Rural doctor shortages: PAs under microscope

Are physician assistants the solution to rural doctor shortages?


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PA student Monique Hindmarsh will be the first PA in Australia to be engaged in full time salaried general practice when she starts with Dr John Hall next year.

PA student Monique Hindmarsh will be the first PA in Australia to be engaged in full time salaried general practice when she starts with Dr John Hall next year.

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With the issue of rural and remote doctor shortages ongoing, physician assistant (PA) positions are the topic of great debate as a possible solution to the health disparity in the bush.

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The lingering issue of doctor shortages in rural and remote areas is causing many health professionals to look for solutions and an American health model utilising physician assistants is currently under the microscope.

Physician assistant (PA) educator at James Cook University Allan Forde originated in the United States and said PAs were enjoying a successful 50 year history there.

“PAs are a type of healthcare provider trained up to practice medicine in a delegated model,” he said.

“The PA course is quite intense. Students get a lot of the same information that medicine students get but we cut right to the chase and get into clinical medicine fairly quickly. 

“The whole point is to address health workforce shortages and we strongly believe PAs can help, especially in very strained areas like rural, remote, tropical and indigenous health where we can get people out there in half the time.​”

Mr Forde said education was not forsaken on PA students where the majority of entrants at JCU are mature aged with healthcare backgrounds.

“A typical student is a paramedic or a nurse, a physio or a podiatrist and because they already have a certain degree of medical expertise we can jump in quickly,” he said.

“There is a baseline requirement of two years healthcare experience and we regularly share resources so a lot of the same people teaching medicine also teach PA students.”

Mr Forde said upon graduating PAs worked alongside doctors in a collaborative role under supervision, but the “beauty of the model” was this supervision could be external and online from another building or town.

The Queensland and South Australian governments ran a pilot program in 2009-10 where American PAs were hired to work in rural positions which governments believed may benefit from the prototype.

Mr Forde said the move was designed to test if PAs could augment registrar and junior doctor training as well as share the everyday workload.

“After a small adjustment period in Cooktown PAs were able to take weekend calls and for the first time in the history of the multi purpose centre there, doctors had weekends off,” he said.

“PAs would man the hospital, the aged care centre and the emergency department and if they needed help they’d call and get advice or ask for backup- PAs were sorely missed when the pilot program concluded.”

Mr Forde said despite the overwhelming benefits of PAs in rural and remote healthcare, the PA pathway was not receiving the governmental support it deserved.

“PAs can do anything their supervising doctor can do- they have the same prescriptive privileges and are essentially equals,” he said.

“Nonetheless, PAs cannot access the medicare reimbursement. Lots of doctors would love to hire a PA but there is simply no way to pay them.

“There is also no access to the PBS for PAs even though PA students are well trained in pharmacotherapeutics and these are major drawbacks facing PAs in Australia.”

Dr John Hall, Downs Rural Medical, Oakey, plans to employ PA student Monique Hindmarsh at his practice when she completes her studies this year and said the aim was for Miss Hindmarsh to take on a strong supportive role.

“I work in a small country town with a hospital and a busy general practice so Monique’s role will involve her doing things I would do in a supported and delegated role to therefore improve my efficiency,” Dr Hall said.

“It’s a new model so we weren’t sure how it would fit into the system in Australia and one of the challenges is there's no funding tool, but we’ve found the basic increase in efficiency having someone like Monique who’s a real go getter led to increased billing and worthwhile financial benefits.

“We’re in a position now where we made the decision to go ahead with that employment whereas a lot of people would see that as a real challenge especially in a private general practice but if our experience is anything to go by I think many people would be interested.”

Dr Osman Sanyer is a family medicine provider in Utah and likened issues around lacking health care in regional areas of Australia to his experiences in America.

“Queensland is about twice the size of the state of Texas so the degree of remoteness here is magnitudes larger than even the western parts of the US,” he said.

“In many communities in rural Utah PAs are the primary care providers and their supporting physician may be 50km away.

“I see a huge potential for PAs in Australia. It’s PAs who provide continuity, they get to know the society and culture and build trust in a way that they become the medical interpreter for doctors that come and go.”

Queensland Nurses Union secretary Beth Mohle said a major concern was the lack of regulation surrounding physician assistants and questioned what PAs could do that a nurse practitioner could not.

“Regulation is important from a safety perspective and we believe it is up to the profession of medicine to work out what categories of workers they want and ensure they’re appropriately regulated- to my knowledge there are no plans to regulate PAs,” she said.

“Nurses have been the backbone of rural areas for time immemorial and our concern is they’re creating a new category of unregulated health professionals and not using nurses to the full scope of their practice.

“Why aren’t we looking at the work force we’ve currently got, who are ready and raring to go, and seeing what more they could be doing?”

Australian Medical Association Queensland president Chris Zappala said the reason the PA profession did not take off after the first trial was no one could work out in practical terms how PAs could value add to health care systems over and above the allied health nurses and doctors currently in place.

“Yes, we need more doctors out west but if we want doctors out there we can’t go and train someone to be a little bit like a doctor and say there you go we’ve given you all we can,” he said.

“The remaining sticking block to getting more doctors in rural areas is support. They and their family need to feel supported so we need to consider what their partner will do, how the children will be educated and ensure they get time off and their continued professional development is taken care of.

“If we did that we could forget about trying to have a quasi-doctor and avoid forcing people to accept inferior levels of health care.”

Mr Zappala said PAs were not the answer to drastically below par health outcomes in rural and regional areas.

“You can’t tell me that getting a PA who is not a trained doctor is going to be the best way to fix these issues. We’re trying to put a square peg in a round hole.”

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