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So, what are the arguments against physician assistants?

Lieutenant Ben Stock, OAM, has been a medic in the Royal Australian Navy for 23 years. When he graduates from the University of Queensland in a few months, he is set to become the first Australian-trained physician assistant in the RAN.

While he is guaranteed of a job, many of his UQ classmates are not. “There will be a bunch of people looking for a job,” he says. “It would be a shame to train these people up and lose them.”

Stock is also the founding President of the Australian Society of Physician Assistants Inc.

In the fourth article in a Croakey series examining the potential of PAs to improve access to health care, particularly in rural and remote and other under-served areas, Stock investigates some of the arguments waged against PAs.

How do the arguments against PAs stack up?

Ben Stock writes:

When it comes to Physician Assistants (PAs) in Australia, there seems to be two schools of thought – those who support it and those who oppose it. Perhaps it is worthwhile looking at the opposing views and try to determine if PAs are a potential asset or a potential threat.

Change is always difficult and is often opposed purely for the sake of change rather than considering whether evidence supports the opposition or not. In the case of PAs, the general arguments are that:

1.         PAs will take places needed for medical student training.

2.         PAs will stop new doctors being able to specialise in areas as PAs will take their place.

3.         That using the US healthcare system as an example is not relevant to Australia.

These arguments need to be addressed to determine their validity.

Although this is an article and not a referenced paper, I base my comments on actual papers and studies which can easily be confirmed using the World Wide Web.

As a result, I would suggest that anything that is stated here can be easily supported, should anyone care to look further.

The first point – PAs will take places needed for medical student training.

At first glance, this could be seen as a reasonable statement. There is little doubt Australia needs more doctors, and medical student numbers are being increased. It is important to look at the actual numbers though before making an informed decision on this.

Medical student intakes are increasing, to be projected to 3000 students in 2012 (I am happy to be corrected on this number), yet at this stage there is only one PA program in Australia that is fielding less than 20 students for clinical placements. According to my poor mathematics, this is less than 1% of places needing to be found. If three universities were trying to place 60 PA students, then it would be no more than 2% of places. Therefore, the places PA students will take from medical students is no more than 2%.

From current experience, many PA students are finding their own places in their communities which lessens the requirement for universities to find places. In addition PA students need 12 months of clinical placements compared to a two year requirement for post graduate medical students, therefore the PA burden is reduced in half compared to the medical student placement requirement.

As a result, the argument that PA student will take or jeopardise medical student placements is really unfounded, unless a 1-2% figure is truly disturbing.

Next point – PAs will stop new doctors being able to specialise in areas as PAs will take their place.

Again, this initially, is a legitimate concern, as PAs do tend to move into some specialist areas if the US experience is considered (addressed more in the third point). The important point to note is that the PA is an ‘Assistant’ or ‘Associate’ to the doctor, not a replacement. PAs require a supervising physician, be it direct, overseeing in a clinical setting or remote as in rural and distant settings.

The PA helps in providing many services that have been traditionally performed by a doctor, but does not remove that need. Simply, the PA extends typical doctor services, not replaces the need for the doctor. As a result, the PA can do a lot of things which would take up the time of the doctor (substitute specialist as appropriate), thus freeing the doctor to do more.

We all know specialists (as all doctors) are very busy. If a PA, trained in the role, is reviewing cases, admitting patients, and taking on delegated tasks, that doctors’ very busy week becomes less busy. As a result, more patients can be seen, more procedures can be performed, and more training can be conducted.

My experience is that most doctors love to teach and pass on knowledge. Imagine how a very busy specialist, who has a PA helping out, now has a number of hours free in their week. Will they play golf, will they take on more patients, will they teach? The PA assists in patient care, and provides a stable workforce allowing the doctor to teach and train future specialists.

As a result, PAs won’t stop new doctors training as specialists, PAs will actually increase the opportunity. (This has been really proven in the US, which is a cause of concern ‘Argument 3’and leads to the next point)

The final point – That using the US healthcare system as an example is not relevant to Australia.

This argument has been around and used many times – ‘We aren’t the US, it doesn’t apply’.

I am happy to concede that there are many people who are far more qualified to enter in on this discussion. I have no intention to debate the differences.

My point is this: the US has a very large population (fact). The US has a large health care requirement/responsibility (fact). The US has an aging population (fact). The US has a shortage of health professionals to population ratio (fact). Australia also faces the same challenges.

PAs have contributed positively to healthcare delivery in the US. For over 40 years. If using the US model as an example is not entirely satisfactory, perhaps we should look outside the US. The PA is now being trained and employed in Canada, England, Scotland, the Netherlands, South Africa, Taiwan and Saudi Arabia. New Zealand has also commenced a PA trial.

Regardless of differences and similarities between Australian and US health systems, there is over 40 years of data which is hugely supportive of the PA concept, and the positives far out ways any negatives.

In summary, whilst the general opposition to PAs is acknowledged, there is not of lot of evidence to support this opposition. And there is substantial evidence to support the introduction of PAs.

It is important to remember that PAs are not doctors, we provide healthcare in a collaborative setting, extending doctor services, not replacing them.

We are not a ‘cheap doctor’ replacement, and this is quite insulting. PAs already had a health professional background prior to becoming a PA student, and made the decision to be a PA rather than studying medicine.

I would ask that readers consider this article and its contents. I am sure that there will be many who disagree with what I have written.

Whilst this article is completely unreferenced, I have researched this subject for some time and everything stated is not just personal opinion and can be supported.

The three arguments I have analysed are not valid arguments. My point is that based on the current arguments, PAs are not a threat to doctors, rather they are an asset to health care that needs to be pursued as a priority.

***

The previous articles in this series are:

We’re about to get our first crop of PAs

The evidence shows that PAs could help improve access

Why James Cook University is starting a PA program

Comments 15

  1. SoulmanZ says:

    Did you read the previous articles in this series before writing this? I tried to express a more balanced view

    Full disclosure – I love the idea of physicians assistants. I think they fill an important role and can be trained far quicker than doctors to fill the current service gap.

    That said, the balanced opinion.

    The answers you provide to problems 1 and 2 are just silly. They dont work.

    The major problem, problem 1 (take away training spots for doctors) is twofold. Firstly your argument that “there just arent enough PA trainees to matter” is so contradictory it isnt even funny. What could you possibly think of your readers to write that?

    You are actively promoting building a new profession to the extent that it can service the community. Clearly that is more than 20 students a year.

    If you are honest about wanting PAs in Australia, you have to be honest about what that means. What that means is a goal of hundreds if not thousands of PAs a year, all getting trained by the same people who train doctors.

    If this is not correct, please correct me. If it is correct please never use that argument again. It is so disingenuous it borders on unethical.

    That aside, because saying your argument is bad does not mean the issue of training spots cannot be honestly argued, here is my take.

    Unknown to most people outside of the health system, and many inside it, medical training is currently bottlenecked. Like, massively bottlenecked. The governments, due to doctor shortages, have in some places doubled medical student intake. And the system to train them, made up of public service doctors, has remained exactly the same size.

    There are laws about how many doctors a single specialist can supervise at any one time. In most specialist settings this is not more than 2 or 3 trainees per specialist, and in some areas it is far less. The reason there are these laws is that allowing more juniors means the specialist is unable to provide full supervision, and you end up with unsupervised junior doctors. Clearly I dont need to explain why that is bad.

    So, we are bottlenecked. We have no more specialists to safely train the junior doctors we already have. To be clear we currently have MORE junior doctors than we a legally able to train.

    Even 20 more trainees is 20 we are actually unable to train. So even ignoring the fact your “there are only 20” argument is deceitful, it doesn’t change the fact they will already be taking training spots away from doctors.

    You will argue that the setting they are training in is different from the setting a doctor needs to train in, or something similar. It doesn’t change the fact we could use those resources to finish the training of doctors who have already trained for 6+ years and have no one to supervise them.

    If you can provide evidence the PA program can stream through a totally different training service than junior doctors, then this could work. If you cannot, then the only possible conclusion that makes sense is we need to PLAN for PAs, by integrating PA numbers into future training number decisions. But the current numbers of students going through the system means there are no vacancies now, and wont be for 5-10 years.

    That sucks. PAs are something that could help. But you are wasting millions of dollars by sidelining graduated doctors for a pilot program for PAs.

    I would really love for someone who has written for this blog, or a blog writer to respond. It is feeling a bit didactic here, and certainly pretty one-sided.

  2. Melinda PA-C from the USA says:

    As a physician assistant in Texas I can tell the PAs in Australia to hang in there. We met some resistance from the docs in the early days. But as time went on and the physicians figured out how much the PA brings to their practice, they were totally won over. Remember: We are the docs partner in bring health care to the practice. PAs are not there to take over the practice. That is not the philosophy of the PA profession.

    And I understand the “Just cause they do it there, doesn’t mean it work here” statement. We have that attitude in Texas also. We make our own way, just like you guys do!! BTW, we LOVE Australia in Texas. We are so alike in many ways.

  3. Melinda PA-C from the USA says:

    And as it turns out in the USA,it is harder to get into PA school than medical school these days. Just not enough open spots. I think the fear that the places for the docs is being taken up by the PAs in unfounded. Other way around.

  4. benjamin.stock says:

    As requested by SoulmanZ, who has asked for someone to respond, seeing I was the author I will try to address the issues that SoulmanZ has raised.

    Firstly, thank you for your support saying you love physician assistants. I will try to answer your concerns you raised.

    “Did you read the previous articles in this series before writing this? I tried to express a more balanced view”

    Yes. I have read them. I write from a PA perspective, although my article did address the negatives and provide positives so I believe it was balanced.

    ‘The answers you provide to problems 1 and 2 are just silly. They dont work.’

    I am unclear on why they are ‘just silly’ and don’t work. They are simply based on current facts. And I did not state at all “there just arent enough PA trainees to matter”(sic). This is not my comment. I (we) are actively promoting building a new health professional, however, if you re-read my article, I quoted the number of students (PA) versus the number of student (medicine). Perhaps you may wish to look at this

    Australia’s Health Workforce Online 2008, Health Workforces in Australia and Factors for Current Shortages April 2009, National Health Workforce Taskforce,www.ahwo.gov.au .

    As I said, given three universities training PAs, there will be only 60 PA students needing placements in 2013. You should re-read my article and do the maths. It is still 2%, and PAs are finding their own placements. I can’t see how more honest I can be about this, as there are only three universities that are conducting or intending to conduct PA courses. So yes, I will correct you, there are not thousands.

    It is so disingenuous it borders on unethical .
    This is a bizarre comment, I didn’t lack frankness or candor (disingenuous), and ethics is really not questioned here, perhaps you may wish to reexamine your use of words? Or spend some time with a dictionary.

    I was intending to address your post piece by piece. However I won’t. As I read your article, I can understand your concerns, however PAs prove no threat to medical students or junior doctors, in fact will actually assist in the Doctor training pipeline.
    Training Pas will not influence the training of medical students. The important thing to remember is that PAs are reliant on a Doctor as an overall supervisor.

    My suggestion is that if you wish to attack the PA issue, perhaps you should investigate things further. And also not to misquote the articles or blogs you comment on. Perhaps reading them and understanding the content would be advantageous.
    Regards
    Ben

  5. SoulmanZ says:

    Thanks for taking the time to reply Ben. I will admit I was a bit combative in some of my wording, although in my defense you were using the exact same argument no-one felt like defending earlier in the week. It felt like I was talking to a wall.

    That said, I am surprised you don’t see the problem here.

    You state “given three universities training PAs, there will be only 60 PA students needing placements in 2013”

    Ignoring the fact that you said 20 in your article, so have somehow added 200% more students in the last day or two, I still ask you one question:

    Do you intend the PA program in Australia to only ever train 20-60 students per year?

    If so, we have little disagreement. It will make little difference. So little difference it may be worth questioning if it is worth setting up training schools at all (I have some experience with developing training programs and the costs involved are very high). After 10 years we would have around 200 – 600 PAs in the country, ignoring training time?

    Very clearly that is not what you mean, because you say they can fill the current skills shortage to some extent.

    So what I believe you mean is “this is a pilot program, and we should ramp this up in the coming years”.

    Fine. If that is what you mean, say it. But let us debate that, not “oh, there are only 20-60 per year, what are you worried about?”

    That is what I meant by disingenuous.

    Now, to the real issue, now the snark is out of the way. Can we train PAs in adequete numbers to make it worth it?

    Unless you have some groundbreaking evidence, I think the answer is no. A training PA does require the same resources as a training doctor, albeit perhaps less of them, making it more efficient to train PAs.

    To just be very clear, I mean this. In 2009 we had 2.1 million training days provided for doctors. The system was managing that, with some leeway to even train 60 PAs a year, or whatever.

    But some short-sighted politicians decided increasing doctor numbers simply meant increasing student numbers, ignoring the clinical training requirements being a bottleneck.

    The number of student doctors will have increased by 60% by 2012! This means 60% more clinical training days are required to give them the same quality of education they would have got 2-3 years before. But the number of clinical supervisors is roughly the same as it was, across the board. So what we are left with is a huge problem – Medical training is currently verging on untenable. We need to incorporate 60% more training with the same resources, meaning each student will lose around 40% of their supervised time compared to before.

    This is already a huge problem. This is why the discussion of PAs is not a doctors trying to protect their practice against the PAs trying to take their jobs. Most Australian doctors I have seen talk on this love the idea of PAs. But Australia has one very specific, and very immediate issue. The nationwide training facility is full.

    So, if you truly believe what you are preaching, and there should be enough PAs in Australia being trained to make a difference (lets pluck a number out of the air and say 500-1000 per year, that would be reasonable), then where do they train? In a system that already is so stretched that trainees are being forced into unsupervised roles, you want to add an extra burden.

    The current training burden of too many junior doctors will take 10 years to clear, if we lower medical student numbers now. And we wont. Politically it would be suicide, right? So even best case scenario, the system could not cope with large numbers of PAs for 10 years.

    Even if a PA student only requires a third of the clinical hours a doctor does (I dont think that is true, 1/2 to 2/3rd would be more accurate) it has to be clear to you that those training hours already dont exist. It is impossible to do what you want to do, even though it makes sense and would be good for the health system. Dreams versus reality.

    Which is why I say “yes, plan for PAs”. Keep advocating for them. Make sure when politicians make decisions about future workforce they include them in the pipeline. Even run a small pilot program … I am not against that at all.

    But do not describe PAs as the solution to the workforce problem for the next 10 years. It is false, unachievable, dangerous, wrong and yes, disingenuous.

    Again, thanks for your time. Hopefully you do return and can maybe answer some of these concerns. I would love to be proven wrong, and PAs have a way to get off the ground without putting patients in the hands of unsupervised practitioners.

    SMZ

    ps. full disclosure. I have worked with a PA in Australia, one of the ones from US. They were fantastic.

  6. ihaywood says:

    The descriptions I’ve seen of a PAs role are largely similar to an Australian intern. This is one point of major divergence with the US system: American interns earn more and have more clinical responsibility. Therefore there isn’t a big advantage: PAs and junior doctors are baically competing for the same role for around about the same pay (in fact, PAs may expect to earn more, living on an intern’s wage isn’t much fun)
    Traditionally there would still be a good argument for non-medical interns as Australia doesn’t have enough, however numbers are about to increase a lot, Australian may well have unemployed doctors over the next few years, so training lots f PAs may add to the problem, for one or both groups.

  7. Duggy the DC3 says:

    I would welcome a PA or three here in my Rural Town. I am a procedural rural GP, the only one left in a town with 14 non procedural 9 – 5 GP’s. It only makes sense to utilize my skills in operative obstetrics and Anesthetics while assisting and supervising PAs in all aspects of General practice for which they would be eminently qualified. It might make Rural Practice more attractive to Doctors wishing to maintain their procedural skill set and still meet the needs of their rural clients. The problem I see is a complete lack of proper structure and funding for Private Rural Practice to make using a PA sustainable; as an alternative to Section 135 International Medical Graduates forced to the Bush without support; on 10 year moratoriums.

  8. benjamin.stock says:

    SoulmanZ,
    At this stage, perhaps we should agree to disagree on parts of this.
    PAs will never be the sole solution to Australia’s healthcare issues and shouldn’t be viewed like this. It can be an intregral part though.
    What is needed is more funding, in the right areas, more doctor training and placements opprotunites and better use of all aspects of health providers (established and new), encompassing everyone to deliver smarter, better, more cost effective outcomes with the overall outcome – better healthcare access for all Australians.

    Perhaps a debate would be a worthy arena.
    Regards
    Ben

  9. SoulmanZ says:

    No worries, I can agree to that!

    I really am only arguing from the same side as you, in the sense I support PAs. I worry that people from other fields dont quite realise the mess that medical training is in right now, and at best pushing harder will not succeed, and at worst will tumble the whole stack of cards

    I guess it may be hard to see that as a different view from being ‘protectionist’ or whatever, but honestly I can see a future world without doctors, and it doesnt scare me. There will always be jobs for hard workers, right?

    Re: debate, then yes, I agree. It would be nice to see a bit of divergent opinion on the blog.

    Sorry if I got you offside at the start. Thanks for your time.

  10. bluebyyou says:

    Interesting thread here. The first thing that comes to mind to me is the arguments against PAs being about a competition for training slots. May I suggest that a system that is incapable of providing sufficient training slots for its medical students is basically flawed? Why does a medical student or a junior doctor for that matter, have to spend so much time and energy trying to find the next training slot? Hardly a PA-induced problem. This is a systemic problem that needs to be addressed.

    I cannot think of any industry that would decide to open up the production line only to later realize they don’t have anyone to put trim out the product. If you were the Managing Director, you’d be fired for being so short-sighted.

    Next, the fallacy, or fear-mongering that insists that PAs take away jobs from doctors and nurses; that takes away training slots; that results in inferior medical care are all based on just that: ignorance and fear. People naturally resist change. But EDUCATED people go beyond that initial reaction and learn the FACTS. The facts are that a Physician Assistant in every other country in which they operate generates more productivity for a doctor by an exponential factor; that a Physician Assistant does take some mentoring and training just like any other medical professional, but once up to speed and on-site again exponentially increases the training capabilities at that site (both because the SMO would have more time available, AND because that Physician Assistant can do the training as well). As for the reduction in quality of care, there really is no going there: historically and statistically a Physician Assistant spends more time with a given patient, looking more deeply into the underlying problem than a rushed and overworked doctor (who incidentally could use a Physician Assistant) and generally has improved the patient’s overall experience at the clinic.

    These are the findings of the Queensland and South Australia studies as well as a 50 year history in other countries that I know we hate to emulate. But just like we all watched Will and Kate get married and secretly loved the monarchy, by God, we’ll overcome this brash and baseless fear of Physician Assistants.

  11. bluebyyou says:

    P.S. Something else that is missing from this thread is the fact that all of the UQ PA students have extensive medical backgrounds going into the program. They are older, more mature, highly motivated and experienced. For example, one of these students had over 10 years experience as a rural ambo. That’s 10 years of emergency medicine – triaging and stabilizing patients, often entirely on their own. Let’s compare that to the 22 year old kid fresh out of med school.

    So when you think about training slots, for example, compare the training time needed for an older, more mature and more experienced practitioner (PA) and the standard time a fresh new kid requires. I think it would be a fair and logical assumption that the PA’s on site training would be significantly less, both because of their previous experience and because their scope of practice is somewhat limited by their role.

  12. bluebyyou says:

    P.P.S. And for those that think the “solution” to the rural medical shortages is in the upcoming “flood” of medical school graduates, let me ask this: What is so different about these new numbers and their profiles that makes you think they’ll go and stay in a rural area? It hasn’t happened in the last 75 years, so why will it happen now? Have the medical universities installed chips in each of their brains that blocks the view of a city? Or where they grew up? All they can see is rural….rural…rural….

    I think it is a logical assumption that these new folks will serve out the time that is required of them and then go back to a more familiar and comfortable life. Maybe they might want to get married and raise kids. Etc etc. This is the history. Why would it be different now?

    Want to know who is going to be taking away your doctor jobs? It won’t be the PAs because they’ll be the ones serving the rural communities and serving as the stabilizing force in a transient community of doctors serving out their time and fleeing.

  13. aussiedeano says:

    Wow, this has been a great series of debates, for a hot topic. I’d like to just add a few things, from my perspective, and I don’t want to step on any toes or try and persuade people to come around to a different way of thinking.

    I am currently in the second cohort of the UQ Physician Assistant program. I’m a Paramedic working in Melbourne, and have been for the past 10 years. Before that I was a paramedic in Christchurch NZ for 4 years and before THAT, I trained as a Paramedic in Canada and worked for 2 years in a rural setting. As bluebyyou stated about one of the Qld Paramedics, I have a lot of experience in urban and rural emergency work. At the moment I do not think I am a Doctor, or pretend to be one. And as a PA, I do not pretend to be a Doctor. I will work with a Doctor under their supervision and do what they delegate me to do. My goal is to work in outer regional/rural areas in a family practice setting, hopefully specializing in ob/gyn & paediatrics. I’m old (45), I’m somewhat set in my ways, and I cannot see me going to med school. As a PA, I think that we can help the health system, because let’s face it, it needs help.

    Just from the limited research I’ve done, there are places in rural Australia that are crying out for Doctors, they can’t get them. Or they get them, but they don’t stay. Will the current crop of 25 year old’s want to live in a rural area? Some maybe, but I think the majority will want to work in the big cities, at least for a little while. So we will always be lacking in regional/rural Australia. PA’s could fill that gap. If you were able to have one Doctor and 4 PA’s working together, how good would that be?

    SoulmanZ, I like you…really healthy debater who I think sees all sides of the picture, and you seem to like PA’s. Cool, thanks! And I agree with what you are saying, there are lots of medical students that need supervision, and not enough supervisors. But can I ask, once these medical students graduate, how long before they are allowed to supervise themselves, so they can come on stream to teach? And every year, are there not more Doctors that are eligible to help supervise? I’m sure the numbers aren’t there to make a huge difference, but over the years the number of supervising Doctors must increase?

    The other point you make about the number of PA’s right now versus the future is correct, too. For 2010/2011 the total number of people needing to be trained will be less than 40, and that’s broken up over the 2 years, so last year there were say, 17, this coming year there will be around 18 (don’t quote me, but those are the numbers I think were in cohort 1 & 2). So for now it’s not a lot, and those numbers are spread all over Australia (from cohort 2 I think it’s something like 3 in WA, 3 in Vic, 1 each in Tas & ACT, a couple in NSW & the rest scattered over QLD). So it’s not too bad right now. It will become popular, like the Paramedic program, and may be oversubscribed, and then we will have issues. But hopefully by then we will have more supervisors to mentor. Plus there appear to be reciprocal agreements in the US to take some of us and train us (I might be going to New Orleans next year to train with PA’s, and people from cohort 1 went last year). So there are options.

    As far as diluting the pool and having too many people doing the same thing (Nurse Practitioners, PA’s & Paramedics), they are all fundamentally different in training and their role. There may be some cross-over, but that’s bound to happen. I guess don’t discount something because it’s new and different. And don’t discount it because its American. It can actually work. We aren’t a bunch of wanna-be Doctors out to be cowboys. We are mature, clinically sound practitioners that are looking for change, and to help change the face of health care in some respects. If I can be delegated a role by a Doctor, that frees him up to do his own training, or train others, that might help in the long run. We have to get over that first hurdle, then see where it goes from there. Because once we are out there and working, and Doctors trust us, they will let us do some of the day to day stuff, and they can concentrate on more important things.

    Great stuff, I’m really excited to be a part of this new role, wherever it goes from here. I hope we do well on clinical placements, and people like us, because we could really make a difference…

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