skills they have gained to help the patient. Many have a plan based on their previous existence – ED support, GP support or surgical assisting, to name but a few. In both private and public sectors, these roles complement that of doctors, both junior (in training)and senior. They do not compete.

  10. sociologist says:

    The dire economic outlook for Australian business [other than the mining sector] will be reflected in the health sector. Australia the continent that is the world’s lowest polluter is to introduce another tax – labelled as a carbon tax – so cost of living will rise. With productive unemployment increasing – this unemployment time bomb is being camouflaged by service industries being the only avenue for commercial activity – the major industries are the health industry & the ‘education’ industry. Soon it will ‘mandatory’ to have either a certificate or university diploma to be a grocery checkout operator. There is no necessity for another category of health worker in our society – the tsunami of doctors is about to strike the population [in addition to the OTD migration scam] – on top of the other ‘allied health’ – in 10 years unemployment will be a feature of the health industries. Universities for commercial reasons establish courses that are profitable – universities are not socially responsible institutions. They have been forced to be commercial entities & should be classed as such – same category as Bunnings, Coles & Woolworths etc, – thus there now is an oversupply of lawyers – law courses have shrunk & now are incorporated as part of arts faculties. Next is medicine or ‘health sciences’, as is the present product jargon. So why lament a commercially savvy decision to cease a course.

  11. Ockham says:

    Drs. Jay & Bidstrup – why is a university course of 3+ years required to set up suture trays? Are nurses [various categories EN, RN, trainees] not sufficiently qualified or too busy??

  12. bully says:

    What a great debate! Let me add my 10 cents worth. I like to think these issues through by taking a strategic or big picture view of this whole issue by asking 4 questions – questions that I cannot answer despite my 25 years of provincial & rural specialist medical practice, my experience of & interest in military medicine, my 40 years in the training for & practice of medicine and my energetic attempts at trying to influence society directions via the political process.
    1] Who takes medico-legal responsibility for the actions/practice of PAs & NPs?
    2] Who takes financial responsibility for the cost of the PA/NP service or assistance? & also consequentially
    3] Who takes responsibility for the knowledge & technical experience of our next generation of medical practitioners?
    4] What is the supposed future role & actual job of the medical profession?
    This “brave new world” that is evolving is NOT thinking of the consequences of the current decisions and actions.
    It is a bit like the global warming, sustainable world population, sustainable individual lifestyle debate that is currently raging.
    Actions have consequences. Can we live with those consequences????

  13. andy says:

    As a medical student I’d make the following points.
    1. Exactly why would we expect PAs to be any more likely to work in rural Australia than medical officers? It is just as hard to get allied health and to a lesser extent nurses to work in rural Australia.
    2. Where is the money to train PAs meant to come from? Health dollars are scarce and trainee doctor numbers have exploded.
    3. As a former military medic, the defence system cannot be equated to that of public health (insurance, operational requirements, very well developed training system with one employer and solid checks and balances) and having looked at the training, the skills of a PA are totally different.

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