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Do physician assistants have a future in Australia? Yes, says the Minister…

Could physician assistants (PAs) help fill the workforce gaps in rural, remote and Indigenous health, and improve access to healthcare for under-served communities?

Minister Warren Snowdon seems to think so, according to a Croakey contributor, Tony Wells, who heard his address to a national rural health students conference in Alice Springs last week.

Wells reports that the Minister said there were only a handful of physicians assistants in Australia but they were a significant option for adding to the health workforce in rural and remote areas. He also said there was potential for the role to expand workforce and career options, particularly for medics and Aboriginal health workers.

The Minister made similar comments earlier this year when I interviewed him for a profile for Australian Rural Doctor magazine. He told me: “I’m an advocate for physician assistants. I’ve spoken to quite a few practitioners in the bush who believe they’d be very helpful to them. But I’m also conscious there’s a whole debate, discussion got to take place in the broader medical community about workforce changes so I don’t think it will happen today. But it will evolve and there will be physician assistants.”

Interestingly, one of the gurus of the PA profession in the United States, Associate Professor Ruth Ballweg, was also speaking at the Alice Springs conference. When I interviewed her in 2008, she advised those seeking to introduce PAs into Australia to keep arrangements flexible and under the control of local doctors, rather than taking a centralised prescriptive approach which rigidly defines what PAs can and can’t do.

Ballweg, director of the MEDEX Northwest program at the University of Washington in Seattle, said that one of the reasons her training program has been so successful is that it was initially designed by doctors to help relieve their workload stresses.

“Washington State Medical Association was the co-sponsor of our program,” she says. “All these doctors were burning out, and they were miserable so this was seen as the fix. They got to design the fix. It wasn’t imposed on them from above, which never works.”

Physician assistants have also recently been in the news in New Zealand, where at least one hospital is trialling the role.

Meanwhile, Croakey thanks Professor Peter Brooks, Director of the Australian Health Workforce Institute, at the University of Melbourne, for reviewing a newly updated book that sounds like essential reading for those interested in the history and scope of physician assistants.

Snapshot 2010-07-23 11-26-31

Physician Assistants – Policy and Practice –  Roderick S. Hooker, James F. Cawley, David P. Asprey, 3rd edition (2010).

Peter Brooks writes: This is surely the PA ‘bible ‘ and is significantly updated from previous editions. It acts as a great source of data on how the PA movement started – essential reading for anyone who is interested in how  the conservative silos that currently constitute the heath care system react when face with a change (challenge).

The book discusses what PAs do, what they don’t do, and how they learn. The text is surprisingly up to date – activities occurring during 2009 such as the opening of Australias first PA program are included and there is important information on the various types of programs and the  registration and accreditation requirements from around the world.

The majority of PAs still work in the USA (73000 plus) but there is expansion in Canada, Europe and the UK with Australia and South Africa developing a number of training programs .

Of interest are the broad areas in which PAs work – primary care, emergency rooms, procedural medicine, rural and remote and in a wide range of  hospital and ambulatory care settings.

They continue to contribute to the Military (from whence they came – the “medics” and corpsmen).  PAs work in underserved areas more frequently than other health professionals and have different gender balance from nursing.

Although working primarily  in the US and therefore a different health system, they do provide a cost effective model of care and allow doctors to see more patients – they are true medical “extenders”. The model therefore lends itself very much to a human resource constrained health system that continues to exist around the globe.

Fundamental to the physician assistant is the delegated model of care, emphasised significantly in the book . They are very much a part of the health care team and the role that they play with other members of that team – particularly nurse practitioners is again discussed, emphasizing their complementarity. Interestingly the issues of patient satisfaction and clinical outcomes are also discussed – and, as expected, they are no different from those of physicians.

This book is a must for anyone interested in provision of health services in 2020 and beyond, and will dispel some of the myths that always circulate when new ideas are developed in a very conservative environment such as health. We should thank the authors for stimulating this important debate about how we provide health services and by whom.

This has now become a global movement – which Australia has joined. PA programs have commenced at the University of Queensland and are being planned at James Cook , Adelaide and in Western Australia.

The South Australian and Queensland Health Departments have employed PAs from the US and are  evaluating  their performance in the Australian context and the results are awaited with interest.

With the ageing and chronically diseased population, we desperately need to increase health workers both traditional and new – PAs will be a welcome addition to the health care team.

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  • 1
    ron batagol
    Posted July 23, 2010 at 8:17 pm | Permalink

    Shannon Nott, Co-Chair of the National Rural Health Students’ Network, recently told Croakey readers about the first day of the National University Rural Health Conference, held in Alice Springs and mentioned Ruth Ballweg, a physician’s assistant and Associate Professor from the University of Washington, Seattle, who discussed with students the role that physician assistants can play within the Australian rural and remote context.
    The concept of training up and using physicians assistants is great and sorely needed, given the fact that there is a dire overall shortage of doctors. As Prof. Brooks has also noted,noted, physician’s assistants are being utilised in many countries in a wide spectrum of medical and practice environments
    Recently, in my article “What do nurses know about medicines, anyway?” http://blogs.crikey.com.au/croakey/2010/07/09/what-do-nurses-know-about-medicines-anyway/#more-2572, I referred to ABCs Radio National “Life Matters” programme, when Richard Aedy interviewed Prof. Des Gorman, Head of the University of Auckland’s School of Medicine. The audio of the complete interview by Richard Aedy is available on the web http://www.abc.net.au/rn/lifematters/stories/2009/2561543.htm The interview was entitled “Doctors of the Future” and for anyone interested in the future direction of how our society should organise the delivery of medical care to the community, and the future directions of health care, it is well worth listening to. It was one of the most controversial but thought-provoking interviews on public health issues, and how to best utilise our highly-trained medical and other health professional resources, that I have heard.
    Amongst Prof. Gorman’s suggestions for more efficient use of medical and other healthcare resources was to have a pool of trained technical support personnel for many of the activities currently being carried out by doctors
    Prof. Gorman believes that a key driver to the increasing expenditure on health lies with the Colleges of Medicine, which he refers to as the “Medical Guilds” and which, he asserts, operate with the prime function of creating a silo and then building a series of hurdles to be jumped, to keep people out and maintain the status quo in the medical market place rather than responding to the needs of the community. The actual wording he used in this context was “The Medical Guilds exist to sustain the power of the Guild – that’s what Guilds do.”

    Gorman cites the examples of two medical specialties, orthopaedic surgery and anaesthesia. In the case of orthopaedic surgery, rather than the community spending 10-15 years and millions of dollars to train a qualified doctor to “belt bones with chisels”, we would be better off training medical technicians for 1-2 years to carry out many of these procedures. Similarly, he says, 85% of the work of anaesthetists – (intubation, putting in lines, maintaining anaesthesia) could be carried out by appropriately-trained anaesthetic technicians, leaving the anaesthetist to concentrate on deciding whether the patient is fit for anaesthesia and managing critically-ill patients, who require their highly-trained expertise, during anaesthesia.
    There is, however, an important distinction to make here between physician assistants and the popular quick fix of “physician substitutes”, where we attempt to upskill other health practitioners to take the differential diagnostic role of doctors because we may have a shortage of doctors.
    In this context, Prof Gorman refers to the self-evident reality that it is the doctor, and only the doctor, with his or her training, expertise, and what Gorman calls “intellectual muscle” (aka, I think, as professional expertise in differential diagnosis and referral), who is most appropriately skilled and trained, for example, to decide which of 6 or 7 kiddies who come through the door with seemingly similar presenting symptoms, require a lumbar puncture for suspected meningitis, or whether a patient with breathing difficulties is likely to have pneumonia, cardiac disease, asthma etc. In terms of the doctor’s differential diagnostic skills, Gorman emphasises that much of the skill, expertise, judgment and professionalism that doctors acquire during their professional life derives from the early-career “apprenticeship” that they serve, rather than the formal university coursework they have undertaken in order to qualify as doctors. Or, as Gorman says, “”role substitution makes sense only if the skills are transferable”.
    By contrast, he does envisage “doctors of the future” referring diabetic or wound care patients on to a nurse to manage at a nurse-initiated clinic, or to other health professionals for advice within their professional area of expertise. For instance, I would suggest, patients could be given a medical referral to a pharmacist for advice on smoking cessation, weight-loss, or medication review programmes (obviously one may add, as one would for the nurse clinics “funded under Practice Incentive” or Medicare arrangements in the same way as visits to medical practitioners).
    So, collaborative use of the expertise of various health professionals, plus the training and career development of physician’s assistants to ensure optimum use of medical expertise ? Seems eminently sensible. But, given that we can’t seem to even sort out the undiffentiated muddle in the structure, functions, funding criteria and interrelationships of the various Government and community group components of the forthcoming Primary Health Care and Local Hospital Networks, don’t hold your breath for any innovative moves of this dimension any time soon!!!
    Ron Batagol

  • 2
    kym
    Posted July 26, 2010 at 7:17 am | Permalink

    Physcians Assistants or doctors assistants may have a place in some areas of the United Stae. They are ex medics who work under a delegated medical model. This provides the notion that doctors lead the health care in the areas where there is this model. The most effective health care is one whereby the system is integrated and all health workers work together for positive outcomes for their clients/patients. These health workers provide fragmented care such as other technician roles. There are other health professionals which can provide a superior model of health care and do not work under a delegated medical model. They work together for positve patient outcomes. Australia does not require yet another level of unregulated health workers-we need to work to improve the numbers of registered health professionals we have/could have

  • 3
    raymond1
    Posted July 27, 2010 at 6:25 pm | Permalink

    Re: ron batagol’s link tothe the ABC’s Life matters
    I would like to hear from an orthopaedic surgeon that they just “bash bones with chisels”, and a technician could do their job in 1-2 years! Des Gormon forgets that an orthopod would assess patients in outpatients, look after patients on the ward, follow up, plan operations, deal with complications etc.

    Role substitution may have a role in some circumstances, but I think some of these views underestimate what some specialists do (ie the Dean – who is a neurologist arguring that neurology is ‘complex’ whilst ortho and anaesthetics are ‘easy’ and can mostly be done by technicians!)

    Though I think he makes a good point that “role substition only makes sense if the skills are transferable”
    I think some get caught up in task substitution as a quick fix that this gets forgotten.
    What skills are actually transferable is another matter though. The Dean in this interview would have limited exposure to surgery, anaesthetics and ED. This should be borne in mind.
    (Also his view that nurses differentiate patients in ED triage is wrong. They place the patient in a triage category and the diagnosis is made by a doctor.)

  • 4
    nikojusters
    Posted August 13, 2010 at 10:56 am | Permalink

    I am a PA from the US. Please let me clarify the title Physician Assistant. We are not Physician Assistant’s. We are midlevel practitioners not technicians; very capable of assessment and diagnosis. PA’s are just as good as a physician and many patients here would rather see us. Although some are ex-medics, not all are, this is only how we started as a profession. We work independently although the name does not suggest it. We also work as a team with the MD. Together we provide better access to healthcare. I am moving to Australia with my husband who is a physician. I think Australia will sooner or later adopt our profession and I can’t wait to be there when it does. I am currently leaving a practice and a profession I love to support my husband, but when PA’s are regulated and the profession adopted, I will be the first to look for a job.

  • 5
    Hreiss
    Posted April 3, 2012 at 4:45 am | Permalink

    I am a US Physician Assistant, BS Chemistry, MS Health Science, and a Pharmacy Doctorate.- I used to work in Orthopedics, but have since went in to doing Urgent Care (minor emergency and what I believe is referred to as non-urgent care by your emergency departments). A little better pay with whole lot less call and more free time. PA’s have evolved into a significant role along with NP’s in the United States. As far as I know all PA programs in the United States have switched to a Masters level program. Such programs aren’t like getting a normal college degree or even a normal Masters. My PA Program was a little over 100 graduate hours the course work is a 40 plus hour a week training program with essentially no free time lasting about 24-26 months. Pharmacy Doctorate was only a 120 graduate hours over 4 years and had more free time than I knew what to do with by comparison to PA school. Initially in the United States, PA’s saw the same kind of flack especially nurses and doctors organizations. The same organizations in the US who control the supply of these professionals (supply and demand). Low supply, higher salaries- get the idea. The arguments were always concern over quality or patient safety. The US model has clearly demonstrated that proper training and integration actually improves patient care and safety. The nursing organizations will almost always not like PA’s, because they will see it as a roadblock to the expansion of the NP role. In practice it usually isn’t. You still occaisionally get some rub from older nurses but for the most parts nurses usually enjoy having the PAs as an extra go to source or even as a liason to the Doctor at times. The Doctors who hire PA’s in the United States are almost always happy to have one, because it allows them to expand their practice and take less call because the PA’s often take on some of that responsibility. The training issue is newer argument. If your country wants to integrate PA’s but can’t train enough of them, why not look into partnering with some US schools, PA organizations, to help train and provide similar certifications. The certifying exam would have to change to integrate practice in australia and medication names and doses as they vary by country. But you could simply offer an adjunct program through one of your schools to essentially retool for the medicines and tests used in australia. Shouldn’t be that difficult. The way the medicines work and what you use them for doesn’t change just the names and the preferred dosages. In the short run you could set up a program to import experienced US PA’s to come to australia and work. Provided it was just a one year trial and the laws were in place to allow them to practice similarly to the way we do in the United States. You may find a significant number that might take you up on it. Relieving the training burden and still increasing practicioners. Once you have good PA’s that your Doctor’s trust, they can train new PA’s as well. Ultimately as populations grow, countries will have to do something to provide basic medical care to their populations. Training time for Doctor’s, especially specialist is too long and too expensive. Especially when most day to day illnesses and medical needs can be met by a midlevel provider such as a NP or PA for a lower cost. Freeing Doctors to focus on more difficult cases that require utilization of their superior knowledge set. It just makes sense.

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  1. ...] This post was mentioned on Twitter by Physician Assistants and Eric J. Veltman , Melissa Sweet. Melissa Sweet said: Do physician assistants have a future in Australia? Yes says Minister Snowdon. And some "essential reading" on PAs: http://bit.ly/cnTWte [...

  2. ...] http://blogs.crikey.com.au/croakey/2010/07/23/do-physician-assistants-have-a-future-in-australia-yes... PLEASE VISIT THEIR SITE FOR FURTHER INFORMATION [...

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