Physician assistants: education, practice and global interest

Abstract

Background: In the United States, the physician assistant (PA) model has proven to be a cost-effective way to train quality primary care providers with a high degree of acceptance of the PA role by patients and other healthcare providers.

Aim: Discuss PA model as it pertains to other countries.

Methods: Review of relevant literature related to physician assistant education, practice and global interest.

Results: Several countries including the United Kingdom, Scotland, Canada, the Netherlands, Taiwan, South Africa and Ghana are exploring or re-exploring the concept of the physician assistant as a way to quickly and efficiently train and employ autonomous and flexible health workers to address their nation's healthcare needs. Conclusions: Physician assistant education is efficient and flexible and the PA model can be easily adapted to the specific health system needs of other nations. In addition, many PA programs have affiliation agreements with institutions outside of the United States to host PA students for clinical rotations and there is an ever-growing interest by students in international rotations. The Physician Assistant Education Association along with the American Academy of Physician Assistants is actively involved with sharing information about the PA profession with other countries.

Introduction

The physician assistant (PA) is a health professional licensed to practice medicine in the United States. Within the physician–PA relationship, physician assistants exercise autonomy in medical decision-making and provide a broad range of diagnostic and therapeutic services. These include physical examination, diagnosing and treating illnesses, ordering and interpreting tests, counseling on preventive healthcare, assisting in surgery, and writing prescriptions. Physician assistants are also involved in education, research and administrative services. PA education is based on the medical model which aims to create a physician–PA team that enhances the delivery of high-quality healthcare. The legal basis of physician assistant practice is the concept of delegation of medical tasks by licensed physicians to qualified professionals. PAs work with the supervision of physicians and practice in a variety of clinical settings including rural clinics, multi-specialty group practices, community health centers and hospitals (Hooker & Berlin 2002; Hooker & Cawley 2003). According to the US Department of Labor, the PA profession is one of the 10 fastest growing occupations in the United States.

The establishment of the physician assistant profession in the US health system was an important health workforce development. PAs emerged in the 1960s as a new concept based largely in response to a perceived shortage of physicians, particularly in primary care and in rural communities. The PA was modeled on the ex-military medical corpsmen who had served in the Vietnam War and who were returning to civilian life (Salyer 2002). In the 1970s, the US embarked on a marked expansion of medical school capacity doubling the number of medical graduates, yet it was unclear whether sufficient numbers of new physicians would be produced or if these physicians would enter practice in rural and underserved areas or in generalist specialties. Simultaneously, a second policy approach was to promote the physician specialty of family practice as a means of rejuvenating the dying field of general practice. A final approach aimed at filling gaps in the health workforce was the creation of the physician assistant. Since that time, the physician assistant role has expanded into all areas of primary, specialty and surgical practice. Recently, many other countries have begun to look at the US physician assistant model as a potential solution to their workforce shortage.

Table

Practice points
•Physician Assistants (PA) are licensed to practice medicine in the United States.
•The US Physician Assistant educational model is flexible and adaptable.
•There is increasing global interest in the Physician Assistant concept.
•PAs are a potential solution to health workforce shortages in primary care.
•There is a high degree of patient acceptance and satisfaction with Physician Assistants.

Education

PA educational programs are designed to create clinicians for roles that expand physician services. As the PA concept evolved, a wide range of institutions such as medical schools, universities, four-year colleges, community colleges, teaching hospitals, the uniformed services and federal healthcare systems sponsored educational programs. The federal government became involved in providing support for PA education in the 1970s and its mandate for the PA profession was to train clinicians for roles in primary care and to serve in rural and other medically underserved areas (Cawley 1992). PA programs are designed to be educationally efficient with a shorter period of education, typically two years in length, than standard medical programs. In the formative years of the profession, the different types of sponsoring institutions resulted in a great variety of curriculum models incorporating philosophies and approaches that were considered innovative and at the forefront of medical education (Smith 1972). Often, these models were initially designed based on the recruitment of individuals with extensive healthcare experience and intended to meet specific national, state and community needs; this was particularly the case with the MEDEX model (Golden et al. 1981). PA educational programs have evolved into well-recognized and highly acclaimed medical educational programs based on progressive and innovative medical curricula (Glicken 2005).

In 2005, there were 137 PA educational programs, with a few more in development. The average class size is 28 with a range between 10 and 100 students and an annual graduate output of 4850, which is equivalent to more than 25% of the 17,000 physicians trained annually. At least 105 PA programs (80%) award the master's degree or provide a graduate degree option with almost all committed to this degree endpoint by 2008 (Simon 2004–05). This growth in PA graduates comes at a time when patient demand for access is increasing and medical school graduation rates have not kept pace with population growth.

Physician Assistant Education Association ‘Guide for International Program Development’ indicates the typical PA curriculum requires prerequisite courses in basic sciences (such as anatomy, physiology, chemistry, microbiology) and some prior healthcare experience Many are now also requiring a prior bachelor's degree. The professional component is 24–28 months in length and includes both didactic course work and clinical placements (Simon 2004–05). Didactic coursework includes anatomy & physiology, pharmacology, patient evaluation, clinical medicine, preventive medicine, ethics, diversity and other health-related courses. The clinical year includes rotations in family medicine, women's health, pediatrics, internal medicine, surgery, emergency medicine, orthopedics and other specialty areas. Programs that offer a master's degree may require students to complete a clinical project and a written paper.

PA practice

The deployment of PAs in medical care is wide-ranging. The 2005 American Academy of Physician Assistants Census Report showed that 41% of PAs work in the primary care areas of family practice, internal medicine, pediatrics and obstetrics & gynecology with the rest employed in various medical and surgical specialty practices. Approximately 17% work in non-metropolitan communities with 10% in towns with a population of less than 20,000. The general medical education of PAs gives them the ability to move between various clinical settings and specialties including clinics, medical centers and hospitals. In all settings they share in diagnosing and treating common medical problems and providing preventive care and health education. PAs are also utilized in all of the surgical specialties and the majority of the medical specialties. PAs have been shown to have proficiency in the performance of medical diagnostic and therapeutic procedures that require a high degree of technical proficiency (Gunneson et al. 2002).

Studies of PA employment and task analysis consistently reveal the cost-effectiveness advantage of PA utilization (Hooker 2000). Demand for PA services has exceeded supply for the past 10 years (Freeborn & Hooker 1995), with opportunities for employment fairly strong in nearly all parts of the country as per the recent US Department of Labor Report (2006). The US government, including the military and the Department of Veterans Affairs, employs over 12% of PAs; state governments and large health maintenance organizations are other major employers (AAPA 2005).

From the beginning the satisfaction of patients with PAs has been consistently high, rivaling that for physicians (Freeborn & Hooker 1995). Acceptance by nurses, pharmacists and other allied health occupations was slower than by physicians but eventually came about. PAs are now regarded as effective healthcare providers; the scrutiny they have undergone has been as extensive as any other innovation in healthcare delivery.

Career satisfaction has also been a concern of those interested in the profession. However, over 20 studies show that PAs are generally satisfied with their role and are not interested in becoming a physician (Marvelle & Kraditor 1999). Over 95% of PAs surveyed say they would become a PA again. This survey result is substantiated with an attrition rate of PAs estimated to be 2% per annum and demonstrates that role frustration has not been a matter of concern to most practicing physician assistants.

Legal status

PAs are licensed in all 50 US states and most territories and are authorized to prescribe in all but one state. Qualifications to practice as a PA require that individuals be graduates of an educational program accredited by the Accreditation Review Commission for Physician Assistants (ARC-PA) and pass the Physician Assistant National Certifying Examination (PANCE). The PANCE is a nationally standardized examination in basic medical and surgical knowledge administered by the National Commission on Certification of Physician Assistants (NCCPA) with the content and standards developed in cooperation with the National Board of Medical Examiners (NBME). Successful completion of the initial PANCE is a required qualification for PA practice in all states and to maintain certification NCCPA requires that PAs obtain 100 continuing medical education hours biennially and recertify by formal examination every six years (NCCPA 2006).

Malpractice has been a subject that arises when discussing employment liability. To date, the liability of PAs in the US is considerably less than that of physicians in comparable roles as measured by medical insurance premiums and malpractice cases. The National Practitioner Data Bank is a repository of judgments and settlements in medical malpractice cases that come to trial in the US. This 15-year registry documents that the rate of settled litigation for PAs is less than one-fourth that of physicians in comparable roles (Cawley et al. 1998).

Global interest in the PA profession

Several nations experiencing health workforce problems have considered adopting or adapting the physician assistant (PA) concept. Countries facing shortages of medical care providers and or facing shortages of primary care practitioners, or experiencing cost pressures, have examined the US PA concept as a possible means to deploy capable and flexible health workers to address health system needs (Mittman et al. 2002; Cawley & Hooker 2003). Several countries are utilizing US-trained PAs in pilot programs including England and Scotland and the Netherlands has established four PA programs. In addition, many PA programs have affiliation agreements with institutions outside the United States to host PA students for clinical rotations (Legler et al. 2005). The International Affairs Committee of the Physician Assistant Education Association has developed guidelines concerning PA student clinical placements at international sites and serves as a resource to other countries seeking advice concerning the development of physician assistant educational programs.

Countries are utilizing the expertise of educators and practicing physician assistants from the United States to assist with the development of similar programs to respond to workforce shortages. The United Kingdom Department of Health (2005) has developed PA-type programs to train Medical Care Practitioners at several universities and is in the process of finalizing the national curriculum and developing regulations for practice of this new health professional (Westwood & Richardson 2005) and Scotland has recently completed a critical review of the concept (Buchan et al. 2006) with an intent to rapidly incorporate the profession. Beginning in 2001, the Netherlands developed several university-based programs to educate PAs with plans to expand these programs in the near future (Verboon 2005). Taiwan has developed a PA-type program that would convert nurses into PAs (Lo 2005). In Canada, where PAs have been part of the Canadian military for years, a program to train physician assistants in the military at Base Borden Ontario has been in operation for more than a decade and there is also a proposal in the province of Manitoba to begin a civilian PA program in the near future (Legler et al. 2005). The province of Ontario has also recently announced the incorporation of civilian PAs into the workforce (HealthForceOntario 2006). South Africa and Ghana are moving forward in developing PA educational programs and legislation that would permit providers to enter medical practice (Legler et al. 2005).

Trends in the utilization of PAs outside the US represent a full cycle in their natural history. While some early questions arose (Hutchinson et al. 2000), comparable to early US experience, a recent review of the literature from a wide range of countries on how the role of the physician can be expanded with additional types of personnel concluded that: ‘The use of [PA equivalents] does not compromise care quality and could serve to improve access for needy populations’ (Buchan & Dal Poz 2002). Although the majority of studies originated in the USA, the literature contains useful examples of expanded roles of PA-type personnel around the globe. The authors conclude that the use of health personnel with different skills remains relatively unexplored but probably has merit for solving health workforce shortages in other nations. This may well be the case, since the demand for PAs in the US is outpacing supply, suggesting that they must contribute to efficiency or they would not increasingly be employed.

Conclusion

The US models of training physician assistants have proven to be a cost-effective means to prepare quality primary care providers. Empirical evidence and policy consensus indicate that the introduction of the PA has been a successful experiment in medical workforce expansion. Countries facing a variety of health workforce difficulties are considering the utilization of PAs or PA-like healthcare workers as a means to deal with these issues. The US experience has shown that patients are satisfied with PA care and accepted by other healthcare professionals. Early data suggest similar results in other countries (Woodin et al. 2005). In the US system, physician assistants have responded to unmet societal needs by practicing in areas that have shortages of physicians. The selection of a career as a PA is a rewarding one with PAs reporting high degrees of job and career satisfaction (Hooker 2000). Globally, the US model has been examined by several countries and appears to lend itself to address the workforce needs. Thus far countries have fashioned and modified the US concept of the PA to meet specific health system needs. Finally, the quality of education the PA obtains and the ability to maintain lifelong learning provides a model for other professions to emulate.

Physician Assistant profession

• Physician Assistant Education Association (PAEA): http://www.paeaonline.org/

• American Academy of Physician Assistants (AAPA): http://www.aapa.org/

• Physician Assistant History Center: http://www.pahx.org/

• National Commission on Certification of Physician Assistants (NCCPA): http://www.nccpa.net/

• Accreditation Review Commission on Education for the Physician Assistant (ARC-PA): http://www.arc-pa.org/

Additional information

Notes on contributors

Christine F. Legler

CHRISTINE F. LEGLER, Chair, Physician Assistant Education Association International Affairs Committee, founding Director of the Pacific University School of Physician Assistant Studies, and Associate Professor in the Doctor of Health Sciences Program at Nova Southeastern University.

James F. Cawley

JAMES F. CAWLEY, is Director, Physician Assistant & Master of Public Health Program, Professor and Vice Chair, Department of Prevention and Community Health in the School of Public Health and Health Services, and Professor of Health Care Sciences in the School of Medicine and Health Sciences, at The George Washington University Medical Center.

William H. Fenn

WILLIAM H. FENN, is Professor, Physician Assistant Department at Western Michigan University, and Chair, Committee on International Affairs of the American Academy of Physician Assistants.