The proposal to regulate the physician associate (PA; formerly physician assistant) workforce is a step in the wrong direction from the Ministry of Health.
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The proposal to regulate the physician associate (PA; formerly physician assistant) workforce is a step in the wrong direction from the Ministry of Health.1
Regulation of the profession appears to be an attempt to compensate for a shortage of healthcare professionals resulting from a lack of investment in the education and vocational training of existing workforces, especially doctors. Historically, PAs functioned as true “physician extenders” and performed the clerical and basic clinical tasks that detracted from a doctor’s ability to practise medicine efficiently. However, over recent years, the profession has sought independence from doctors, lobbying in North America and the United Kingdom to be able to diagnose, treat and prescribe with little or no oversight from physicians. See how PAs have rebranded as “physician associates” to distance the profession from their initially intended auxiliary role as an assistant. PAs are effectively attempting to fill the niche of a doctor without a medical degree or vocational training.
The Ministry’s proposal displays an intention to allow PAs to do the same in Aotearoa New Zealand: diagnose, treat and prescribe with little supervision and without adequate training, rather than fulfilling an “assistant” role. The New Zealand Physician Associate Society and PAs are lobbying strongly for this; look only to the recent article published in this Journal promoting the regulation of PAs, and the disappointing absence of opposing viewpoints in local literature.2
It is concerning that the Ministry is not proposing any method of ensuring PAs are appropriately qualified and trained. For a doctor to practise in Aotearoa New Zealand, they must have an equivalent vocational registration, have passed a recognised medical examination or have worked in a comparable health system in a comparable role. PAs do not meet any of these criteria. It would be dangerous to assume that someone is competent to practise medicine because they are registered and have worked as a PA overseas, since the PA degree is extremely heterogeneous, even between different states of the United States. Formal vocational training for PAs is non-existent; continuing professional development, competencies and supervision requirements are vague and vary wildly between jurisdictions.3
In order to regulate PAs, this heterogeneity would need to be addressed. It is inadequate to consider an overseas PA qualification and registration enough to be able to safely practise medicine, especially in contrast to the strict standards that we (rightly) hold doctors to before granting them registration (which is often initially limited in scope and independence). Even putting aside the convincing anecdotal evidence from the medical community, there is quantitative evidence to suggest PAs would provide substandard care when compared with doctors. PAs appear to more frequently prescribe inappropriate opioids and antibiotics, as well as investigate and refer more often without evident improvement in patient-centred or economic outcomes.4–7
Additionally, there is no guarantee that PAs would work in “hard-to-serve” areas, or that the Ministry is even proposing a mechanism to ensure this. Even if this intention was realised, the lower level of care provided by PAs would unacceptably perpetuate health inequities, given that regions under-served by the health system tend to have a higher Māori population. Regulation would simply establish substandard workforces without adequate cultural competence in regions where workers must be culturally competent: a stark failure to meet Te Tiriti o Waitangi obligations. Importing an entirely overseas-trained workforce in no way addresses the specific cultural needs of Aotearoa New Zealand, and this will be especially detrimental for Māori.
The Ministry should focus on training its existing medical workforce rather than putting funding into a “New Zealand-based training programme” for PAs, which is an intended possible outcome of regulation.1 Not only should the Ministry be increasing medical school numbers as proposed, but there should be guaranteed employment of all locally trained medical students, more NZREX examination spots and funding for more training positions for vocational trainees. The inadequate training opportunities for doctors would certainly be harmed when PAs inevitably move out of “hard-to-serve” communities and attempt to take on roles that were once reserved for trainees.
The medical community should advocate for both our profession and patient safety by opposing the regulation and eventual widespread adoption of PAs into the Aotearoa New Zealand healthcare system. If we fail to do this now, we may be left on the back foot similarly to the United Kingdom, where PAs are being established while the medical profession is playing catch-up to voice their overwhelming concern.8,9 It would be unwise to ignore our colleagues’ warnings as the General Medical Council tries to shortsightedly integrate PAs into clinical practice and effectively grant them the same authority as doctors.
Aotearoa New Zealand is facing a shortage of physicians, not associates or assistants to the physician.
Dr William Park, MBChB (Distinction): House Officer, Te Whatu Ora Capital, Coast and Hutt Valley, Aotearoa New Zealand.
William Park
Nil.
1) Manatū Hauora – Ministry of Health. Regulating the Physician Associate profession under the Health Practitioners Competence Assurance Act 2003 [Internet]. 2023 Jun [cited 2023 Dec 13]. Available from: https://www.mcnz.org.nz/assets/News-and-Publications/Consultations/Ministry-of-Health-PA-Consultation-document.pdf.
2) Oberzil V. Physician associates as a potential win for the Aotearoa New Zealand healthcare workforce. N Z Med J. 2023;136(1583):95-97.
3) American Medical Association. Physician assistant scope of practice [Internet]. 2018 [cited 2023 Dec 13]. Available from: https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/arc-public/state-law-physician-assistant-scope-practice.pdf.
4) Lozada MJ, Raji MA, Goodwin JS, Kuo YF. Opioid Prescribing by Primary Care Providers: a Cross-Sectional Analysis of Nurse Practitioner, Physician Assistant, and Physician Prescribing Patterns. J Gen Intern Med. 2020;35(9):2584-2592. doi: 10.1007/s11606-020-05823-0.
5) Roumie CL, Halasa NB, Edwards KM, et al. Differences in antibiotic prescribing among physicians, residents, and nonphysician clinicians. Am J Med. 2005;118(6):641-648. doi: 10.1016/j.amjmed.2005.02.013.
6) Anderson AM, Matsumoto M, Saul MI, et al. Accuracy of Skin Cancer Diagnosis by Physician Assistants Compared With Dermatologists in a Large Health Care System. JAMA Dermatol. 2018;154(5):569-573. doi: 10.1001/jamadermatol.2018.0212.
7) Hughes DR, Jiang M, Duszak R Jr. A comparison of diagnostic imaging ordering patterns between advanced practice clinicians and primary care physicians following office-based evaluation and management visits. JAMA Intern Med. 2015;175(1):101–107. doi: 10.1001/jamainternmed.2014.6349.
8) Royal College of Anaesthetists. Outcome of the RCoA Extraordinary General Meeting on 17 October 2023 [Internet]. London, England: Royal College of Anaesthetists; 2023 Oct 17 [cited 2023 Dec 13]. Available from: https://www.rcoa.ac.uk/news/outcome-rcoa-extraordinary-general-meeting-17-october-2023.
9) British Medical Association. New survey shows “shocking scale” of concern from doctors over use of physician associates [Internet]. United Kingdom: British Medical Association; 2023 Dec 12 [cited 2024 Jan 7]. Available from: https://www.bma.org.uk/bma-media-centre/new-survey-shows-shocking-scale-of-concern-from-doctors-over-use-of-physician-associates.
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