Helping hands

Physician assistants have improved the delivery of health care in the United States, and other countries have introduced the profession. Etienne Laverse considers whether this new breed of healthcare professional could solve the problem of doctor shortages in the NHS

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 Gloria Reuben (far right), starring in the acclaimed ER series as physician assistant Jeanie Boulet

The shortage of doctors has always been a global issue. The United States successfully responded to this challenge in the 1960s by developing a professional body that has since been proved to be essential to the medical profession: physician assistants (PAs). China undertook a similar measure and trained over a million “barefoot doctors” to help deliver health care at the same time.¹ Presently, there are more than 44000 PAs in the US, and numbers are projected to exceed 75000 by 2015.²  They have also been employed since the 1990s in the Canadian forces and similar paramedical healthcare providers exist in India.

The interest in PAs in the United Kingdom has been present for a while and is now intensifying. The NHS and the Royal College of Physicians have actively supported introducing PAs in the UK, calling for an early start of pilot projects. They recognise that the NHS is struggling to recruit and retain general practitioners; to comply with the European Working Time Directive; and to achieve patient access targets. “The physician assistant role has been ignored for too long in debates about shortages of trained medical staff in the NHS,” says Mike Gavin, a research associate in primary care.³ He added that the “recruitment of general practitioners is at crisis point. The creation of physician assistants could help reverse this situation.”

Who are PAs?

In the US, PAs are essentially licensed clinicians who practise medicine under the supervision of doctors—“mid-level healthcare professionals.” They examine, investigate, prescribe, help in surgery, counsel on preventive health care, and treat patients in association with doctors in a manner that is described as “negotiated performance autonomy”—they therefore play an interdependent role. PAs also provide on-call services and, importantly, provide primary care in rural and remote areas, which can be in desperate need of healthcare services. PAs also substitute for junior doctors in institutional settings.

In addition, PAs also work in all branches of the US armed forces as officers. The actual work delivered by PAs is in many cases similar to that of doctors, and they are widely accepted by patients and physicians.¹In this way, PAs provide a substantial clinical service sanctioned by their associated doctor. PAs are not, of course, responsible for surgical procedures; this is an important boundary between doctors and PAs. Since their advent as primary care providers they have spread into almost every branch of medicine, and doctors recognise their role. For example, Alton Morris, a rheumatologist, says that PAs “are very effective in a subspecialty such as rheumatology, which is more cognitive than technical. They have allowed us to provide care that would otherwise be unavailable.”⁴

Primary care

On the kinds of ailments that present often in primary care, PAs work more or less independently, treating sprains, hypertension, depression, asthma, and also minor trauma. The Howard City Medic One Clinic is a family medicine clinic in a rural region of Michigan. A practice nurse and a PA staff the clinic. A general doctor is present for about two days a week and is always available by telephone. The team provides care for all outpatient problems, including emergency treatment of myocardial infarctions before transport to hospital.⁵

Secondary care

The urology service at Spectrum Health Medical Centre in Grand Rapids, Michigan, is staffed by 12 trained urologists, two PAs, nurses, and junior doctors. The medical centre also provides nursing services, and medical students, postgraduate PAs pursuing additional training in the surgical services, and junior doctors training in surgery provide medical care. The PAs on the unit provide preoperative care (including presurgical histories and physical examinations), help in surgery, and provide postoperative care.⁵

Training and licensing process

The average length of core professional education for PAs is about two years in the US, ranging from 11 to 51 months depending on past experience. More than 100 programmes are run in universities, hospitals, and the armed forces. Courses are similar to a medical course but with a much greater emphasis on primary care. Students usually have had three years medical experience before commencing the course. Like doctors, they must pass their equivalent licensing exams, the National Commission on Certification of Physician Assistants. After this they must complete 100 hours of continuing medical training every two years and pass a recertification exam every six years.¹

The Netherlands has adopted a similar approach, running masters degree programmes in Utrecht and Nijmegen. Dutch PAs have similar duties under supervision of a senior doctor. Taiwan started a PA programme in 2003 at Fooyin University in response to a shortage of hospital doctors. Canada’s PAs have worked mainly in the military, but their role within Canada’s health services is expanding.

Advantages

The advantage of PAs is that on one hand they permit the doctor’s attention to be directed to the most demanding cases while still being available to supervise the PA. On the other hand, doctors are responsible for the PAs’ work and educational experience, including reviewing their clinical activities, and this can be time consuming. But some doctors claim that the advantages outweigh the disadvantages, as Sir William Osler once advised “one of the first duties of the physician is to educate.”⁶ In the hospital they play the role of a house officer, including providing continuing care for patients. Surgical PAs also oversee discharge planning and follow-up appointments. The system therefore has considerable advantages, and PAs are certainly not a “quick fix,” as some doctors in the UK have suggested.⁷ Their success in the US is incontrovertible and the ever increasing numbers in the past 40 years is testament of this.
 

The answer to doctor shortages?

As countries such as Australia and the UK are seeking to employ PAs, the possible disadvantages must be considered. Some have questioned whether they are indeed necessary. For example, there is a possible conflict with nurse practitioners, as they perform similar duties but are recognised as a different profession, thereby worsening interprofessional rivalries. But PAs are trained in the biomedical model to provide medical care specifically under the direction and supervision of a doctor, and, accordingly, they see themselves as providing healthcare tasks and treatments.⁸ PAs are employed as house officers and in the US some PAs sit on state medical boards, and as such PAs may be considered to be part of medicine. None the less, some people suggest that initiatives aimed at reducing professional barriers in medicine and mixing skills, for example by improving communication and referral pathways between primary and secondary care will allow patients faster access to specialist treatment than could occur in a primary care setting. This may be more effective in solving the staff shortage problems, thereby removing the need for PAs in the UK.⁵ Either way, training programmes have been started, and the success of PAs in the UK may be judged by patient satisfaction. In a public survey, 69% said that the government is not improving the NHS.⁹ A future survey may reflect the success, or otherwise, of introducing PAs to the UK.

Currently in the NHS

At the moment, the UK has developed roles similar to PAs in the past, but the one directly comparable to that in the US is still at pilot stage. The national director for emergency access, Professor Sir George Alberti, says that the UK is “very short of acute physicians.” Furthermore, he highlighted the success of nurse practitioners and explained that not every area of patient care needed a medical degree.¹⁰

In line with the EU directive, the working hours of doctors in training are to be reduced from 72 hours a week to 48 hours a week, meaning that the total number of doctors available to treat patients at any one time is decreased exacerbating the NHS’s shortage of medical staff.⁹

Tipton Care Organisation was the first general practice to recruit PAs in the UK. An international conference in Birmingham in 2004 brought together clinicians, managers, and educationalists from both the UK and the US to further develop the PA role in the UK. And a course at Wolverhampton University is in the process of being developed. Hilary Paniagua, a senior lecturer at Wolverhampton thinks that this is timely and hopes to develop the role more prominently in primary care “where we have our acute shortages.” The university quality committee is reviewing the proposals.¹¹

Professor Sir George gave a clear overview of the problem: “The time is right to consider a new breed of healthcare professional who could take on many of the tasks currently undertaken by doctors and nurses and free staff for work which they are trained.”¹²
 

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