GUEST BLOG: Ian Powell – Physician Associates: a ‘solution’ desperately searching for a problem

On 17 October Radio New Zealand  reported serious concerns raised by key national health professional workforce organisations: Physician associates a poor use of money.

They feared that doctors, nurses and allied health professionals were in threat of having their objective of addressing severe workforce shortages being addressed instead thwarted by being replaced by a currently unregistered category of health workers (‘physician associates’).

Royal New Zealand College of General Practitioners one of six signatures of joint letter to health minister

The  organisations were the Association of Salaried Medical Specialists (ASMS), NZ Nurses Organisation, Resident Doctors Association (the larger of two unions representing doctors in training),  APEX (a union representing allied health professionals), Royal College of General Practitioners, and the General Practice Owners Association.

They were concerned that Health Minister Dr Shane Reti is intending to bring a formal proposal for Cabinet to have ‘physician associates’ (previously known as ‘physician assistants’) registered under the Health Practitioners Competence Assurance Act 2003.

Consequently they had sent a joint letter to the Minister requesting that he pause his intention. Individually these professional bodies are important voices.

Collectively together they are a powerful voice providing sound advice that deserves serious government consideration.

The core of the objection

At the core of their objection is that there was no task that a physician associate might perform that was not already being undertaken by a locally trained and registered health professional.

They are absolutely right. Around 15 years ago, when representing ASMS, I was involved in an earlier attempt to force physician assistants onto the health system. The fundamentals of today’s controversy have not changed from the first.

In the reported words of ASMS in the above-mentioned RNZ coverage:

Right now it appears the government is not providing the funding to employ enough doctors and nurses. The last thing we should do is spend time and money setting up a new system of vocational registration for a whole new profession when the government isn’t currently spending enough to fund the existing workforces.

All the signatories to this letter support growing the health workforce and want to ensure primary and secondary health care is staffed to safe levels, more people can train as healthcare professionals, and more patients get timely and equitable access to healthcare. It just makes sense to do that through existing occupations rather than inventing new ones.

They recommended that physician associates who wished to work in New Zealand would be better to retrain as nurses, paramedics, pharmacists, anaesthetic technicians or doctors.

In fact, I understand that historically at least, in the United States physician associates had been recruited from nursing.

Aggressive attack from a ‘vested interest’

Five days later Radio New Zealand reported an aggressive response from Shirley Collins, President of the New Zealand Physician Associate Society: Physician associates say they can help health workforce crisis.

Collins accuse the professional bodies behind the joint letter to the health minister as being driven by “vested interests” and “patch protection”.

She added:

Integrating internationally trained PAs while long-term investments in local training are implemented will help ensure New Zealand’s healthcare system remains functional and effective in the short term while building capacity for the future.

It is critical to view these objections for what they are: efforts to maintain existing professional monopolies rather than a genuine attempt to address the healthcare crisis facing New Zealand.

This response, including its lack of empirical substance, was hardly a lesson on how to be professionally collegial or win friends and influence people.

Ironically it had the characteristics of ‘vested interests’ and ‘patch protection’ coated with an overdose of opportunism.

What are physician associates

Physician associates originated from the armed forces of the United States  during World War 11 and then spread into its domestic health system.

Physician associates ‘Born in the USA’

They are an accepted and legitimate part of the US’s regulated health professional workforce; neither bogus nor dodgy. However, the issue is their relevance to particular health systems, including those with a much smaller critical mass.

There is significant variation in the training and scope of practice of physician associates from country to country and within the United States.

Depending on location, they practice semi-autonomously under the supervision of a doctor or autonomously perform a subset of medical services previously provided by doctors.

In the United States, physician associates may diagnose illnesses, develop and manage treatment plans, prescribe medications, and serve as a principal healthcare provider.

In many US states they are required to have a direct agreement with a registered doctor. This is also the case in Canada.

In the United Kingdom, physician associates were introduced in 2003 to support the work of the healthcare teams.

But they are ‘dependent clinicians’ requiring supervision from a doctor. They can’t prescribe medications. However, they are now the source of controversy in the UK’s National Health Service (discussed further below).

Training to be a physician associate is shorter than the time to obtain a medical degree necessary for becoming a doctor. Another defining difference is that it typically does not involve what in the United States is called ‘residency training’ (‘resident’ or ‘junior doctor’ training in New Zealand).

There are now 50 physician associates spread among 27 clinics (general practices) in New Zealand, all from the United States. The only requirements is that they have at least five years’ experience and maintain certification in their home countries.

United Kingdom primary care controversy

NZ Doctor journalist Steve Forbes provides very good coverage of physician associate controversy

In my view the best overall coverage was provided in NZ Doctor by journalist Steve Forbes on 24 October (paywalled): Physician associate controversy coverage. His coverage includes pertinent developments in the United Kingdom,

Forbes noted that the British Medical Association (BMA) had just voted to phase out the use of physician associates in general practice.

This is because it believed physician associates were fundamentally unsafe and were “inadequately trained to manage undifferentiated patients”.

In the BMA’s own words:

It’s no secret that we desperately need more staff in general practice, but we need to be sure that staff who see patients are suitably trained and competent to see them unsupervised. Workload is inextricably linked to the recruitment and retention of the workforce, so additional roles should not generate more work for already-stretched GPs.

We want to be able to give patients the care and services they need, when they need them, with the most appropriate clinician for their needs. To do that, the Government must urgently invest in practice staff such as GPs and general practice nurses.

The BMA’s position followed a vote by the British Royal College of General Practitioners in September to oppose physician associates working in general practice because of these concerns.

Ball now in health minister’s court

In 2017 the Physician Associate Society approached the Ministry of Health to seek registration as health professionals under the Health Practitioners Competence Assurance Act.

The Ministry of Health has now recommended registration to Health Minister Shane Reti who is preparing a cabinet paper in support.

Wise warning from Dr Angus Chambers

General Practitioners Association Chair Dr Angus Chambers, however, has wisely warned that regulating physician associates are not the answer to the challenges facing general practice. Forbes quotes him advising that:

I think we’re missing the boat. We need to invest more in general practice. We need to retain our GPs and stop them going to Australia. That needs to come before investing in new workforces.

Piloting through pilots

There was a pilot of physician assistants in the general surgical department at Middlemore Hospital in 2010. Radio New Zealand incorrectly describes this pilot as “successful”.

It was forced on the department although the surgeons rebelled and managed to ensure that it might be more potentially clinically useful. The above-mentioned RNZ item described it as “successful”. However, this is misleading.

The original reviewers engaged for the external evaluation were dismissed part way through their work apparently because their conclusions fell short of the desired outcome. New reviewers were then appointed.

Despite this, however, the final evaluation was inconclusive on the core issue. Two experienced American physician associates were brought over to Middlemore Hospital.

They were impressive individuals in part because they had the self-confidence to work outside their comfort zone in a quite different health system.

But my reading of the evaluation was that it did not clarify whether the ‘success’ was the role of physician associates in New Zealand’s health system or the calibre of two experienced health professionals. It suggested more the latter rather than the former.

Shirley Collins, in the second above-mentioned RNZ item, argued that a 2010-15 pilot found no adverse patient outcomes involving physician associates across 30,000 patients in general practices.

She may well be right but ‘no adverse outcomes’ is an important but low threshold for assessing the quality of care or the need for the physician assistant role.

Further, the same could equally be said for the outcomes over the same period of time for practice nurses, nurse practitioners and general practitioners.

This pilot claim is insufficient justification for the registration of a new category of health professional in New Zealand.

Just as in the case of Middlemore Hospital, it is more likely to be the calibre of health professionals of one country moving outside their comfort zone in a different health system.

Critical mass matters

Critical mass matters in health systems because population size flows into health professional workforce size. Physician associates may make good clinical sense in a country as big as the United States with a population of around 335 million.

However, it is clearly a challenge in the United Kingdom with a population of around 68 million.

Consequently, physician associates will be much more of an overlapping tight squeeze in a country with a population of around 5 million (1.5% of the US and 7.4% of the UK).

Regardless of their calibre, the fact that there are 50 US trained physician associates is not a justification on its own for granting vocational registration, regardless of calibre. They are still able to work in Aotearoa’s health system, without registration.

The issue is whether, given the nature of our health system, we need an additional registered health profession with functions that are largely, if not completely, already provided by currently registered health professions.

Take nurse practitioners as a case in point. Under the Health Practitioners Competence Assurance Act, nurse practitioners have a scope of practice.

Nurse practitioners make diagnoses and differential diagnoses, and order and interpret diagnostic and laboratory tests.

Further, they prescribe medicines within their area of competence with the same authority as medical practitioners.

The extent that physician associates would offer more than nurse practitioners is around the margins at best, especially in a country the size of New Zealand.

Advice to the health minister

Before last year’s general election, Shane Reti asserted (correctly) that the biggest crisis in the health system was workforce shortages. This would be the new government’s top health priority.

Shane Reti should not play the politics of pretence

However, once in office, what we now have is the political pretence of addressing these shortages. This is the case with the poorly thought out contentious Waikato rural medical school initiative.

It is also the case with the proposed registration of physician associates. It is an attempt to create an illusion of address health workforce shortages.

Unfortunately some physician associates, at least, are opportunistically taking advantage of this pretence.

Instead it simply helps to ensure that these shortages continue and further deteriorate as the workforce ages and workloads become untenable for many.

The six above-mentioned national health professional organisations have firmly made the point that Aotearoa New Zealand’s health system has a shortage of health professionals; it does not have a shortage of health professions.

It cannot be put more succinctly than this. Refusing to diagnose the problem dooms any ‘solution’ to be a failure.

 

Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion