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The Medical Independent has closely tracked the introduction of physician associates into Irish healthcare since 2015. National recognition and regulation have been slow to materialise, but advocates say this mirrors international experiences. Catherine Reilly reports
Prof Lisa Mustone Alexander would “love to see” a physician associate (PA) in every GP practice in Ireland. “That would be my dream,” the new Director of RCSI’s MSc PA programme told the Medical Independent (MI) in an interview last month.
While not wanting to sound “evangelical” about PAs, Prof Alexander is a steadfast believer. She says she is “passionate about what PAs can bring to the health system” in collaboration with other staff.
Prof Alexander comes to RCSI from George Washington University School of Medicine and Health Sciences, US, where she has had a distinguished career as a PA educator and leader. Her appointment signals an intensification of RCSI’s efforts to achieve national recognition – and regulation – of PAs.
“Right now, we have more jobs than graduates,” she comments of the Irish situation.
The RCSI is planning a webinar on 14 January on best practice when hiring PAs. “The reason we have done that is because we have gotten so many phone calls from hospitals, practices, saying ‘I want to hire a PA, but I don’t know how to do that’,” outlines Prof Alexander.
PAs are trained in the medical model and work under consultant or GP supervision. They support doctors in the diagnosis and management of patients and are trained to perform several roles, including taking medical histories, performing examinations, making diagnoses and analysing test results. In the US, they have prescriptive authority.
To date, there is no PA regulatory body in Ireland. The Irish Society of Physician Associates (ISPA) manages a voluntary register and RCSI’s PA graduates take a national certifying exam. According to the ISPA website, PAs “function with a delegate autonomy that is consistent with the consultants’ scope of practice”.
The Department of Health has yet to officially recognise the grade, but several public and private hospitals are employing PAs (see panel).
The RCSI programme – which is two years in length – is the only such course in the Republic of Ireland (Ulster University started a programme in 2017).
Seven students commenced the RCSI course in the first intake, in early 2016. Seventeen students (from approximately 40 applicants) start this month. In 2022 “I would not be exaggerating if I thought we would have 25 to 30”, Prof Alexander tells MI.
Alongside leading the development and delivery of the RCSI programme, Prof Alexander will “play an important role in advocating for the recognition of physician associates” in the Irish healthcare system and in “promoting the value of the role to healthcare professionals”, according to the College.
She will expect bumps on the road. Prof Alexander entered the profession in its relative infancy, in the 1970s. She also has a detailed understanding of the evolution of the PA identity through her doctoral research.
The American backstory suggests doctors are crucial in progressing the PA role. Irish consultants, who undertook part of their training in the US, have spoken positively of their experiences with PAs.
“My dissertation focused on how critical the role of physicians were in our development and evolution, because we needed these physician champions to be a proxy, if you will, for an advocate,” Prof Alexander explains.
“And they were what we would call today ‘influencers’.
“They could influence their peers. We had a harder time with nurses, even though PAs and nurse practitioners evolved simultaneously… nursing was always somewhat skeptical about where PAs fit in, in the grand scheme of things.”
Today, however, there is “tremendous” integration of PAs in healthcare teams in the US. The profession’s advancement is due to a number of factors, including residency working hour restrictions, medical workforce deficits (particularly in non-procedure-driven specialties) and recognition of the economical and continuity value of PAs.
“You saw a lot of those specialties [with workforce deficits] saying, ‘we can bring PAs into our workforce and they can really help with ambulatory care’,” says Prof Alexander. “So they can really help with seeing patients, for instance someone referred by a GP because they think they might have MS. It is a perfect example.
“An intake is by a PA who knows exactly the history and physical they have to do, they know exactly the kind of labs, imaging; they get the ball rolling and in the next visit the patient would see the consultant who would interpret all the labs and make sure everything was going to move forward in their treatment plan. That is one example.”
Despite integration of the role Stateside, the recent #StopScopeCreep campaign by the American Medical Association (AMA) has demonstrated that the embers of inter-professional tensions are not extinguished. The AMA objects to (what it considers) the growing independence of grades such as nurse practitioners and PAs.
Prof Alexander’s personal view is the AMA is “struggling for relevancy” amid years of declining membership, as multiple professional organisations have formed to cater for increasing specialisation in medicine.
“They don’t like the fact nurse practitioners are at the doctoral level, calling themselves doctors, and operating independently,” says Prof Alexander.
“But I would say, and many of my [PA] colleagues would agree, perhaps the AMA were asleep at the switch, so to speak. All of a sudden, all of these states have come up with scope of practice laws for nurse practitioners and the AMA was nowhere to be found, so they are a day late and a dollar short, as they say.
“Now they are trying to show their members, ‘we are with you, we have got to watch out for these non-physician providers because they are going to encroach on our scope of practice’, and that is not what we are really doing.”
In 2015 RCSI commenced a pilot with four qualified PAs working in surgical directorates at Beaumont Hospital, Dublin (the advertised salary was €44,000).
At the time, the Irish Nurses and Midwives Organisation (INMO) issued a directive to members not to cooperate with the PAs, pending reassurances around nurse career pathways. This matter appears to have been long resolved, with 10 PAs now working at Beaumont.
At present, the INMO does not have a comment to make about the grade, indicated a spokesperson.
The timing of the pilot prompted some concerns, as it was sanctioned by the HSE without prior approval from the Department of Health.
In internal Department correspondence in 2015, obtained by MI under Freedom of Information law, Chief Medical Officer Dr Tony Holohan said developing such a role and “dropping it into services” without clear regulatory, scope of practice and accountability arrangements would be “unsafe and unwise”.
“The concept of a PA is a good one and can work but requires to be developed and implemented in the appropriate manner,” Dr Holohan informed Department colleagues.
Following further engagement, the Beaumont pilot proceeded between 2015 and 2017. The PAs were required to have performance reviews with their supervisory consultant surgeons and retain professional registration with native regulatory bodies.
The Department has indicated that a larger exercise is required to assess the impact of PAs. A spokesperson said consideration will be given to regulation “if and when a decision is taken to introduce the grade of physician associate to the Irish public health service”.
Asked whether the Department viewed the PA role as a potentially beneficial addition to Irish healthcare, the spokesperson said: “The reforms identified in the Sláintecare Reform Programme Workstream ‘Teams of the Future’ are centred on planning, building and supporting a health and social care workforce which can deliver on the Sláintecare reforms, as well as initiatives which promote innovation. In this context of innovation, new grades, such as that of physician associates, will be considered.”
According to an RCSI-led evaluation of the Beaumont pilot, published in the Journal of Hospital Administration in 2019: “Some projects demonstrated reduced wait time for services, including wait time for surgery for varicose veins. Others included the setting up of outpatients’ visits, increased numbers of patients seen at a breast clinic and increasing the NCHD time in direct patient care.”
The paper also noted that despite a series of communications about the employment of PAs, a lack of awareness among hospital staff prevailed.
“This presented a challenge for the PAs to assume their role and for staff to bring them on board. Once on board those staff who worked with the PAs found their role beneficial in terms of continuity of care and skillset.”
In the UK, the General Medical Council (GMC) has been selected to regulate PAs. The GMC has said “the UK government is funding all set-up costs and we won’t use doctors’ fees to cover this work”.
In Ireland, the Medical Council and CORU are obvious candidates, although they have substantial workloads. A CORU spokesperson told MI it had not received any requests to evaluate future regulation of the PA profession. A Council spokesperson said there had been engagement from RCSI.
They said there was no provision in the Medical Practitioners Act 2007 to regulate PAs and therefore regulation of this cohort “would fall outside the Council’s remit”.
The “most logical” regulatory body is a medical regulator “because they know medical training”, according to Prof Alexander. “We train our students very much like physicians, they learn those building blocks of medicine… that is the approach we take.”
In the US, medical boards of physicians often have a PA committee that works collaboratively with the board in respect of PA regulation, explains Prof Alexander.
From her initial observations, Prof Alexander has noted that CORU regulates many healthcare professions. She fears PAs “could potentially get really lost” and face a considerable timeframe before commencement of regulation with CORU.
Prof Alexander has sent an introductory letter to the Medical Council to “open the door for a conversation”.
“We would love for the Department of Health to advocate for some kind of regulatory process and we have asked them for that. We are in the process of waiting for a response.”
Prof Alexander has also been working with the ISPA as it develops a strategic plan. It is intended that the Society will become much more active in advocating for the profession.
“Right now, we don’t have a slot in the HSE payscale,” adds Prof Alexander. “If the HSE or the Department of Health could recognise the profession and at least put it in the schema for salaries I think that would really help. And then regulation would be next.
“But I am pragmatic thinker. I think oftentimes regulation is slow and the workforce will start to evolve, and regulation will catch up, that is what has happened in the UK, and that is not unusual, that is what happens everywhere. When I started working as a PA in Washington DC, there was no regulation, I didn’t need a licence, I just got hired.
“Now, I had to pass my national board exam and that is something Ireland has – the ISPA administers it, it will happen in February for this new class that is graduating. So we are not putting people into the workforce who have not demonstrated their competence.”
These are not the best of times to advocate for a new role, acknowledged Prof Alexander. She said “hopefully once we are on the other side of the pandemic” there will be further recognition of the contribution that PAs can have.
In the UK, PA recruitment is part of the government strategy to bolster the general practice workforce. Prof Alexander is aware of substantial retirements facing the specialty in Ireland. While stating that PAs cannot replace retiring GPs, she sees them as part of the workforce solution.
Prof Alexander says PAs could manage a significant amount of chronic disease in primary care.
“People are living longer, and their disease burden is going to really fall on primary care or the GP practice. So you are going to have people living longer with maybe renal insufficiency, a little bit of heart failure, or they might be a post-MI with a stent, they need a provider who is schooled and educated to be able to monitor the complexity of those illnesses.”
The patient could alternate between the GP and PA depending on their needs.
“Even in my practice in DC, when I was working, I had my own panel of patients, they would only see me. But if I knew their disease burden was getting more complicated, I might say to my physician that I worked with, ‘could you see the patient for me because I am a little uncomfortable with her GFR, her renal status’, or I will just do a chart review – ‘here is what is going on, am I on the right path with this set of medications?’
PAs are “hard-wired” to be collaborative and escalate to their physician when necessary. “PAs are trained in a very sophisticated manner to be alert and oriented to identifying when things are not going well.” She says PAs can enable physicians to focus on the “really complex” patients.
“What I always say is there is enough patients to go around,” comments Prof Alexander. If there are fears about professional incursions, “trust me, we are not here to take away anyone’s livelihood, but there are so many people who need access to the system and are not getting it”.
PAs always remain under the supervision of their physicians, broadly speaking, confirms Prof Alexander.
“We would like to use the phrase ‘collaboration’. But many of the [US] state laws still say ‘supervision’ – that is the model. But more and more states are getting away from that [terminology]…. It presents some circumstances that can be difficult for PAs if you are always tied to one physician.
“I can give you an example. I went to New Orleans when Katrina happened and I was part of a medical group that was going to provide emergency care to populations down there, whether they were in Baton Rouge or New Orleans. I had a licence to practice in the District of Columbia but it was with this one physician.
“Well, she wasn’t coming with me to New Orleans; what is wrong with this picture! It makes for so many barriers; like if my physician goes away, then I have to have an alternative physician, it is just a lot of paperwork, I am still operating in collaboration with the team I have.”
In terms of the RCSI course, Prof Alexander is anxious that more financial supports become available for students. While there are a small number of sponsored students, most are self-payers. Currently fees for first year are €12,250 (including an NUI fee) and €12,000 for second year. An RCSI spokesperson said no new courses have been added to the SUSI list for grant eligibility.
Interestingly, since 2017, Northern Ireland’s (NI) Department of Health has commissioned up to 20 places per annum on Ulster University’s postgraduate diploma in PA studies.
“The [NI] Department is committed to supporting an initial six cohorts of students,” a Department spokesperson told MI. It pays tuition fees for the two-year course and provides funding to Health and Social Care (HSC) Trusts and GPs to facilitate clinical placements in accordance with curriculum requirements. The NI Department will undertake an interim evaluation of this programme during 2021.
Students entering the course at RCSI have a variety of academic and professional backgrounds, including some nurses and paramedics. Others have studied physiology or science, for example. The listed entry requirements include a health or science related degree.
“They are an impressive group of people,” says Prof Alexander. “We have a very high bar because when you are putting a new profession out there, you do not want anyone who isn’t going to represent the best of the best.
“And we have a very high bar and it has to stay high because there are going to be naysayers out there. There are going to be people who want to find fault with what we do, and we have to be above reproach.”
Employment profile: Where PAs are based in Ireland
According to RCSI, most of its PA graduates work in the greater Dublin region, including Beaumont Hospital, the Mater Misericordiae University Hospital, Our Lady’s Hospital, Navan, and Bon Secours Health System.
“Outside of Dublin, there are physician associates working in Galway, Waterford and Cork. Graduates work in various surgical and medical subspecialties, including gastroenterology, otolaryngology, infectious disease, emergency medicine, orthopedics, cardiology, and general practice,” a College spokesperson told the Medical Independent. Blackrock Clinic also confirmed it employs two PAs (in acute medicine and cardiology).
Some 28 PAs have graduated to date, commented RCSI’s spokesperson in December. On the issue of indemnity in public hospital services, a spokesperson for the State Claims Agency said the Clinical Indemnity Scheme covers specified healthcare enterprises (State authorities) in respect of services provided by registered medical practitioners, other health professionals, and services provided by persons acting under the direction of registered medical practitioners and other health professionals.
“Physician associate services are thus covered by the scheme where State authorities choose to provide such services and a specific indemnification is not required.”
Dr Rob Hendry, Medical Director at Medical Protection, said PAs are playing an “increasingly important” role in the healthcare workforce.
“Medical Protection will be engaging with the Royal College of Surgeons in Ireland and other bodies representing PAs to understand more about their scope of practice,” he said.
As to the positions on the PA grade held by medical representative and professional organisations, the ICGP said it “has no position or comment to make” and the matter “has not been discussed” to date. The IMO had not responded by press time.
In Northern Ireland (NI), as of September 2020, there were 34 registered PAs working in the public healthcare system – Health and Social Care (HSC).
The first cohort of PA students at Ulster University graduated in January 2019 and entered the HSC workforce shortly afterwards, according to a NI Department of Health spokesperson.
The NI Department is also supporting a pilot scheme in a local GP practice, where a graduate PA has been employed from May 2020. On graduation, PAs enter employment on a “new graduate year”. The NI Department has produced an employers’ guide on supervision, support, and career development for PAs.
NI Department officials are working with colleagues in England, Scotland, and Wales in relation to plans for the regulation of PAs by the General Medical Council.