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Another point of view on physician assistants

Croakey has recently run a series of articles on physician assistants (PAs) which was largely positive about their potential to add to the capacity of Australian health services, especially in rural, remote and other under-served areas.

Readers were asked to speak up if they had concerns about PAs or wanted to address any issues raised by the series.

Dr Luke Oakden-Rayner, a radiology registrar in South Australia, took up the challenge, and has shared his concerns below about the potential of PAs to impact upon already over-stretched medical training. This stressed system is, he says, “the predictable result of perhaps the dumbest approach to a doctor shortage a politician could dream up – dumping more raw materials on a production line, without increasing how fast the production line moves”.

It should be noted, however, that he worked with PAs during the trial in SA, and has also worked with nurse practitioners in several environments, and says he has always been impressed by the experiences, and fully supports the concept of task substitution. But….

***

Physician assistants and the current medical workforce

Dr Luke Oakden-Rayner writes:

Despite the shortage of trained doctors in Australia, one in four medical graduates is not guaranteed an internship. A graduate who does not get an internship cannot attain full registration as a doctor, and if they do not complete an internship within 3 years of graduating, they must return to University for re-accreditation. This is the current status of medical training in Australia.

The system is bottlenecked by vastly increased student numbers, which have grown by up to 120% over 8 years, without any concurrent increase in the numbers of clinical supervisors. Also, there are worrying signs that the aging medical population will start retiring en masse in the near future, widening the imbalance between supervisors and trainees.

There are two potential outcomes of the ‘med student tsunami’. One; highly skilled new doctors will not find training positions. Every year a graduate does not practice is a year the government sees no return on the six-figure sum it cost to train them. This would be a horrendous waste.

But the second option is worse; attempting to ‘push through’ increased numbers of graduates by reducing their supervision. There is clear evidence that reducing supervision is dangerous.

What we are seeing is the predictable result of perhaps the dumbest approach to a doctor shortage a politician could dream up – dumping more raw materials on a production line, without increasing how fast the production line moves.

I wanted to discuss this as a partial answer to recent pieces in Croakey regarding Physician Assistants (PAs). PAs require supervision by the same professionals who train medical graduates, and thus essentially represent even more raw materials on the same, overburdened production line.

Those pushing for PAs argue that they reduce doctors’ loads and create more time for training juniors. The problem with that argument is that junior medical officers do the same thing – they practise semi-independently but require supervision. Indeed, a medical unit could not run without juniors, they do the jobs that seniors don’t have time for.

PA advocates ignore the fact that the situation has passed a tipping point, where additional hands do not make less work, but instead spoil the broth. The problem is a shortage of supervisors, not support staff.

No one could argue that pushing more trainees into a system where up to 25% cannot access supervision would improve the shortfall, but nevertheless, some argue that adding PAs in the same sort of roles could.

In America the number of PAs a doctor can supervise is limited by law, usually to around 4 at most. The supervising doctor is responsible for every decision that a PA makes, every drug order signed and every procedure performed. This, for an already overstretched doctor, cancels any benefit to productivity.

We all have to accept there is a maximum number of ‘supervisees’ of any sort, medical or PA, that can be supervised at one time. It is not unreasonable to assert that an overloaded system will not be able to cope with more load.

Associate Professor Moira Sim wrote that some training of PAs can occur in parallel systems, although she did not provide a reference. If this is true, and the alternate system is capable of training PAs on a national scale, then that is great. It remains to be seen if para-medical training can be performed without using medical training positions. I remain doubtful, but would be happy to be proven wrong.

In this piece I have tried to show that not all concern about PAs is “pure self interest” by “an unholy alliance of interests: that of the medical and nursing lobbies”, as much as some would like to portray it that way.

A single valid concern, such as the one I have raised, negates such an extreme viewpoint entirely. We need to work together, and polemical voices are not helpful.

Our peak medical bodies foresee a positive role for PAs but have some valid concerns about their implementation. Ultimately, doctors are not a protectionist opposition, but protecting patients in an overburdened system.

Comments 4

  1. ihaywood says:

    Perhaps a more succinct way of putting it is, Australia already has PAs: they’re called RMOs. In large public hospitals there simply isn’t a workforce gap to fill as there will soon be heaps of people at that skill/wage level in the system.
    That leaves GPs and district hospitals, where RMOs are (with a few minor exceptions) forbidden to work courtesy of the 1996 provider numbers legislation, and the quota of junior doctors allowed to move to GP is tightly regulated by DoHA, the enforced maximum is still, after 16 years, barely at the level of Keating’s last year of office. (around 800/year offhand)
    This raises a broader point that the workforce restrictions *within* medicine are just as important as the restrictions between medicine and the other professions. Given we are (rightly or wrongly) about to get many more doctors, it may be more efficient to look at loosening some of these restrictions before creating new health professions.

  2. ggm says:

    I recently accompanied an 82 yo woman to emergency. the consultants were sh*ts and the RMO was a saint, respected her personal space, communicated and was a human.

    Whatever we’re doing to fix the health system has to learn how to keep the humanity because I gotta say, the attitude coming off the senior staff is .. dire.

  3. bluebyyou says:

    This is a nice, educated and informed piece, Dr. Rayner. I think that one of the points that is often missed in this “supervision and training slots” dilemma is that Australia could recruit highly experienced PAs from the US and Great Britain (as examples) who do not require a training slot. During the trials in SA and QLD, these highly experienced PAs quickly adapted to the Australian medical system.

    Now what does this bring? It brings another body into play who can help train some medical students and does not require the level of supervision that a new medical student graduate requires. Additionally, these highly experienced PAs can train the Australian grown PAs.

    When you refer to the supervision of PAs, I think this gives the perception of a Doctor needing to look over the PA’s shoulder constantly. As you would know from your experience with the SA PAs, very little actual time was required to properly monitor their work.

    Most importantly, you hit the nail on the head by pointing out that the entire training system is systemically flawed when it has not already identified where each medical student can be trained. PAs are one answer to that puzzle because they have historically provided training capability, and in fact were active in this role in the SA and QLD pilot programs.

  4. Dan Stalnaker PA-C, MS, CLCP says:

    I don’t know what RMO’s are I’m a PA-C in the US. I’m posting this comment in a few places hoping that someone will see it and give it some thought.

    I’m a practicing Physician Assistant (PA-C) in the US. I would like to add that a Physician Assistant can help train doctors. The name ASSISTANT is a very negative name. We are well trained and most of us have many years of medical experience and in many areas of medicine. I have worked in Cardiology doing all aspects from rounding, office, Pacemaker/Defibrillator follow-up and reprogramming, I’ve literally done thousands of stress tests, worked as a Hospitalist and have been on call for my patients many times, due surgical clearance and pre and post op work. I have worked Emergency Medicine and have trained or helped in the training of many medical and PA students. ( Do you think a Student Doctor can’t learn from a seasoned PA?)I have done Primary Care and Urgent Care medicine. I have personally saved a lot of lives and I am very proud of that fact. If you are serious about using PA’s forget they all have to be trained from scratch thought and look at them as partners in your quest to deliver quality healthcare. I would not even dream of using the name physician assistant. Develop an appropriate title that gives them real defining characteristics just as the name Doctor does for you. Treat them as if they are important and not a burden. I personally would love to be a part of helping you develop a system of healthcare that incorporates qualified medical professionals into a well-defined system of care that your country and the world can be proud of; as I would like to do in the US. Doctors please this is not a turf-war, as I’ve heard it defined and feel the same way here in the US. I’ve seen much to often where a good, solid, ,well-trained, Physician Assistant was cast aside for a less capable provider. We are all Healthcare Professionals and most of us have the ability to do the job as most of you do as well.

    Concerned about your debate,
    Dan Stalnaker PA-C, MS, CLCP

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MyHospitals website
National Commission of Audit 2014
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Pregnancy and childbirth
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Acknowledgement
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Health in All Policies
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Croakey Conference News Service 2013 – 2019
2013 conferences
Australian Centre for Health Services Innovation Forum 2013
Australian Health Promotion Association Conference 2013
Closing the Credibility Gap 2013
CRANAplus Conference 2013
FASD Conference 2013
Health Workforce Australia 2013
International Health Literacy Network Conference 2013
NACCHO Summit 2013
National Rural Health Conference 2013
Oceania EcoHealth Symposium 2013
PHAA conference 2013
2014 conferences
#IPCHIV14
AIDA Conference 2014
Congress Lowitja 2014
CRANAplus conference 2014
Cultural Solutions - Healing Foundation forum 2014
Lowitja Institute Continuous Quality Improvement conference 2014
National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014
2015 conferences
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Population Health Congress 2015
2016 conferences
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2017 conferences
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