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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