Physician Assistants Going Global

In the United States in the early 1960s, there was a realization that there was a shortage, as well as an uneven distribution of primary care physicians, so people began looking to other options to fill the need. In 1964, Dr. Eugene Stead of Duke University Medical Center in North Carolina proposed a two-year experimental program for former military medical corpsmen, which would utilize their training and experience, and further develop them into being mid-level civilian medical practitioners. This innovative program was instituted at Duke in 1965. Some 43 years later, at the beginning of 2007, the American Academy of Physician Assistants (AAPA) reports that there are 63,609 Physician Assistants in practice, and 163 accredited programs in the USA.

Proponents cite many benefits to having PAs in a healthcare system. By managing routine, chronic, and follow-up patient care, and providing patient education, they allow doctors to handle the more complicated cases and cases requiring care beyond a PA's scope of practice. They're also less expensive than doctors.

Now, four decades after the pilot project at Duke, other countries are seeing the value of PAs and instituting their own training programs.

Canada

The earliest to catch on were the Canadians. Though PAs in civilian settings are new, the Canadian Forces (CF) have been employing PAs since 1984. The CF's two-year PA training program has been accredited only since 2004 – perhaps not surprising, since the Canadian Medical Association (CMA) did not recognize PAs as a distinct healthcare profession until 2003. As in the United States, the CF initiated the training program to help cope with a chronic shortage of doctors. Military PA training, according to a presentation by Dr. Pierre Ozon, Medical Director of the Canadian Forces PA program, involves completion of specific prerequisites (i.e., paramedic training, advanced emergent care training, and medical administration training) totaling 12 months and two weeks, followed by 12 months of didactic instruction, 47 weeks of clinical rotations (including rotations at civilian hospitals), and a four-day exam period. The CF currently employs about 130 PAs.

In the civilian world, it was only in 2002 that Manitoba became the first province in Canada to allow PAs to work. There, PAs hold the title of Certified Clinical Assistant, and requirements for certification include graduation from a PA training program approved by the American Medical Association Committee on Allied Health Education and Accreditation or the Commission on Accreditation for Allied Health Education Programs, and a pass on the exam given by the National Commission on Certification of Physician Assistants (NCCPA), or graduation from another program acceptable to the Council of the College of Physicians & Surgeons of Manitoba. Currently, there are seven PAs working in Manitoba, with an additional 16 PAs being recruited.

Next, in May 2006, Ontario launched a Physician Assistant Initiative to introduce the role to the province as part of its HealthForceOntario program. One-year PA pilot projects for the emergency room are underway at six hospitals in the province, and a two-year pilot project to introduce PAs who work in other specialties into large tertiary care centers, academic health sciences centers, and urban and rural community hospitals is being carried out jointly by the Ontario Ministry of Health and Long-Term Care, the Ontario Medical Association, and the Ontario Hospital Association.

Currently, PAs working in Canada are covered under their employer's comprehensive general liability insurance, while additional professional liability protection is typically available through professional associations and some insurance companies. The Canadian Medical Protective Association provides professional liability protection to those physicians who supervise and work with PAs. Since PAs are not yet a regulated profession in Ontario, the April 18, 2007 Scope of Practice document states that PAs "… must be supervised by a registered physician and follow a recognized process of delegation. The PA is not an autonomous health care provider and cannot act as the principal medical decision maker."

So what about a home-grown, civilian PA program in Canada? A June 28, 2007 news release from the CMA reported that plans for the first civilian PA program in Canada, at Winnipeg's University of Manitoba Faculty of Medicine, may launch as early as September 2008. Obstacles to meeting the launch date include funding and bureaucracy (i.e., obtaining approval from the university's Board of Governors). Applicants for this Master's-level program will require, similar to the United States, a Bachelor's degree in the health sciences and experience in a clinical setting. Also, two schools in Ontario have been approved in principal to start PA programs: McMaster University and the Northern Ontario School of Medicine (partnering with the Michener Institute).

Additionally, Ontario has a plan in place to allow international medical graduates who score at a certain level in their evaluating exam, and who complete a four-month training program, to practice as PAs.

United Kingdom

PAs first entered the UK in 2003, when several general practitioners in England's West Midlands employed US-trained PAs as part of a demonstration project. A June 2007 article on OnMedica.net reported that currently there are more than 20 PAs working in the West Midlands area and a total of 50 PAs working across the UK. In 2005, the UK Association of Physician Assistants was founded by American PAs working in the UK. Training programs for PAs are scheduled to begin in January 2008 at the universities of Wolverhampton and Birmingham, and sometime later at Warwick with Coventry. The programs, supported by NHS West Midlands Strategic Health Authority, involve intensive training over two years, with students studying for 46 weeks each year. Applicants are expected to have a science-orientated first degree or hold a healthcare qualification (e.g., nursing).

Elsewhere in the UK, Scotland began a two-year pilot project using 12 American PAs in September 2006, and the Royal College of Physicians of Edinburgh offers free "e-Associate" membership to PAs.

More Countries Signing On

At a health innovations conference in 2005, the idea of introducing PAs to Australia was first discussed, and interest in the idea has quickly grown. On July 11, 2007, a report from a conference attended by Australian military, government, and academic institutions was released, stating that they hope to have a PA training program in place in Australia in 2009. In the meantime, the report recommends that Queensland Health (the University of Queensland is a major proponent of instituting PA training) be urged to initiate a two-year pilot program using US-trained PAs in the Queensland healthcare system.

The Australian conference also had presentations from practitioners in the Netherlands, who reported that there are four "true PA programs" in the country (as well as one other that includes midwifery training). The first PA program in the Netherlands was started in 2001.

As for Africa, on March 29, 2004, the South African Minister of Health announced the launch of a "Medical Assistant Programme." Medical Assistants, she explained, who in the United States are called PAs, would be mid-level practitioners, but would not have the same training as American PAs. Instead, they would complete three years of training followed by an internship in a district hospital. The particular goal is to use PAs in rural and underserved areas of South Africa. Meanwhile, a 2005 presentation to the Global Health Education Consortium reported that plans to develop PA programs were underway in Ghana.

In Asia, Taiwan has a form of PA. A July 2005 article in Health Policy on the survey responses of 196 Taiwanese PAs stated, "PAs in Taiwan are not governed by laws and regulations, and the absence of legislation to define their roles and responsibilities can lead to confusion in the work environment and potential communication barriers with coworkers and supervising physicians." Additionally, since 2002, American PAs have visited sites in China and in Taiwan on several occasions to make presentations.

Clearly, the world is expanding for PAs, and hopefully other countries will find their PA programs as successful as those in the United States.

For those New to the World of PAs … What does a PA do? The AAPA explains the role of Physician Assistant as follows: "Physician assistants are health care professionals licensed, or in the case of those employed by the federal government they are credentialed, to practice medicine with physician supervision. As part of their comprehensive responsibilities, PAs conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery, and write prescriptions. Within the physician-PA relationship, physician assistants exercise autonomy in medical decision making and provide a broad range of diagnostic and therapeutic services. A PA's practice may also include education, research, and administrative services." How long does it take to become a PA? Today's PA programs are typically 24-32 months long, and to be admitted a person requires at least four years of college (usually a BSc/BA) and some healthcare experience. Want more information? For more information on PAs, see the General Information and Facts at a Glance pages on the AAPA website. Also see the Canadian Association of Physician Assistants (CAPA) website. To learn about the history of the PA profession, visit the Physician Assistant History Center.

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