The physician assistant: would the US model meet the needs of the NHS?

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Abstract
The US physician assistant In the 1960s a shortage of primary care medical providers in the United States, especially in the rural and urban underserved communities, coincided with the return of military servicemen who had delivered medical care in Vietnam but were “unqualified.” One solution was to train these men quickly and allow them to work under the supervision of a physician. Dr Eugene Stead, an advocate for a new breed of healthcare worker, created the first training programme for physician assistants in North Carolina in 1965. Four former Navy corpsmen enrolled. From this, the profession has grown to over 45 000 practitioners, 55% of whom are women.6 This compares with 2 697 000 registered nurses (95% women), 196 000 nurse practitioners (data on proportion of women not available),7 and 778 000 physicians (23% women).8 Half of all physician assistants work in primary care; others work in emergency care, surgery, orthopaedics, and other specialties (box 2).9 Most applicants today are not former military personnel but school leavers or health professionals who have made an early decision to become physician assistants. They have decided against medical school, trading some future income and additional prestige for lifestyle factors such as a more defined schedule and fewer hours on call. Physician assistants are dependent practitioners, always working under the supervision (direct or by telephone) of a designated physician. Physicians may delegate to physician assistants only those medical duties that are within their scope of practice (box 3). Box 2 : Real examples of role of physician assistants Primary care The Howard City Medic One Clinic is a family medicine clinic in an underserved rural region of Michigan. An advanced practice nurse and a physician assistant routinely staff the clinic. A general practice doctor is on site for a day and a half each week and otherwise available for consultation via email and telephone. The practitioners on site provide medical care for the entire range of outpatient conditions from “well child” check ups to emergency treatment of myocardial infarctions and surgical conditions before transport to hospital. The Kentwood Family Medicine Center in suburban Grand Rapids, Michigan, is staffed by a team of five physicians in private practice, one physician assistant, one advanced nurse practitioner, and junior doctors at various levels of training. All patients are private patients who select the centre as the site for their medical care; reimbursement for services follows the traditional US model. The physician assistant and advanced nurse practitioner provide health maintenance and preventive care, diagnose and treat minor illness, provide prenatal care, and perform routine follow up care for illness and surgery. In addition, the centre provides instruction to medical students, physician assistant students, and advanced practice nursing students during the clinical experience part of their training. Secondary care The urology service at Spectrum Health Medical Center in Grand Rapids is staffed by 12 trained urologists (consultants and surgeons) and two physician assistants. In addition, the medical centre provides nursing services, and medical students, postgraduate physician assistants pursuing additional training in the surgical services, and junior doctors training in surgery provide medical care. The physician assistants on the unit provide preoperative care (including presurgical histories and physical examinations), assist in surgery, and provide postoperative care. The emergency department at St Mary's Mercy Medical Center is staffed at all times by three to five board specialty trained physicians in emergency medicine, an advanced practice nurse, and a physician assistant. As a training health facility, the department also has medical, nursing, and physician assistant students. In this setting the mid-level practitioners provide care such as first response at trauma cases, diagnosis and treatment of illnesses commonly seen in community clinics, repair of uncomplicated lacerations, and treatment of minor fractures and sprains. RETURN TO TEXT Training There are 126 accredited educational programmes throughout the United States. 6 10 The typical programme lasts 24 months, but the range from 11 to 51 months reflects widely varying entry requirements and qualifications awarded (table 1).10 Most programmes require some previous healthcare experience. The training offered in a typical physician assistant programme (see box on BMJ's website) is strikingly similar to a condensed traditional medical course. Programmes vary in the degree or credential awarded at the end of training, with an increasing trend towards masters degrees. Box 3 : Typical tasks performed by physician assistants Taking histories Performing physical examinations Making clinical diagnoses Ordering and interpreting laboratory tests Suturing Applying casts Assisting at surgery Educating patients Making rounds in nursing homes and hospitals RETURN TO TEXT View this table: In this window In a new window Table 1. Table 1. Differences between physician assistants and nurse practitioners in the United States10-13 Students take a national board certification examination before graduation, and success in this is a requirement for licensure in most states. To maintain certification, 100 hours of continuing medical education every two years must be documented and a recertification examination must be passed every six years.11 Conflicts and difficulties Several factors have affected and continue to affect the profession. The relationship with physicians is a major issue. Despite increasing acceptance of the value of physician assistants to healthcare teams considerable opposition remains to non-physicians providing any medical care, especially diagnosis and treatment. 14 15 Competition in a system oversupplied with physicians seems to be the main concern.14 The...