Myth busting common claims around the use of Physician Associates
“Physician Associates (PAs) are already here and practising in New Zealand so we should regulate them.”
The purpose of regulating health practitioners is to protect the public from risk of harm, not simply because a profession exists. Regulation alone cannot compensate for the lack of medical training and clinical competence required to practice safely. More importantly, regulation should be driven by the evidence base, not swayed by the interest of a small overseas-trained group who have been allowed to work in Aotearoa.
Health workforces must exist to meet a population need, and ultimately PAs are not a workforce we need. They are not aligned with our national Health Workforce Plan, nor can they act as a substitute to fill our very real doctor, nurse, and AST shortages.
Regulation also gives confidence to the public which may be misplaced given the confusion of what a PA is, what training they have and that they are not a doctor.
To proceed would be a sunk cost fallacy, with regulation cementing in known risks to patient safety. It is better to cut our losses with this experiment. If this is genuinely about public safety, we are safer investing in existing regulated workforces that have the required training and accountability mechanisms and supporting PAs to retrain to fill these crucial workforce gaps.
“PAs provide a cheaper workforce alternative to plug the workforce gaps”
Our population’s increasingly complex health needs require more qualified medical practitioners, not the cheapest skill mix. We cannot save our way out of a health crisis. Historically, efforts to ‘sovietise’ medicine by paring away at established professional training pathways and introducing assistant roles, result in worse population health outcomes.[1]
Claims that PAs are a cheaper alternative are also unsubstantiated and may represent a false economy. Evidence on PA productivity and efficiencies is mixed, and where there may be marginal savings in hiring costs, this is frequently offset by their longer consultation times and additional supervision requirements.
Importantly, there is no robust conclusive evidence on patient safety and effectiveness of care by PAs.[2],[3] The UK is only now going through the process of establishing this evidence base through an independent review – some twenty years after PAs have been allowed to practice. There is no reason we need to follow this backwards logic when we know this is not an effective nor sustainable workforce solution.
“Any health practitioner is better than none”
We have a shortage of health professionals, not health professions. There is no ‘value add’ in employing PAs because there is nothing a PA can do that doctors, nurses, or AST professionals cannot. But there is enormous risk with employing them, as we have already established.
In rural areas, where PAs are most likely to be deployed, this can perpetuate inequities in terms of who gets to see an actual doctor and increase harm to patients in vulnerable communities.[4] This also creates a postcode lottery of health, which is precisely what our centralised our health system was designed to avoid.
“PAs have been used overseas”
Where PAs have been employed overseas, this has been in entirely different sociopolitical contexts than Aotearoa.
In the UK, which has the most similar universal healthcare system to ours, the use of PAs has proved to be a failed experiment and an ‘unqualified mess’.[5] Following a series of patient deaths and adverse events, and fuelled by vocal opposition by the medical profession, the government is now independently reviewing the use of PAs.
Where this has had slightly more success in the US, the expansion of PAs has largely been driven by the profit-seeking goals of private health providers operating in a ‘user pays’ health system.[6] Most New Zealanders would not want to see the US health system being adopted here.
Ultimately, this model of “care” does not fit with our values of equitable and accessible health for all.
“We’ve had PA pilots in NZ”
The two PA pilots in New Zealand provide limited evidence that they are the best option for meeting our population health needs. These pilots have also been critiqued for their flawed methodology and resulting conclusions, particularly because of the small sample sizes – in some cases just two PAs.[7] The evaluation itself states that “the two experiences of Middlemore Hospital are not conclusive in terms of gains for the health sector or return of investment”.[8] We are yet to be presented with a robust case for their regulation.
“But this is helping GPs”
The PA model of practice fragments medical work into a conveyer belt where doctors are allocated only the most complex and difficult cases. Not only does this strip doctors’ work off meaningful and genuine connection with patients, but it disrupts continuity of care making the process more error prone and contributes to burnout of the medical workforce. In fact, evidence shows that the use of PAs increases doctor workloads and comprises the training and supervision of our future medical workforce.[9],[10]
Claims about the utility of PAs in New Zealand have been less substantiated. While the CE of a medical centre in Gore has been a vocal champion for the use of PAs, two doctors have since quit this clinic over concerns around patient safety being at risk. Moreover, his claims that there have been “no clinical complaints” about the PAs have since been proven false, with reports of patient harms and adverse outcomes also emerging.[11]
“Doctors are just ‘jealous’”
The same CE whose claims have since been disproven, also alleges that the opposition to PA regulation in NZ is driven by “jealousy” and “patch protection”.[12] This could not be further from the truth.
Doctors have spent their entire medical career being trained to make evidence-based decisions and to prioritise patient safety. The rush to PA regulation in New Zealand violates both these fundamental professional values.
This is less about “patch protection” and more about patient protection.
References
[1] McKee (2024) McKee, M. (2024). The Sovietisation of British medicine. Journal of the Royal Society of Medicine, 117(6), 192-196.
[2] Andrew (2024) Andrew, A. (2024). Exploring the role of physician associates in Aotearoa New Zealand primary health care. Journal of Primary Health Care, 16(2): 210-213. doi: 10.1071/HC23134
[3] Halter, M., Drennan, V., Chattopadhyay, K., Carneiro, W., Yiallouros, J., de Lusignan, S., … & Grant, R. (2013). The contribution of physician assistants in primary care: A systematic review. BMC Health Services Research, 13, 1-13.
[4] Council of Medical Colleges New Zealand. (2023). Response to Consultation on Proposal to regulate the Physician Associate profession, 20 December 2023. Retrieved https://www.cmc.org.nz/media/yaiaegn5/pa-consult-cmc-response.pdf
[5] Kar, P. (2023). Sorting out the mess around medical associate professionals. BMJ: British Medical Journal (Online), 383, p2689. doi: 10.1136/bmj.p2689
[6] Ferreira, T. (2024). The role of the physician associate in the United Kingdom. Future Healthcare Journal, 11(2), 100132-100132. doi: 10.1016/j.fhj.2024.100132
[7] New Zealand Nurses Organisation (NZNO). (2012). Critical Review of the final Evaluation of the HWNZ Physician Assistant Demonstration Pilot, Counties Manukau DHB. Retrieved https://www.nzno.org.nz/Portals/0/publications/Critical%20review%20of%20final%20Evaluation%20of%20the%20Physician%20Assistant%20pilot%202012.pdf
[8] New Zealand Nurses Organisation (NZNO). (2014). What gap is physician assistant role filling? Kai Tiaki Nursing New Zealand, 20(11).
[9] Wise, J. (2024). Physician associates increase doctors’ workloads, survey finds. BMJ (Clinical Research Ed.), 384, q291-q291.
[10] The Association of Surgeons in Training (ASIT). (2024). The physician associate role and its impact on surgical training and patient care. ASIT report, January 2024. Retrieved https://www.asit.org/media/gb3g3z0m/asit-physician-associate-report-2024-v2.pdf
[11] Shaw, R. (2024). Doctors quit amid patient safety risk disagreement. Otago Daily Times, 25 November 2024. Retrieved https://www.odt.co.nz/southland/doctors-quit-amid-patient-safety-risk-disagreement
[12] Hepburn, S. (2024). Roles vital to system, Metzler says. Otago Daily Times, 30 October 2024. Retrieved https://www.odt.co.nz/southland/the-ensign/roles-vital-system-metzler-says