As PA practice becomes established outside the United States, the experience of the first efforts to utilize PAs in a nation is sometimes documented by research efforts. This installment of Research Corner reviews a detailed analysis of a pilot project that utilized five US-trained PAs in various settings in Queensland, Australia.
Evaluation of the Queensland Physician's Assistant Pilot — Final Report 25 June 2010. Urbis Social Planning and Social Research, Brisbane, AU.
EXECUTIVE SUMMARY: The Queensland Physician's Assistant Pilot was conducted between May 2009 and May 2010 to test the potential suitability of the role within the Queensland health system. The Physician Assistant (PA) role was developed in the United States in the 1960s and provides a medically-trained clinician who works under the supervision of a qualified medical practitioner. Today, there are around 68,000 PAs in the United States who work in all health settings, from small rural health clinics to highly specialized tertiary hospital departments. Urbis was contracted by Queensland Health to provide an independent evaluation of the PA Pilot to assess the following: the contribution value of the Physician's Assistant role to the capacity of the health care team to address patient needs; the organizational and legislative features which facilitated or inhibited the implementation and effectiveness of the Physician's Assistant role; the fit and appropriateness of the Physician's Assistant role within Queensland Health; the requirements for the sustainability and spread of the model beyond the pilot sites. The Pilot employed five US-trained PAs for 12 months at four separate Pilot sites: the Interventional Cardiology Unit of Princess Alexandra Hospital, Brisbane (1 PA); Cooktown Multi-Purpose Health Service, Cooktown (2 PAs); the Emergency Department of Mt Isa Hospital, Mt Isa (originally 2 PAs, then 1 PA); a GP clinic and local hospital at Normanton (1 PA, previously at Mt Isa).
Overall, the evaluation has found that once the initial implementation phase had passed, most doctors and nurses worked well with the PAs. At each site, the PAs, with their supervisors, developed job descriptions which were suitable to the demands of the local clinical environment, complementing the work of the medical staff and working collaboratively with the health care team. PAs were delegated medical responsibilities in line with their experience, assessing, diagnosing, and treating within a primary care setting and providing clinical coordination of scheduling, preparation, and discharge of surgical patients within the Interventional Cardiology Unit. At each site, medical supervisors indicated that the quality of care was excellent, that the PA had contributed to improving service delivery, and that the ability to delegate tasks appropriately had assisted with workload pressures. It was reported that the PA role had facilitated medical teaching by allowing doctors to balance their teaching responsibilities with clinical responsibilities. Most doctors, nurses, and other health providers who worked with the PAs reported that the PAs had made a positive contribution to the team and had provided excellent care.
Two main concerns were expressed by doctors and nurses regarding the role and its potential impact for the future. One was a concern that PAs might impact negatively on medical training, either by reducing junior doctor opportunities to learn on the job or by increasing competition by providing a cohort of newly-trained PAs who would also be seeking supervision. During the Pilot, these concerns diminished once doctors actually worked with PAs and came to understand the role. Larger questions regarding the capacity of the system to provide training, with or without the establishment of the PA role, were outside the scope of the Pilot. However, some participants did see clear benefits of the PA role in facilitating medical training, either by providing another clinician from which to learn or by freeing the supervising doctor to spend more time teaching. The other concern was that establishing the PA role may reduce opportunities for nurse practitioners and other expanded nursing roles. The Pilot provided no evidence that this would be the case; however, the PAs did not work regularly with nurse practitioners in any site except at Cooktown, where the nurse practitioner was employed in community health, so the potential for competition between the two roles was untested.
The Pilot had a number of limitations, most notably the small number of PAs and sites involved. Nevertheless, the Pilot demonstrated that within the participating sites, the PAs integrated well with their clinical teams, created distinct roles which complemented the existing nursing and medical roles, and enhanced service delivery. There were no quality or safety concerns identified during the Pilot. However, the Pilot PAs were all extremely competent professionals, and it is likely that newly-trained PAs would perform at a more junior level initially.
The findings of the evaluation suggest that a number of structural, regulatory, and legislative considerations would need to be addressed before the PA role is firmly established. These include a funding model, taking into account parity with other health professionals, infrastructure needs, supervision requirements, and professional development needs; a regulatory framework including training and accreditation, continuing medical education, and licensing; legislative requirements, particularly regarding the Medical Benefits Scheme and the Pharmaceutical Benefits Scheme; needs assessment to determine appropriate deployment and ensure adequate supervision information and training for supervisors and clinical teams to understand the potential of the PA role; and consultation with peak professional bodies and stakeholders to ensure the role is aligned with existing health professionals.
Within a small sample, the Pilot has demonstrated that a delegated medical role is acceptable to doctors, nurses, and patients; can enhance teamwork; and has potential to improve workload pressure. Further research and development are required to determine whether, and how, to establish the organizational system and professional and team structures that would enable the PA to make a full contribution to the Queensland health system.
DISCUSSION
The move toward establishment of the physician assistant (PA) profession in Australia is driven by the same forces as in other developed countries, including the United States: a shortage of trained medical providers and the development of mechanisms that would increase the health care workforce. In Australia, the addition of the physician assistant raised concerns from physicians that PAs might displace training opportunities for physicians in training and concerns from nurse practitioners that the addition of PAs might complicate the establishment of the NP profession. A pilot project was launched in May 2009 to assess the potential impact of the introduction of PAs into a variety of settings in Queensland, Australia. Five experienced US-trained PAs were recruited to practice at four different sites for 12 months. One PA was placed in an inpatient interventional cardiology unit, two were placed at a multipurpose outpatient clinic, one was placed at a hospital emergency department, and one was placed at a general practice clinic and local hospital. Site-specific research evaluated by surveys and field visits investigated the contribution of the PA role to the health system capacity in six domains of quality: patient safety, effectiveness, patient-centeredness, timeliness, efficiency, and the provision of equitable care. The PAs were reported to deliver high quality care, and no adverse events were attributable to care given by the PAs. Both doctors and nurses reported that the addition of the PAs allowed medical staff to allocate their skills where they were most needed and for nursing to allocate their time more effectively. Patient surveys documented a very high level of satisfaction with the quality of care provided by the PAs, with no patient indicating dissatisfaction with the quality of their care. Each site reported that adding the PA role improved waiting times for patients, and most patients surveyed reported a waiting time that was the same or shorter than before the addition of the PA. Supervisors indicated that efficiency of utilizing PAs was likely less than ideal because of Australian restrictions placed on what the PAs could do, estimated by one PA to decrease efficiency by as much as 50% compared to PA practice in the United States. No data were collected to document whether PAs increased the equitable provision of care, which is difficult to demonstrate given the small sample size.
Reports such as this can be placed in the context of similar detailed accounts of pilot projects describing new PA utilization, as well as the research done on PAs early in their establishment in the United States. This in-depth Australian study, rich in detail and attentive to multiple medical workforce factors, contains findings similar to a report describing the Scotland PA project.1 Although these current pilot projects are much more controlled and the data collected substantially richer than early American research on the PA profession, investigators asked similar questions in the establishment phase of the US PA profession: What did PAs do? How were they accepted by physicians and patients? What increased efficacy was gained from their use? 2 Since the profession was established in the United States by gradual growth driven by small educational programs rather than by a concerted national health workforce initiative, these early US studies were small and rudimentary compared to the Scotland and Australian pilot projects. However, the results were similar to those found in Scotland and Australia: that PAs were accepted by physicians and patients, that they provided high quality care, and that they increased the efficacy of the medical setting where they worked. JAAPA
Rick Dehn is a clinical professor in the Department of Family and Community Medicine and program director of the FNP/PA program at the University of California at Davis School of Medicine, Sacramento. He is a member of the JAAPA editorial advisory board. The author has indicated no relationships to disclose relating to the content of this article.
REFERENCES
1. Dehn RW. The physician assistant experience in Scotland [Research Corner]. JAAPA. 2009;22(4):
54-55.
2. Dehn RW. Physician assistant educational research. Journal of Physician Assistant Education. 2007;18(3):94-99.