Physician assistants in general practice

Position

All patients should have access to high-quality GP led primary healthcare services, provided by a multidisciplinary general practice team.

Implementation of the physician assistant role could:

• increase barriers to training for medical students, interns and registrars
• reduce numbers of GPs working in rural areas
• reduce support for the current primary care workforce if funding is diverted to support a new health professional role.

Patients in rural and remote communities need access to the same quality of care as patients in metropolitan and regional areas.

The RACGP:

• does not support an increase in the implementation of the physician assistant role in the current Australian medical workforce context
• recognises that when distribution of medical workforce is balanced across urban, regional, rural and remote areas, combined with sufficient intern and GP training places, the physician assistant role may complement the general practice team and the rural hospital workforce.

Background

In response to medical workforce shortages in rural and remote areas of Australia, stakeholders in interested state governments and universities have proposed the introduction of the physician assistant role into the medical workforce, including general practice. Interest in the physician assistant role has been concentrated in Queensland and South Australia.

Definition of physician assistant

Physician assistants are medical professionals who work under the delegated authority of a medical practitioner. Physician assistants are generalist trained, augmenting the services traditionally provided by a doctor.

Working under the delegation of a medical doctor, and depending on the jurisdiction, a physician assistant’s scope of practice includes:

• physical examination
• diagnosing and treating illnesses
• ordering and interpreting medical tests
• assisting in surgery
• writing prescriptions
• referring to other medical specialists
• providing preventive health care services.

Overseas experience of physician assistants

In the United States, physician assistants have been found to contribute to the primary care effectiveness, safety and outcomes of care comparable to primary care physicians. In the primary care sector, patient satisfaction regarding care access or overall experience for physician assistants is reported to be equivalent to care provided by a primary care physician, with patients generally making no distinction between the roles.

In the UK, it has been reported that physician associates (equivalent role to physician assistants) provide care comparable to a GP. However, reports suggest that physician associate consultations generally take longer than those with GPs, and physician associates provide care to younger patients, with fewer medically acute problems and fewer long-term conditions. UK physician associates do not currently have statutory registration and do not require a licence to work in the UK.

Managing complex GP caseloads and reducing burnout have been reported as recognised benefits of physician associates in the UK and it is suggested that the role may provide both a short and long term solution to such medical workforce pressures.

Physician assistants in Australia

History of physician assistant role in Australia

Physician assistants have been considered as a potential solution to medical workforce shortages in rural and remote areas of Australia by Health Workforce Australia (the Department of Health) and tertiary institutions such as James Cook University (JCU).

The first physician assistant education program in Australia was offered by the University of Queensland (UQ), however this program ceased in 2011 citing concern over the uncertainty of the physician assistant workforce in Australia.

The physician assistant role has been piloted in Queensland (completed in 2010) and South Australia (completed in 2009) using qualified physician assistants from the USA. These pilots were predominantly carried out in public hospital settings.

Currently physician assistants cannot register with Australian Health Practitioner Regulation Agency (AHPRA). Physician assistants are not recognised under the Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefit Scheme (PBS). Therefore, there are no rebates for patients who see a physician assistant and patients would pay more for medication prescribed by a physician assistant.

Physician assistants in Australia today

JCU is the only university in Australia that offers physician assistant training, through their Bachelor of Health Science (Physician Assistant). This course offers students with previous healthcare experience an opportunity to:

• gain the knowledge and skills necessary to deliver clinical medical services in a supervised, delegated team model with a medical practitioner
• identify a scope of practice consistent with their level of experience and delegation and demonstrate appropriate self-care and self-evaluation
• be trained to perform many of the tasks previously done solely by medical practitioners, including history taking, physical examination, diagnosis, and treatment
• be trained to provide medical services within a team based practice model in rural and remote locations in Australia.

In 2016, there were approximately 40 Australian-trained physician assistants. A small number of these physician assistants were employed in the public health care sector, while the remaining were employed in the private health care sector. Of JCU physician assistant students, 50% reside in regional areas.

Lack of research on physician assistant role in Australian general practice

There has been limited research on the implementation of the physician assistant role in Australian general practice. State pilots did not address issues such as the capacity of the system to provide positions and training for physician assistant graduates. The final evaluation report on the Queensland Physician’s Assistant Pilot recommended that structural, regulatory, and legislative considerations be examined before establishing a physician assistant role in Australia.

Issues

Competition for medical training places

It is essential to ensure training places are available to accommodate medical students, interns and general practice registrars in Australia. There is an increasing number of medical students graduating and a corresponding increase in the number of training places sought. The employment of physician assistants in clinical teams could reduce health system capacity to provide training places to medical students, interns and general practice registrars.

GPs need to be attracted to and retained in areas that have little access to primary health services and areas of greatest need. By taking away opportunities for medical students, interns and general practice registrars to train in these areas through the use of physician assistants, the number of GPs may further reduce in these areas.

Inequitable solution to maldistribution of GP workforce

The number of Australian-trained medical students, interns and general practice registrars seeking places in general practice is now increasing, yet GP workforce is not evenly distributed. The number of GPs decreases significantly with greater remoteness, with considerable variation across jurisdictions. Projections show there are not enough GPs in rural and remote Australia. Poor coordination of medical training and lack of support for rural doctors have been attributed as leading causes to current maldistribution problems.

While physician assistants are potentially a low-cost, short term option to medical workforce shortages, the role may be unsuccessful in the long-term if there are insufficient numbers of GPs in rural and remote areas to support them. There is no requirement for physician assistants to work or remain in rural and remote communities. The role may exacerbate the issue of patient over-servicing in urban areas, as physician assistants are not incentivised to work in rural or remote areas.

Patients in rural, remote and Aboriginal and Torres Strait Islander communities should have ongoing access to the same standard of medical care as patients in metropolitan and regional areas.

Task substitution

Task substitution introduces a broader range of professionals to fulfil roles normally undertaken by a doctor (or other health professional).

Introduction of the physician assistant role may reduce training opportunities and resources available to medical students, interns and general practice registrars impacting their clinical experience. Fewer learning opportunities can have a flow on effect in compromising patient safety.

In addition, physician assistant training programs are in no way equivalent to those completed by GPs. Undergraduate medical education and work-based clinical specialty training across a broad range of healthcare contexts is the appropriate training for clinicians to provide safe, effective medical care. Physician assistant training does not fulfil such a scope of training and their clinical skills are by no means equivalent to those of a GP.

Attempts to perform at the same level and scope of practice as GPs without equivalent training will increase the risk of:

• mis- or delayed diagnoses
• inappropriate or delayed treatment – including pharmacological treatment
• adverse events resulting in physical or psychological harm to a patient
• confusion for patients over the roles and qualifications of clinical staff at their practice
• inconsistencies in patient payments, given physician assistant services do not attract MBS patient rebates.

Although physician assistants may allow for more task substitution, a qualified GP must still be available to work with or supervise their role. This ongoing supervision may increase time burdens for GPs, especially in rural and remote areas, and nullify any benefit of task substitution.

In addition to the risks of task substitution, taking away less complex tasks from GPs may lead to less time spent with their patients, affecting GP/patient relationships and losing opportunities to practice preventive medicine (eg checking in on a patient while completing a simple repeat prescription).

Lack of funding strategy

Programs to support medical students, interns and general practice registrars need to be appropriately funded. The introduction of the physician assistant role in general practice may reorient funding away from medical students, interns and registrars, further impacting on availability of training opportunities.

Australian physician assistant pilots provided no publically available detail on the funding allocated by each state to conduct the pilot program. There is no indication of required funding to implement a physician assistant role, including in general practice, nationally in Australia.

Strengthening and supporting rural general practice

The RACGP supports efforts to increase the number of doctors working in rural and remote Australia.

Australia has an ageing population with markedly increasing rates of chronic disease, comorbidity, and polypharmacy. Australia needs more trained doctors with their FRACGP, willing to work in rural and remote areas, to cope with population health needs and current misdistribution of the GP workforce.

The RACGP is committed to initiatives that strengthen and support rural general practice, including additional training for rural practitioners to support the acquisition of advanced rural skills to meet the needs of their community.

More than 3110 rural procedural GPs are supported each year by the RACGP to maintain and enhance their clinical skills in obstetrics, anaesthetics, surgery and emergency medicine through administration of the Australian

Government’s Rural Procedural Grants Program. The skills and knowledge held by Fellows of our College both here and internationally are the standard for unsupervised general practice regardless of location.

Related resources

• RACGP Position Statement – Rural Generalism 2020

Nurse practitioners

There are comparisons between nurse practitioner and physician assistant roles. The RACGP supports the role of nurse practitioners within GP-led general practice teams, either collocated or external to the general practice location, but does not support nurse practitioners working autonomously in the primary healthcare sector.

Independent nurse practitioners seeking the same level of authority, autonomy and scope of practice as GPs will compromise the quality, safety, efficiency and cost effectiveness of patient care.

Related resources

• RACGP Position Statement – Nurse practitioners in primary healthcare outlines issues surrounding and principles for nurse practitioners working in primary healthcare.

Conclusion

RACGP calls for improved support for doctors in rural and remote Australia and other areas of workforce shortage.

Limited training places need to be prioritised for medical students, interns and registrars and the introduction of the physician assistant role would further limit such training opportunities. Paradoxically, increasing physician assistants may reduce numbers of GPs and resourcing for the current health workforce roles in rural health. Given these issues, it is not appropriate to broaden the introduction of the physician assistant role in Australian general practice at this time.

The RACGP endorses targeted research into the role of physician assistance and nurse practitioners to support clinical care.