Physician assistants
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7339.735 (Published 23 March 2002) Cite this as: BMJ 2002;324:735
Many general practitioners would welcome having physician assistants
- Mike Gavin, research associate in primary care. (mike.gavin{at}man.ac.uk)
- Rusholme Academic Unit, School of Primary Care, Rusholme Health Centre, Manchester M14 5NP
- Western Michigan University, Kalamazoo, MI 49009, USA
EDITOR—The possibility of creating an American style, intermediate medical practitioner or physician assistant role has been too long ignored in debates about shortages of trained medical staff in the NHS. In casting doubt on the appropriateness of this particular approach, however, Hutchinson et al lamentably fail to appreciate the scale of the problems currently faced by the NHS in providing effective primary medical care.1
They state that more than half of all doctors are general practitioners. Not so. Half of all medical graduates may eventually finish their careers as general practitioners—an artefact of the way the medical labour market is organised—but general practitioners currently make up about 31% of all doctors.2 The number as a proportion of the medical workforce has been falling for years; and research examining the career preferences of junior doctors suggests that the difficulties may soon get worse.3
Problems of recruitment in general practice, as the authors observe, are particularly acute in inner cities, which have never had much “doctor appeal.” The backbone of the medical labour force in such neighbourhoods has come from the ranks of doctors who qualified in south Asia. More than 60% of this group will shortly reach retirement age. Who will replace them?4
The government's current strategies aimed at addressing the undersupply of general practitioners, such as increasing places at medical school and offering doctors cash, either to enter general practice or delay retirement, are seriously flawed.5 Much more radical solutions are called for. The idea of physician assistants is a radical one, and it is time it was given serious consideration. It certainly deserves to be piloted and evaluated.
Recruitment of general practitioners is at crisis point. The creation of physician assistants could help reverse this situation. It would be a great shame if rhetoric about the need for “seamless care” and the breaking down of professional boundaries were to hamper efforts to establish a physician assistant role in the NHS and get in the way of providing effective medical care, especially among deprived populations.
The physician assistant role has been an overwhelming success in the United States. There is no reason why it could not be so here, given good will and the desire to see it succeed.5 My own research among general practitioners clearly indicates that they would regard physician assistants as a welcome addition to the primary care team.
American idea of physician assistants can be anglicised
- William H Fenn, professor. (fenn{at}wmich.edu)
- Rusholme Academic Unit, School of Primary Care, Rusholme Health Centre, Manchester M14 5NP
- Western Michigan University, Kalamazoo, MI 49009, USA
EDITOR—As a physician assistant educator from the United States completing a sabbatical with a medical school in the United Kingdom and the NHS, I am well placed to comment on Hutchinson et al's article.1
Shaw's concept of “two countries separated by a common language” applies to the United States and the United Kingdom. The education of doctors in the United States takes eight years from the time they leave school to the time they graduate from medical school. The article states that the education of physician assistants takes six years. With few school leavers becoming physician assistants, however, a better figure is the average length of core professional education for physician assistants (24-25 months)2; this is shorter than the evolving four year graduate entry programmes in medical schools in the United Kingdom.
Differences in the length of programmes reflect differences in the countries' overall education systems, not substantial variation in core training for physician assistants. American degree standards are less consistent then British ones, and assessment of experiential learning is uncommon. Education of physician assistants is competence based (not degree based) and accredited as such3; this matches the NHS plan's “skills escalator” concept (para. 9.18).4
The authors note that physician assistants neither “perform … tasks of other therapists” nor “remove professional boundaries or barriers to expanding scope of practice.” While some physician assistants perform such tasks (for example, rural physician assistants can perform basic x ray examinations in the absence of a radiographer), this is not a core function. The authors regard this negatively; it perpetuates a confusing blurring of new roles identified by the NHS plan and the Royal College of Physicians.5
Importantly, the call for a “healthcare practitioner” (para. 9.15), analogous to American physician assistants, addresses one set of needs (access to primary care, junior doctor issues) whereas the “assistant practitioners” concept addresses needs of “other areas” (for example, shortages in the professions allied to medicine) (para. 9.14). A justifiable concern is that an overly generic practitioner, simultaneously combining the American physician assistant core with multiple assistant (profession allied to medicine) practitioner roles, might be a dangerous “Jack of all trades, master of none.” The concept of healthcare practitioner in the United Kingdom must be evaluated solely against needs that it is intended to address. Physician assistants have proved their worth and flexibility in the United States but are not the solution to all ills.
Simply importing an American physician assistant “package” would not be an ideal British solution, but evidence suggests that physician assistants can be suitably anglicised to patients' benefit—presumably this is the ultimate goal.
References
- 1.
- 2.
- 3.
- 4.
- 5.