There are many reasons for the physician shortage that now exists, and this medical human resources crisis is likely to deepen as our aging population of doctors moves into retirement. But while cogent explanations for the current situation abound, sensible and timely solutions are more elusive.
Government efforts to expand the scope of practice of numerous groups into the domain of family physicians could simply result in increased costs, lower-quality services, and fragmentation of primary care. Efforts to import physicians from abroad and to repatriate foreign-trained Canadian doctors have yet to deliver the hoped-for bonanza, and even the recent doubling of the intake at the UBC Medical School will not solve the projected shortfall.
While doctors are in short supply, there are ways to amplify the work done without separating patients from their physicians, compromising on quality, or incurring undue costs. One group that offers such a suite of advantages is physician assistants (PAs).
Initially developed by the US and Canadian armed forces, physician assistants have begun to move into the civilian sector.
PAs are not independent practitioners. They are trained to work under the supervision of a doctor and, in almost all cases, they practise under the delegated authority of the hiring physician.
In their core education, PAs are typically trained to provide minor medical and surgical care in acute care settings, but because they operate under the licence and supervision of the hiring physician, they are used in a very wide range of situations.
For example, PAs can be used to perform the screening tests that go along with clinical prevention services, or they might assist in putting on casts and splints in an orthopaedic outpatient clinic. There are opportunities for PAs to assess and treat minor illnesses in a GP’s office, work in ERs, or to perform patient education and outreach as part of chronic disease management.
In addition to their flexibility, PAs also have the advantage of being relatively quick to train. Although the length of the four Canadian programs varies, the time to produce a PA is typically 2 years—less than that of nurse practitioners, and the PA training is very much focused around the medical model.
There is yet no consistent regulatory framework for the roughly 200 civilian PAs across Canada. The Canadian Medical Association has been lending support to the Canadian Association of Physician Assistants so that uniform educational and regulatory structures can be put into place. As yet BC does not regulate PAs, although the government has expressed a desire to bring them into the health profession fold.
Where would PAs fit into the health care system in BC? A number of demonstration projects have shown that PAs work well in a variety of settings. For example, in a recent pilot in Winnipeg, PAs worked with orthopaedic surgeons in their outpatient clinics. Not only did throughput increase dramatically, but the income generated by the PAs more than offset their salaries.
PAs have been used in hospital settings to assist in surgery, to care for patients in emergency departments, and to help in nursing facilities. Demonstration projects are ongoing in Ontario. While the business case for PAs seems clear in specialty settings, finding a place for PAs in general practice may be more difficult.
The issue doesn’t arise in the US, where every minute is billable, but in Canada most work is done on a fee-for-service basis, and some practices might find it hard to justify the $75 000–$130 000 typically commanded by PAs in Canada. However, there may be opportunities to negotiate targeted government funding for services that add value such as chronic disease management and clinical prevention.
A recent study addressed the concern that adding a PA to physician’s practice might cause the doctor’s income to drop. The study, albeit US-based, demonstrated an increase in physician revenue for those with PAs, and a reduction if nurse practitioners were utilized. Whether this is because PA salaries are typically lower than those of nurse practitioners or whether there are greater efficiencies remains an open question.
It may also make sense to insert PAs into existing hospital programs that utilize nonphysician staff. PAs could easily find a role in a variety of programs such as pain clinics, diabetes education, and inpatient duties.
The advantages of using physician assistants to extend the effectiveness of physicians and increase patient access seem compelling:
• A relatively short and practical training.
• A collaborative model that works with—not in competition with—doctors.
• A flexible practitioner limited only by what the supervising physician feels is appropriate.
• A way to keep primary care focused in the physician’s practice.
Physician assistants may well become very useful partners as we move to preserve quality care in the face of too few doctors.
—Lloyd Oppel, MD
Chair, Council on Health Promotion
1. Canadian Medical Association and the Canadian Association of Physician Assistants. Physician Assistant Toolkit. A resource for Canadian physicians. 22 January 2010. www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Advocacy/Physician_Assistants/PA-Toolkit_en.pdf (accessed 26 April 2010).
2. Perry J. The rise and impact of nurse practitioners and physician assistants on their own and cross-occupation incomes. Contemporary Economic Policy. 2009;27:491-511. doi:10.1111/j.1465-7287.2009.00162.x.