Croakey has recently run a series of articles on physician assistants (PAs) which was largely positive about their potential to add to the capacity of Australian health services, especially in rural, remote and other under-served areas.

Readers were asked to speak up if they had concerns about PAs or wanted to address any issues raised by the series.

Dr Luke Oakden-Rayner, a radiology registrar in South Australia, took up the challenge, and has shared his concerns below about the potential of PAs to impact upon already over-stretched medical training. This stressed system is, he says, “the predictable result of perhaps the dumbest approach to a doctor shortage a politician could dream up – dumping more raw materials on a production line, without increasing how fast the production line moves”.

It should be noted, however, that he worked with PAs during the trial in SA, and has also worked with nurse practitioners in several environments, and says he has always been impressed by the experiences, and fully supports the concept of task substitution. But….


Physician assistants and the current medical workforce

Dr Luke Oakden-Rayner writes:

Despite the shortage of trained doctors in Australia, one in four medical graduates is not guaranteed an internship. A graduate who does not get an internship cannot attain full registration as a doctor, and if they do not complete an internship within 3 years of graduating, they must return to University for re-accreditation. This is the current status of medical training in Australia.

The system is bottlenecked by vastly increased student numbers, which have grown by up to 120% over 8 years, without any concurrent increase in the numbers of clinical supervisors. Also, there are worrying signs that the aging medical population will start retiring en masse in the near future, widening the imbalance between supervisors and trainees.

There are two potential outcomes of the ‘med student tsunami’. One; highly skilled new doctors will not find training positions. Every year a graduate does not practice is a year the government sees no return on the six-figure sum it cost to train them. This would be a horrendous waste.

But the second option is worse; attempting to ‘push through’ increased numbers of graduates by reducing their supervision. There is clear evidence that reducing supervision is dangerous.

What we are seeing is the predictable result of perhaps the dumbest approach to a doctor shortage a politician could dream up – dumping more raw materials on a production line, without increasing how fast the production line moves.

I wanted to discuss this as a partial answer to recent pieces in Croakey regarding Physician Assistants (PAs). PAs require supervision by the same professionals who train medical graduates, and thus essentially represent even more raw materials on the same, overburdened production line.

Those pushing for PAs argue that they reduce doctors’ loads and create more time for training juniors. The problem with that argument is that junior medical officers do the same thing – they practise semi-independently but require supervision. Indeed, a medical unit could not run without juniors, they do the jobs that seniors don’t have time for.

PA advocates ignore the fact that the situation has passed a tipping point, where additional hands do not make less work, but instead spoil the broth. The problem is a shortage of supervisors, not support staff.

No one could argue that pushing more trainees into a system where up to 25% cannot access supervision would improve the shortfall, but nevertheless, some argue that adding PAs in the same sort of roles could.

In America the number of PAs a doctor can supervise is limited by law, usually to around 4 at most. The supervising doctor is responsible for every decision that a PA makes, every drug order signed and every procedure performed. This, for an already overstretched doctor, cancels any benefit to productivity.

We all have to accept there is a maximum number of ‘supervisees’ of any sort, medical or PA, that can be supervised at one time. It is not unreasonable to assert that an overloaded system will not be able to cope with more load.

Associate Professor Moira Sim wrote that some training of PAs can occur in parallel systems, although she did not provide a reference. If this is true, and the alternate system is capable of training PAs on a national scale, then that is great. It remains to be seen if para-medical training can be performed without using medical training positions. I remain doubtful, but would be happy to be proven wrong.

In this piece I have tried to show that not all concern about PAs is “pure self interest” by “an unholy alliance of interests: that of the medical and nursing lobbies”, as much as some would like to portray it that way.

A single valid concern, such as the one I have raised, negates such an extreme viewpoint entirely. We need to work together, and polemical voices are not helpful.

Our peak medical bodies foresee a positive role for PAs but have some valid concerns about their implementation. Ultimately, doctors are not a protectionist opposition, but protecting patients in an overburdened system.