Physician's assistants: the thin edge of a terrifying wedge

The ongoing debate around the role of Physician Assistants (PAs) in our healthcare system has reached a pivotal moment. As Queensland Health pushes forward with its framework and guidelines to expand and integrate PAs into clinical settings, it’s imperative for us as resident doctors, to understand the profound implications these changes will bring upon our training and healthcare landscape.
 
One of the most glaring issues with the current Queensland Health PA guidelines is the absence of a cap on the scope of practice. Coupled with a role description that essentially positions them as replacements for resident doctors, the thin edge of a terrifying wedge is manifest. 

While proponents (...and the guidelines) may claim "physician's assistants are not a substitute for doctors", this is factually incorrect because they already see undiagnosed patients, perform a role and undertake tasks which otherwise a resident doctor would do. The reality is they do not bring any different skills or functions than that of a resident doctor.
 
The training of PAs in the medical model has also been touted as though this rapid-fire training model promotes their utility and safety. This terminology is ironically non-standard and unrecognised by the Australian Medical Council (AMC) when it comes to medical accreditation. The medical model ostensibly refers to a framework where disease and illness are seen as deviations from normal wellbeing, with signs and symptoms serving as indicators - requiring categorisation. This categorisation forms the basis of differential diagnoses and treatment, indicating that PAs are, in essence, trained as diagnosticians. Despite claims to the contrary, this training model inherently positions PAs as direct replacements for resident doctors.
 
Indeed, every implementation of PAs has highlighted concerns about their expanding scope of practice. Once PAs are integrated into the system, their roles tend to expand, diverting funds away from resident doctors and their training. Fundamentally, this is a shift in resources that could otherwise be used to support the training and development of resident medical professionals into advanced roles - which ironically could address the shortages currently faced now and into the future. 
 
Evidence from the National Health Service (NHS) in the UK underscores the negative impact of PAs on resident doctor training. A significant 70.5 per cent of surgical trainees reported a detrimental effect on their training due to the presence of PAs. Additionally, 55 per cent of doctors in the British Medical Association survey indicated that PAs actually increased their workloads. The regulatory body for PAs in the UK, the General Medical Council (GMC), now also faces legal challenges over the blurring of lines between doctors and PAs, further highlighting the inherent risks with this model of care. 
 
Interestingly, many assert that PAs are intended to free RMOs from administrative tasks, yet there’s no corresponding mention of this in any guideline by QLD Health. Instead, we have 32 pages of information about their clinical relationship with SMOs, their ability to specialise anywhere based on their experience, and their delivery services with infrequent and remote supervision. Never stated is any role or core duties with an intention to alleviate the workload of junior doctors, a significant red flag, and a subtle but very clear indicator about their intended implemented. 

Supporting an RMO does not mean replacing them in tasks; it means making their workflow easier and more efficient. Offloading 'simple' tasks or presentations is a fundamental misunderstanding of how doctors learn. The IV cannula magically inserted in the most challenging of resuscitations, is built on every cannula that came before. Yet seemingly, the proposed solution to RMO workload is to instead create a two-tier medical system, by substituting less trained, higher paid PAs as a labour-for-hire approach. This strategy overlooks the primary issue: the insufficient number of RMOs as a core strain on our healthcare system. 

It almost appears the goal is to do anything to avoid hiring more RMOs; and while people may point to how RMO jobs go unfilled as a reason for this approach, the focus completely ignores Why they are unfilled. No longer is there a hostage workforce barrelling toward the public health system being churned out of medical schools, and QLD Health needs to recognise the challenges of recruitment which have long been known in the external private sector. 

Modern RMOs are more than just about a job, and to attract, grow, and sustain our dedicated and hardworking RMOs Queensland Health needs to do so much more, to stay competitive as a workplace. 

Finally, success of PAs in the USA is often cited in defence of their integration into our system. However, it’s crucial to note that the USA healthcare system lacks resident level doctors as a system. In the USA, PAs instead serve as the middle tier between nurses and senior doctors, a role that does not align with our existing healthcare structure. Importing this model into our system risks disrupting the balance and efficacy of our medical workforce.
 
As this movement to follow the UK and USA gathers steam, we must draw a line in the sand. As future recipients of our healthcare system, it is vital to maintain the high standards we currently enjoy and avoid descending into the chaos observed in the UK or a two-tier system seen in the USA, where access to doctors appears determined by wealth and geography.
 
As House Officers and Registrars, must voice our concerns and advocate for a system that prioritises training and ensures the delivery of safe, high-quality care to all patients. If we do not make a stand now, then when?

Please sign the ASMOFQ petition here at this link bit.ly/qldhealthpa