The contemporary US Physician Assistant (PA) profession arose in the United States of America (US) from a critical need to augment and redistribute the medical workforce in the turbulent mid-1960s. They were then the latest iteration of a model of “delegated practice” which had many historical predecessors dating as far back as the Feldshers in the 17th Century, a Russian military medical assistant model taken up by Peter the Great for the Russian armies.1 It seems little is new under the sun, just an evolution of ideas and concepts to meet the needs of the time. The American Academy of Physician Assistants (AAPA) provides a concise definition that illustrates how the physician assistant undertakes some of the responsibilities previously only granted to medical practitioners:
“Physician assistants are clinicians who are licensed throughout the United States to practice medicine in association with physicians*. They perform many of the tasks previously done solely by their physician partners, including examination, diagnosis, and carrying out investigations, as well as treatment and prescribing. All physician assistants must be associated with a physician and must practice in an interdependent role, described as “negotiated performance autonomy”.2
PAs practice to a skill set that is delegated by the supervising physician and although there is a legislative framework in all 50 states and the federal government, their role is a negotiated and delegated one between physician and PA. Supervision does not necessarily require the physical presence of a physician at the place where services are rendered.2 Initially involved in primary care the role has evolved to specialist care and grown dramatically in areas like emergency medicine, orthopaedics and cardiovascular surgery. The profession experienced an initial period of rapid growth during the 1970s and then substantial expansion in the early 1990s that continues today. The US Bureau of Labor Statistics predicted a 49% growth in PA jobs in the 10 years between 2002 and to 2012 and physician assistants are now the third-fastest growing professional group in the country.3 There are approximately 74,000 practicing PAs throughout the country (compared to 700,000 physicians).2 Not unlike the trend in medicine, there has been a significant gender shift in the PA profession since its inception. Of currently registered PAs, 61% are female and the ratio is nearly 3:1 for PA students.2, 4
Physician Assistants in the US Military
A link between PAs and the US military can be construed as occurring long before US involvement in the Vietnam conflict. In 1942, in the midst of World War II, Dr. Eugene Stead, then the Dean of Emory University Medical School, was asked by the US government to develop an accelerated medical education program to supply doctors for the war effort.5 He created a successful three-year program and this experience with condensed medical education would become the educational cornerstone of the PA concept when he initiated the first PA program at Duke University in 1965.5 Early physician assistant educational programs principally recruited returning military medics and corpsman from the conflict in Vietnam. The experience of these returning armed forces personnel and their medical officers provided a supportive population for the introduction into the civilian sector of an experienced and skilled health workforce. The intent was to take this predominantly male cohort of veterans with hands-on clinical experience, often in combat and highly adverse circumstances, and rapidly bring them into the primary care workforce. In particular, the focus of this new profession was on the unmet healthcare needs of underserved rural, inner city and indigenous communities. The intense training was attractive to ex-medics, who were used to hard work and had the inculcated discipline necessary to absorb such large amounts of information in such a short period of time.
The US military began to make use of physician assistants in 1971.6 There are a number of important reasons the PA concept gained a foothold in the armed services, but the crucial one was the termination of the draft and obligated service for physicians in 1973.6
Allan Forde and Dennis Pashen * The terms physician and doctor are used interchangeably in the USA to indicate medical practitioner. For the purpose of this paper physician is meant to be inclusive of Australian doctors and physician medical specialists
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An exodus of junior doctors combined with a serious recruiting deficit, at least partially driven by the developing fee-for-service marketplace, led to a much greater reliance on PAs.6 Of note, Canadian Forces have also been utilising a “mid-level” provider for over 50 years and with up-skilling began to produce what they called physician assistants in 1984.7 Canada now has a civilian PA career track and education system. The close relationship between Physician Assistants and the US Armed Forces remains strong in 2009. Military PAs serve as commissioned officers and most have received their training from the Inter-service PA Program (IPAP) at the US Army Academy of Health Sciences in San Antonio, Texas.6,8 Currently, a workforce of more than 1700 active duty and reservist PAs in the military serve as the backbone of primary care and support some 1,500,000 active duty and 1,260,000 reserve and National Guard personnel.6,8 Their medical duties also span a wide variety of specialties and tactical assignments from the more typical clinic and hospital work to ships and forward combat hospitals. While continuing to maintain delegated practice, the role of PAs in combat theatres has expanded to the point that in many instances they have replaced physicians as the front-line care providers.8 PAs are now being promoted to field grade ranks and some are assuming command of clinics, medical units and even mobile combat support hospitals.8, 9
A Case for PAs in Australia
The physician assistant model as a potential strategy to address medical workforce shortages and maldistribution has gained considerable interest and acceptance among many in the Australian healthcare system. A March 2008 research paper on PAs by the Australian Department of Parliamentary Services Librarians concluded “there is potential to adapt this model to suit the Australian health system so that quality of care and safety in the delivery of services is not compromised”.10 The state health departments of Queensland and South Australia are currently exploring the concept further, each with 12 month pilot programs employing 14 US PAs in a variety of clinical settings in Adelaide, Brisbane, Mt Isa and Cooktown. The University of Queensland (UQ) and James Cook University (JCU) medical schools are actively developing PA programs. Both universities will have degree curriculums. The University of Queensland has launched their first intake in July 2009. Similar to the US education model, candidates will be recruited from those with a first degree in a biological science or health field and from the ranks of experienced and properly prepared healthcare workers. Becoming a PA would serve as a much needed career path and means of advancement for skilled medical technicians. Professionals such as ambulance officers, military medics and various allied health workers who are looking for a change in direction or the ability to extend their contribution in the clinical arena would benefit. Leaders in the Australian Defense Force (ADF) and Centers for Veterans and Military Health (CMVH) are attracted by the possibility that up-skilling may serve as a retention tool for military medics (Professor Nikki Ellis, Director, Centre for Veterans and Military Health 16 DEC 2008, Personal Communication). Mature candidates would bring a wealth of past life experience as well as professional skills from their particular disciplines to the PA role. Representatives from CVMH are currently members of the UQ PA program Steering Committee.
Conclusion
Physician Assistants have been an integral part of the US military for a number of years. They have continued to have relevance both in internal military application along with Medics and as a post-military career choice option. Australia has similar issues to which the use and application of the PA model can provide similar answers. However it must be recognised that there are fundamental differences between both health systems which would mean that the model of application of PAs in Australia would need to be an Australian Model similar to, but not necessarily the same as that from the US.