A workforce solution for Australia?

Nurses would support the introduction of the physician’s assistant, as long as opportunities for the nursing profession were not compromised.

Significant medical workforce shortages, particularly in rural and remote locations, have prompted a range of responses in Australia at both state and federal levels. One such response was a pilot project to test the suitability of the Physician Assistant (PA) role in the Australian context. Five US-trained and accredited PAs were employed by Queensland Health and deployed in urban, rural and remote settings across the state.

An evaluation of the pilot, which was conducted for a 12 months period from May 2009 to May 2010, found that the PAs provided quality, safe clinical care under the supervision of local medical officers. The findings of the evaluation were published in the recent issue of Australian Journal of Primary Health. The majority of nurses and doctors who worked with the PAs believed that the PAs made a positive contribution to the health care team by increasing capacity to meet patient needs; reducing on-call requirements for doctors; liaising with other clinical team members; streamlining procedures for efficient patient throughput; and providing continuity during periods of doctor changeover.

The Queensland Pilot recruited five PAs for 12 months to work within:
• The Interventional Cardiology Unit of Princess Alexandra Hospital (PAH), Brisbane
• Cooktown Multi-Purpose Health Service, Cooktown
• The Emergency Department of Mt Isa Hospital, Mt Isa
• Normanton Hospital and GP clinic.

The work practices of the five PAs differed across sites and evolved over time, reflecting the diverse and flexible nature of the role.

At Cooktown Multi-Purpose Service, two PAs joined a team of two registered medical officers (RMO) and three senior medical officers (SMO) working across emergency, outpatient and inpatient departments. Cooktown had approximately eight nursing positions, a radiographer and co-located community health facilities. The PAs were included in the medical roster, attended medical meetings and participated in ward rounds where they assessed, diagnosed and treated patients. From July 2009 the PAs were rostered as the sole medical practitioner at the hospital on weekend days, with the duty doctor on-call if required. Each week, one PA accompanied a doctor to the clinics held at remote communities such as Wujal Wujal, 70 km south of Cooktown. From January 2010, one PA also visited the Wujal Wujal clinic each Friday, with remote medical supervision provided from Cooktown.

In Mt Isa, two PAs worked in the emergency department (ED) of the Mt Isa Hospital. There were 14 full-time equivalent (FTE) RMOs on staff and three FTE SMOs. The ED doctors saw – 100 patients per day. In response to a H1N1 outbreak in July 2009 the PAs began to operate a supervised primary care clinic alongside the ED, to which non-urgent (category 4 and 5) patients could be referred. This was well received by both ED clinicians and patients, and was continued following the flu season. ED presentations and waiting times decreased as primary care clinic attendances increased over the course of the following 9 months.

After several months, the PAs at Mt Isa began to rotate to Normanton Hospital (14 beds), 500 km north of Mt Isa. The general practitioner in Normanton works in private practice and also acts as medical supervisor to the hospital. After several months, one PA remained in Mt Isa at the primary care clinic and the other relocated to Normanton to work within the GP clinic, the hospital and the Karumba health centre, 70 km north of Normanton.

At PAH, the PA worked in the Cardiology Department, a tertiary referral unit offering electrophysiology (EP), invasive intervention and echocardiography. The PA role was located within the Heart Rhythm Group. This group included up to 15 staff: consultants, scientists, an EP clinical nurse coordinator (CNC), an EP registrar, resident doctors and a research fellow. The PA worked in EP, pre-admission and out-patients clinics, and provided referral, scheduling and discharge liaison for patients in the coronary care unit or cardiology patients located elsewhere in the hospital. She was a first point of contact for cardiology staff and EP/pacing scientists regarding EP/pacing patients, undertook the pre-admission clinic twice a week, assisted outpatient scheduling and facilitated post-procedure discharge.

An aim of the Pilot was to assess the impact of the PA role on the provision of quality health care in Queensland. This referred not only to the standard of clinical care but to the ‘cultural fit’ of the PA role within the clinical team.

The Pilot PAs were highly experienced, each with over a decade of clinical practice. Supervisors’ reports and feedback from Pilot site staff consistently indicated that all Pilot PAs provided safe and high quality care.

By the end of the Pilot, all doctors who were interviewed believed that the role had the potential to assist medical workforce pressures and fatigue management through appropriate task delegation under supervision. At Cooktown, a comparison of doctor overtime on weekends in March 2009 (before the Pilot) and March 2010 (during the Pilot) indicated that overtime had decreased by 18 per cent, despite a 13 per cent increase in presentations and a 34 per cent increase in admissions.

The potential for the role to improve rural health workforce retention was also mentioned consistently. In addition to sharing the medical workload, doctors suggested the presence of PAs could offset isolation. While many nurses agreed, many also expressed a concern that promoting the PA role may occur at the expense of the advanced nursing roles, in particular reducing opportunities for nurse practitioners.

The potential for competition between the two roles was untested as none of the Pilot sites had NPs who worked closely with the PAs. However, nurses at the Pilot sites used their own observations, knowledge or experience of each role separately to form their views. Interviews with nursing staff throughout the life of the Pilot indicated a shift in perspectives over time regarding the PA role.

Among nurses who responded to the post-Pilot survey, 54 per cent felt that the PA role had complemented existing roles (up from 18 per cent), 33 per cent thought some aspects of the role had overlapped with existing roles (down from 47 per cent) and others were unsure. However, role distinction between NPs and PAs will need to be made more explicit in order to allay nursing concerns regarding opportunities for advanced nursing roles.

Despite these and other initial nursing concerns regarding role definition, most nurses who worked with the PAs felt the health system could potentially benefit from utilising PAs as additional mid-level clinicians, as long as opportunities for the nursing profession were not compromised.

One of the identified strengths of the PA role was its ability to adapt and respond to identified gaps in service delivery. While some doctors and nurses continued to feel that the role was not clearly defined, many more perceived that the lack of a fixed definition was an asset as it allowed the PA role flexibility to evolve according to the needs within the clinical team. n

The full copy of the report, by Linda Kurti, Susan Rudland, Rebecca Wilkinson, Dawn DeWitt and Catherine Zhang, is avilable at www.publish.csiro.au/nid/261/paper/PY10055.htm

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The Physician Assistant (PA) role was originally developed in the United States of America (USA) in the 1960s to address rural workforce shortages using trained military medics returning from active duty. Since that time, the role has been introduced into several other countries. Currently in the USA there are more than 74 000 PAs in all areas of medicine, according to the American Academy of Physician Assistants 2010. PAs are health professionals licensed to practice medicine in a delegated role, working autonomously under the supervision of a medical practitioner. PAs are qualified by graduation from an accredited national body and completion of a national examination. Re-certification is required every six years and PAs must also undertake approved continuing medical education every year. PAs receive generalist medical training, which enables them to work across a wide variety of clinical areas. In the USA, 35–40 per cent of PAs practice in primary care.

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