Substitution of regulated health professionals, such as doctors and nurses, with unregulated health care workers, such as physician assistants, gives rise to concerns around patient safety and accountability issues: No
Allan R. Moffitt
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| While evidence can help inform best practice, it needs to be placed in context. There may be no evidence available or applicable for a specific patient with his or her own set of conditions, capabilities, beliefs, expectations and social circumstances. There are areas of uncertainty, ethics and aspects of care for which there is no one right answer. General practice is an art as well as a science. Quality of care also lies with the nature of the clinical relationship, with communication and with truly informed decision-making. The BACK TO BACK section stimulates debate, with professionals presenting their opposing views regarding a clinical, ethical or political issue. |
Introduction
Integrating non-registered healthcare providers, such as pahysician associates (PAs), into primary healthcare settings has garnered attention for its potential to enhance access to care, improve patient outcomes, and alleviate the burden on registered healthcare professionals. However, concerns regarding patient safety and accountability have been raised amidst these benefits. The same issues apply to other workforce groups such as healthcare assistants (also known as clinical or medical centre assistants1) and health coaches.2,3
Extending the primary care team to non-regulated roles is not a panacea for general practice’s current workforce crisis. These roles will not replace general practitioners (GPs) or nurses. We still need to grow the medical/nursing workforce in primary care, but the reality is that we are facing a global doctor shortage that will only worsen over the coming decade.4 It is not an option but a necessity to consider substitution to alleviate pressure on GPs, nurse practitioners (NPs), and practice nurses (PNs) and delegate to non-regulated roles in our care teams. The question is, ‘How do we do this safely?’.
Despite recent anecdotes from the UK, evidence is clear that PAs are safe and achieve equivalent outcomes to GPs.5–7 The extension of the primary care team and the move to interdisciplinary team care is a global phenomenon8–10 because teams consistently outperform individuals. The added value these roles deliver is explored below.
The value of physician associates in primary health care
Bridging the gap in healthcare access:
Many regions have a shortage of GPs and nurses, leading to long appointment wait times and limited access to healthcare services.
PAs can alleviate this by providing essential primary care services. 10, 11
Integrating PAs into primary care settings increases patient access to timely, quality healthcare services, 10, 11 thereby improving health outcomes. However, the people seen must know they are consulting with a PA not a doctor. 12, 13
Enhancing interprofessional collaboration:
Trained to work collaboratively with other healthcare professionals, including physicians, nurses and allied health professionals, PAs foster a team-based approach to patient care. 10
Interprofessional collaboration enhances the efficiency of healthcare delivery, promoting knowledge-sharing and continuous learning among healthcare team members. 5, 14
Improving continuity of care:
PAs often develop long-term relationships with whānau, providing continuity of care essential for managing chronic conditions and preventative care.
Their availability for same-day appointments and extended clinic hours can help reduce emergency department visits and hospital admissions for non-urgent conditions, resulting in cost savings for healthcare systems.
PAs, in addition to other non-regulated roles such as healthcare assistants 1 and health coaches, 2, 3, 15– 17 kaiāwhina/kaimanāki whānau 18– 21 augment the team to provide more comprehensive and holistic care that can be culturally congruent. This assists to connect with people by providing better engagement. 19, 20, 22 They are also able to spend more time with the person and whānau in between visits.
These roles can also address the social and other determinants of health that impact whānau and therefore help address inequity. 19– 21
Extending the primary care team improves access,11,13 saves regulated professionals’ time,11,13 and improves care outcomes without sacrificing patient experience.23,24
Various systematic reviews25–27 have shown that quality of care is not significantly different to physician-only care. The quality of care delivered by a PA was comparable to a physician’s care, as demonstrated in 15 studies,27 and exceeded that of a doctor in 18 studies. This also holds true for detailed observational studies.28 In the Veteran Affairs organisation (USA), a year of care for adults with diabetes, provided by NPs and PAs achieved the same or better outcomes at a substantially cheaper cost than solely medical care.29
Addressing concerns and mitigating risks
Supervision and oversight:
Set aside time, as the level of supervision required to oversee PAs’ clinical practice and decision-making is demanding, especially for the newly graduated.30
Allow longer consultations for the first 6 months (as for new NPs), but after this, they should be able to see people at similar intervals to GPs.31 On average, PAs spend 5 min longer with patients than GPs do.32
Use the ‘Teamlet’ model of care15 to facilitate supervision, with time set aside for pre-consult huddles, pre-visit sessions with a health coach or PA, and post-visit sessions producing a treatment plan (summary).
Establish clear protocols, guidelines, and communication channels,30,33 between PAs and supervising GPs to ensure appropriate supervision and enhance patient safety.
Regular performance evaluations, peer reviews, and continuing education opportunities further contribute to PAs’ accountability and competence in delivering high-quality care.
Standardisation of training and education:
Standardisation of education and training programmes addresses concerns about variability in PA training and competencies.13,30,33,34
This is best achieved through the accreditation of PA programmes by regulatory bodies and adherence to competency-based curricula to ensure that PA competencies align with established professional standards.10
In the USA, ongoing professional development and certification requirements help PAs stay abreast of advancements in healthcare and maintain competency in their practice.10 Such programmes would need to be developed and established in NZ.
Integration into collaborative care models:
Integrating PAs into collaborative care models that emphasise teamwork, communication, and shared decision-making promotes a culture of safety and accountability.
It is essential that all team members (and patients) understand the PA role, its scope, capabilities, and limitations.13,30,33,35
Emphasise interdisciplinary team meetings, case conferences, and regular feedback sessions to facilitate effective communication and coordination of care among healthcare team members.
Patient education and involvement in shared decision-making processes to improve patient self-efficacy in managing their long-term conditions will contribute to safer healthcare practices, as does medicine reconciliation.
Conclusion
PAs play a valuable role in primary healthcare by expanding access to care, enhancing interprofessional collaboration, and improving patient continuity of care. Although patient safety and accountability concerns exist, proactive measures including appropriate supervision, standardised training, and integration into collaborative care models, good communication and coordination, can mitigate associated risks. Embracing the contributions of PAs and supporting their professional development are essential steps toward building a resilient and patient-centred primary healthcare system.
A recent summary of the evidence entitled ‘Who’s who in General Practice? Research can help practices introduce new roles,’36 summed it up nicely and I would recommend colleagues read this.
Data availability
Data sharing is not applicable as no new data were generated or analysed during this study.
Conflicts of interest
The author is employed as a Clinical Director of ProCare Health (PHO) Ltd. The author declares no other conflicts of interest.
References
1 Clark TL, Fortmann AL, Philis-Tsimikas A, et al. Process evaluation of a medical assistant health coaching intervention for type 2 diabetes in diverse primary care settings. Transl Behav Med 2022; 12(2): 350-361.
| Crossref | Google Scholar | PubMed |
2 Bosley S, Dale J. Healthcare assistants in general practice: practical and conceptual issues of skill-mix change. Br J Gen Pract 2008; 58(547): 118-124.
| Crossref | Google Scholar | PubMed |
3 Reich K, Butterworth SW, Coday M, et al. Integrating Lay Health Coaches into Primary Care: acceptability, credibility, and effectiveness from the provider perspective. Cureus 2022; 14(5): e25457.
| Crossref | Google Scholar | PubMed |
4 Clarke A. 2021 GP Future Workforce Report. 2021. [cited 4 February 2024]. Available at https://www.rnzcgp.org.nz/documents/6/2021-GP-future-workforce-report-FINAL.pdf]
5 Everett C, Christy J, Batchelder H, et al. Impact of primary care usual provider type and provider interdependence on outcomes for patients with diabetes: a cohort study. BMJ Open Qual 2023; 12(2): e002229 PMCID: PMC10277144.
| Crossref | Google Scholar | PubMed |
6 Everett C, Thorpe C, Palta M, et al. Physician assistants and nurse practitioners perform effective roles on teams caring for Medicare patients with diabetes. Health Aff (Millwood) 2013; 32(11): 1942-1948 PMCID: PMC3909681.
| Crossref | Google Scholar | PubMed |
7 Yang Y, Long Q, Jackson SL, et al. Nurse Practitioners, Physician Assistants, and Physicians are comparable in managing the first five years of diabetes. Am J Med 2018; 131(3): 276-283.e2 PMCID: PMC5817031.
| Crossref | Google Scholar | PubMed |
8 Dankers-de Mari EJCM, van Vught AJAH, Visee HC, et al. The influence of government policies on the nurse practitioner and physician assistant workforce in the Netherlands, 2000-2022: a multimethod approach study. BMC Health Serv Res 2023; 23(1): 580 PMCID: PMC10242803.
| Crossref | Google Scholar | PubMed |
9 Pany MJ, Chen L, Sheridan B, et al. Provider teams outperform solo providers in managing chronic diseases and could improve the value of care. Health Aff (Millwood) 2021; 40: 435-444 PMCID: PMC9166311.
| Crossref | Google Scholar | PubMed |
10 Hooker RS, Kuilman L. Physician Assistant Practice around the world. J Am Acad Physician Assist 2020; 33(9): 14-18.
| Google Scholar |
11 Moote M, Krsek C, Kleinpell R, et al. Physician Assistant and Nurse Practitioner utilization in academic medical centers. Am J Med Qual 2019; 34(5): 465-472.
| Crossref | Google Scholar | PubMed |
12 Howarth SD, Johnson J, Millott HE, et al. The early experiences of Physician Associate students in the UK: a regional cross-sectional study investigating factors associated with engagement. PLoS One 2020; 15: e0232515.
| Crossref | Google Scholar | PubMed |
13 Gibson J, McBride A, Checkland K, et al. General practice managers’ motivations for skill mix change in primary care: results from a cross-sectional survey in England. J Health Serv Res Policy 2023; 28(1): 5-13 PMCID: PMC9850398.
| Crossref | Google Scholar | PubMed |
14 Roland M, Barber N, Howe A, et al. The future of primary care creating teams for tomorrow. Report by the Primary Care Workforce Commission. Health Education England. July 2015. [cited 4 March 2024]. Available at https://napc.co.uk/wp-content/uploads/2017/09/Future_of_primary_care.pdf]
15 Bodenheimer T, Laing BY. The teamlet model of primary care. Ann Fam Med 2007; 5(5): 457-61 PMCID: PMC2000308.
| Crossref | Google Scholar | PubMed |
16 Scheinbaum S. Health coaching in primary care: considerations for collaborative practice. Spring: Holistic Primary Care; 2018. 19(1). 4. https://holisticprimarycare.net/topics/practice-development/health-coaching-in-primary-care-considerations-for-collaborative-practice/
17 Irving M, Mortensen N, Wallace M, et al. In adults with type 2 diabetes mellitus, does the addition of a health coach to the primary care team improve outcomes compared with usual care? Evidence-Based Pract 2022; 25(4): 1-2 Irving.
| Crossref | Google Scholar |
18 Selak V, Stewart T, Jiang Y, et al. Indigenous health worker support for patients with poorly controlled type 2 diabetes: study protocol for a cluster randomised controlled trial of the Mana Tū programme. BMJ Open 2018; 8: e019572.
| Crossref | Google Scholar |
19 Harwood M, Tane T, Broome L, et al. Mana Tū: a whānau ora approach to type 2 diabetes. N Z Med J 2018; 131(1485): 76-83.
| Google Scholar | PubMed |
20 Tane T, Selak V, Hawkins K, et al. Māori and Pacific peoples’ experiences of a Māori-led diabetes programme. N Z Med J 2021; 134(1543): 79-89.
| Google Scholar | PubMed |
21 Hartzler AL, Tuzzio L, Hsu C, et al. Roles and functions of community health workers in primary care. Ann Fam Med 2018; 16(3): 240-245 PMCID: PMC5951253.
| Crossref | Google Scholar | PubMed |
22 Chima CC, Swanson B, Anikpezie N, et al. Alleviating diabetes distress and improving diabetes self-management through health coaching in a primary care setting. BMJ Case Rep 2021; 14(4): e241759 PMCID: PMC8061809.
| Crossref | Google Scholar | PubMed |
23 Halter M, Drennan VM, Joly LM, et al. Patients’ experiences of consultations with physician associates in primary care in England: a qualitative study. Health Expect 2017; 20(5): 1011-1019 PMCID: PMC5600217.
| Crossref | Google Scholar | PubMed |
24 Hooker RS, Moloney-Johns AJ, McFarland MM. Patient satisfaction with physician assistant/associate care: an international scoping review. Hum Resour Health 2019; 17: 104.
| Crossref | Google Scholar | PubMed |
25 van den Brink GTWJ, Hooker RS, Van Vught AJ, et al. The cost-effectiveness of physician assistants/associates: a systematic review of international evidence. PLoS One 2021; 16(11): e0259183 PMCID: PMC8559935.
| Crossref | Google Scholar | PubMed |
26 Sheringham J, King A, Plackett R, et al. Physician associate/assistant contributions to cancer diagnosis in primary care: a rapid systematic review. BMC Health Serv Res 2021; 21(1): 644 PMCID: PMC8254243.
| Crossref | Google Scholar | PubMed |
27 Halter M, Drennan V, Chattopadhyay K, et al. The contribution of physician assistants in primary care: a systematic review. BMC Health Serv Res 2013; 13(1): 223.
| Crossref | Google Scholar | PubMed |
28 de Lusignan S, McGovern AP, Tahir MA, et al. Physician associate and general practitioner consultations: a comparative observational video study. PLoS One 2016; 11(8): e0160902.
| Crossref | Google Scholar | PubMed |
29 Smith VA, Morgan PA, Edelman D, et al. Utilization and costs by primary care provider type: are there differences among diabetic patients of Physicians, Nurse Practitioners, and Physician Assistants? Med Care 2020; 58(8): 681-688.
| Crossref | Google Scholar | PubMed |
30 Cottrell E, Silverwood V, Strivens-Joyce A, et al. Acceptability of physician associate interns in primary care: results from a service evaluation. BMC Fam Pract 2021; 22(1): 250.
| Crossref | Google Scholar | PubMed |
31 Brooks PB, Fulton ME. Driving high-functioning clinical teams: an advanced practice registered nurse and physician assistant optimization initiative. J Am Assoc Nurse Pract 2020; 32(6): 476-487.
| Crossref | Google Scholar | PubMed |
32 Drennan VM, Halter M, Joly L, et al. Physician associates and GPs in primary care: a comparison. Brit J Gen Pract 2015; 65(634): e344-e350.
| Crossref | Google Scholar | PubMed |
33 Brown M, Laughey W, Finn GM. Physician Associate students and primary care paradigmatic trajectories: perceptions, positioning and the process of pursuit. Educ Prim Care 2020; 31(4): 231-239.
| Crossref | Google Scholar | PubMed |
34 Howarth SD, Storr E, Lenton C, et al. Implementing the Safe and Effective Clinical Outcomes (SECO) simulation to prepare physician associate students for practice. Educ Prim Care 2019; 30(6): 387-391 AN: 140355186.
| Crossref | Google Scholar | PubMed |
35 Nelson PA, Bradley F, Martindale A-M, et al. Skill-mix change in general practice: a qualitative comparison of three ‘new’ non-medical roles in English primary care. Br J Gen Pract 2019; 69(684): e489-e498.
| Crossref | Google Scholar | PubMed |
36 Roland M, Barber N, Howe A, et al. Who’s who in General Practice? Research can help practices introduce new roles. Health and Social Care Services Research; 2023. 10.3310/nihrevidence_61223
