The U.S. physician assistant (PA) profession is rooted firmly in the compressed medical curriculum originally developed by the military to quickly train doctors, medics, and corpsmen. The profession was further influenced by the history of Russian feldshers and the use of Chinese barefoot doctors. The PA movement is expanding globally in response to specific access, quality, and efficiency needs in many countries. Perhaps it is driven by the growing worldwide need for skilled medical providers, along with the harsh economic realities that not everyone can become a doctor, nor can everyone afford to have a doctor treat every ailment. Jane Farmer‘s evaluation of the Scottish PA pilot program considered the international PA movement by saying that “the current wave of international development in deploying and training PAs can…be viewed in alternative ways. First, it could be viewed as a ‘fashion.’ The PA profession is neatly packaged, emanates from the United States (as many health system fashions do), has some assiduous ‘product champions,’ and is promoted in a panacea-like way. Alternatively, PAs can be viewed as the profession, designed as uniquely adaptable (i.e., moving from the United States to other parts of the world at this time expressly because it can meet the world’s current health workforce gaps).”
This chapter reviews international PA models that are close analogs of the American PA and therefore knowingly excludes many other nonphysician clinicians (NPCs) who contribute substantially to health care delivery around the world. It is important to acknowledge that no slight is intended by this distinction. Rather, it is our attempt to say the role of all NPCs, including PAs, is on a continuum. NPCs can be viewed as either complementing the existing health services provided or actually substituting services for those usually performed by physicians, especially as is often necessary in many developing countries. This chapter focuses on models that typically provide complementary services with linkages to supervising or collaborating doctors and surgeons. We explore some of the common and diverse issues and challenges faced in each country as the PA model evolves. It is important to acknowledge that this is intended as an overview of the current state of affairs as of the summer of 2019, when this chapter was written. It is not intended to be a comprehensive, in-depth report on the PA model worldwide.
The PA profession has continued to grow and develop in the Canadian health care system over the last few decades. PAs were introduced in Canada for a variety of reasons. They were first introduced in the Canadian Armed Forces (CAF) to augment the medical services provided by a small number of physicians across a vast geographic region. In Manitoba, they were implemented to address rapid turnover of fellows in specialty services. Specialties such as neurosurgery, cardiology, bone marrow transplantation, and plastic surgery were early adopters and continue to be the primary employers of PAs in Manitoba. In Ontario, they were introduced to address a shortage and maldistribution of primary care providers in rural, remote, and other underserved areas. Canada is the second largest country in the world by land mass. There are over 35 million people living in Canada, with approximately 90% living within 100 miles of the southern border. This leaves large swathes of Canada with low population density and difficulty providing medical services to widely scattered people.
According to the 2019 Canadian PA census, as of July 2019 there were over 870 Canadian Certified Physician Assistants (CCPAs), representing a 41% increase since 2016. Geographically, approximately 42% work in Ontario and 10% in Manitoba, with the rest spread among different provinces and territories. Almost half work in urban or metropolitan areas; 46% work in communities of less than 250,000 people, and of these, 11% work in communities of less than 5000. Finally, 6% work at military postings.
Canadian PAs work in over 30 medical or surgical subspecialties. Many PAs report working in primary care, with 24% in family practice and 14% in emergency or urgent care. 18% work in hospital medicine and 14% in hospital surgery. 11% report working in the CAF.
Scope of practice
Similar to their American counterparts, Canadian PAs are “medically educated clinicians who practice medicine within a formalized agreement with physician(s).” Canadian PAs work in collaboration with physicians in a wide range of settings and clinical roles, often in interprofessional teams. The PA scope of practice is determined by a formalized agreement with one or more physicians and by the laws of the province or territory. PAs must practice within the scope of practice of their collaborating physician. The specific role of an individual PA is determined by the practice setting and by the physician–PA relationship.
The Occupational Competency Profile for civilian PAs was developed in 2001. This professional competency profile was updated in 2009, and again in 2015, to mirror the widely accepted Canadian framework for physician training, CanMEDS, which was developed by the Royal College of Physicians and Surgeons of Canada in the late 1990s. The PA Competency profile, now known as CanMEDS-PA, defines the roles and competencies that a generalist PA should possess on graduation. It is the accepted standard in Canada for PA education, certification, continuing professional development, and program accreditation.
To obtain PA certification in Canada, candidates must graduate from an accredited PA program and pass the National PA Entry-to-Practice Certification Examination, administered by the Physician Assistant Certification Council of Canada (PACCC) since 2005. Additionally, to maintain certification, PAs must log continuing professional development hours annually.
Graduates of both Canadian and American PA programs are eligible to take the Canadian entry-to-practice exam; however, Canadian-educated PAs are not yet eligible to write the American National Commission on Certification of Physician Assistants (NCCPA) exam. Practically, this means that Canadian-educated PAs are not eligible to become certified in the United States, whereas U.S.-trained PAs are eligible to become certified in Canada.
There are four accredited PA educational programs in Canada. From 2004 to 2018, these programs were conjointly accredited by the Canadian Medical Association (CMA) and CAPA. At the time of this writing, CAPA is engaged in a search for a new accrediting body, after CMA’s divestment from its conjoint accreditation services. The CAF PA program has been delivered by the Canadian Armed Forces Health Services Training Center in Borden, Ontario since 1984 and is open only to qualifying members of the Canadian Forces. There are three civilian university PA programs that opened between 2008 and 2010. The Consortium program is housed at the University of Toronto and is delivered in collaboration with two other institutions, the Northern Ontario School of Medicine and The Michener Institute of Education at UHN. The Manitoba program offers a master’s degree, whereas McMaster, Toronto, and the CAF programs offer a bachelor’s degree. The CAF program began awarding a bachelor’s degree in 2009; the degree is granted by the University of Nebraska Medical Center, with which CAF maintains a formal agreement. All programs are approximately 24 months in duration and deliver curricula aligned with CanMEDS-PA ( Fig. 6.1 ).
Like the American model, the Canadian PA profession has its roots in the Canadian military, evolving from earlier roles similar to PAs. In Canada, PAs were first educated and employed by the CAF to support and extend medical services beyond the capacity of the relatively small number of physicians serving the military. Before World War II, these assistants were called “sick berth attendants.” After WWII, they were known as medical assistants, and with more advanced training, they could become medical technicians. In 1984, the title “physician assistant” was adopted, and in 1991, the role of senior medical technicians was formally changed to PA. For many years, PAs in the Canadian Forces were the only PAs in Canada.
The PA national organization, the Canadian Association of Physician Assistants (CAPA), was formed in 1999, with support from the CAF. In 2003, CMA recognized being a PA as a health care profession. In 2010, CAPA and CMA collaborated to create a national PA Toolkit as a resource for physicians and other stakeholders considering hiring PAs. The same year, on November 27th, a funding agreement allowed CAPA to incorporate as a civilian agency, removing the CAF’s fiduciary oversight role. Therefore November 27th is National PA day in Canada each year. In 2016, CAPA commissioned the Conference Board of Canada to research and create a detailed review of the impact of PAs in Canada to date. Three reports and a final briefing were published between 2016 and 2017, highlighting the positive impact of PAs on the Canadian health care system.
Canadian armed forces
PAs in the CAF provide medical services under some of the most extreme conditions, often in austere settings with only remote physician supervision. The National Defense Act stipulates that the CAF has the legal authority to provide and manage its own health care professionals. Accordingly, CAF PAs work on military bases located in all provinces and territories, even those in which civilian PAs cannot work under current provincial legislation ( Fig. 6.2 ).
Until recently, the pathway to becoming a CAF PA was through advanced training for noncommissioned officers who had been previously trained and were experienced as medical technicians. A significant advance came in 2016 when PAs transitioned from their status as senior enlisted noncommissioned officers to the newly identified commissioned officer occupation within the CAF. This is the first time in CAF history that a military occupation has gone from noncommissioned member to commissioned officer. This change will favorably address a number of challenges for military PAs. There will be better alignment between the level of education PAs receive and their status as commissioned officers. This will further improve teamwork with other Health Services officers, such as nurses, and justify potential clinical leadership opportunities for PAs. Additionally, the change to commissioned officer will address pay disparities between CAF PAs and their civilian counterparts. This will further enhance CAF recruitment opportunities, allowing the CAF to compete fairly with civilian employers and improve retention by mitigating the incentive for military PAs to leave the CAF for higher paying civilian jobs.
Each province or territory has its own medical act that delineates the degree of delegation and supervisory requirements for PA practice.
Manitoba was the first province to introduce the PA concept in 1999. Regulated PAs have been working in Manitoba since 2003. Under the provincial Medical Act, PAs were issued certificates of practice under the title of “certified clinical assistants.” In 2009, those regulations were amended to permit practice under the title of PA. PAs in Manitoba are associate regulated members of the College of Physician and Surgeons of Manitoba, with certificates of practice issued after the Registrar’s approval of their practice description and contract of supervision.
The highest concentration of PAs in Canada is found in Ontario. In Ontario, PAs practice under the Delegated Medical Authority of the Medical Act. In 2007, Ontario’s Ministry of Health and Long-Term Care (MOHLT) launched its PA demonstration project as part of its human health resource strategy, HealthForceOntario, to determine the impact of PAs on the provincial health care system. The demonstration projects also included a bridging program for international medical graduates to work as PAs.
In 2012, CAPA submitted an application for PA regulation to the Health Professions Regulatory Advisory Council (HPRAC). In a significant setback for Ontario PAs, HPRAC decided to recommend against PA regulation, citing insufficient risk of harm to the public, based on the relatively small number of PAs in the province and the physician supervisory model of practice. A mandatory PA registry under the Ontario College of Physicians and Surgeons was recommended, which would at least provide some form of title protection for an unregulated profession; however, this has not yet been implemented ( Fig. 6.3 ).
Additional barriers for PAs in Ontario are the absence of a billing structure for PA services and the lack of a steady source of employment opportunities. Although most physicians bill the provincial health system directly, there is no equivalent structure for PAs. Most PAs are paid salaries from their institutions, such as hospitals and clinics, whereas others are paid directly by their supervising physician, or from other, sometimes creative, funding sources. PA program graduates are offered employment under the Health Force Ontario Career Start Program, which is subject to annual renewal. These contracts generally only last 1 to 2 years in duration, with many PAs finding themselves back in the job market when the contract expires.
In 2009, the College of Physicians and Surgeons of New Brunswick (CPSNB) amended the New Brunswick Medical Act to include PAs in the health care model. Under this act, PAs can be licensed and registered under the CPSNB. PAs in New Brunswick are employed by regional health authorities and work under physician supervision and delegation of controlled acts. Most PAs in New Brunswick work in emergency departments.
In 2010, the College of Physicians and Surgeons of Alberta (CPSA) passed legislation allowing PAs to practice under physician supervision. To practice in Alberta, PAs must be certified and registered with the CPSA. PAs are currently unregulated in Alberta. An application for regulation of the profession was submitted in 2013, for which the Ministry of Health has indicated their support; however, a decision has not yet been made and the process of regulation is ongoing.
British Columbia has been considering adding PAs to their health care system for several years, although this has not yet occurred. In 2005 the British Columbia Medical Association published a policy paper indicating their support of the PA profession. One of the barriers is that British Columbia law currently does not allow physicians to delegate to unregulated health care providers.
The first PAs to work in the United Kingdom (UK) were two Americans who were recruited in 2003 for primary care posts. They worked in the Black Country, so-called from its days as an industrial hub. It is now an economically distressed and medically underserved area of England’s West Midlands; this area encompasses Birmingham, England’s second largest metropolitan area. A larger scale demonstration project followed in Scotland from 2006 to 2008, with 12 experienced American PAs deployed across a number of specialties. It was from these early projects that the UK Association of Physician Assistants (UKAPA) was established in 2005. As the first professional body, UKAPA was created by expatriate American PAs to provide necessary continuing medical education and to encourage the advancement of the PA profession.
Initial efforts by the British to “grow their own” PAs started in 2002 with pilot training programs for what were then called “health care practitioners” (HCPs), precursors to the PA role, at St. George’s University of London, in conjunction with Kingston University. The HCP model then evolved into the medical care practitioner (MCP) model and then to the PA, with the University of Wolverhampton as the first to identify its curriculum as a “physician assistant” program in 2004. The three pilot programs were run at the Universities of Wolverhampton, Hertfordshire, and St George’s (in conjunction with Kingston). The first substantive programs, as defined by class size with cohorts of 10 or more, were launched in 2008 by the University of Birmingham, the University of Wolverhampton, and St. George’s, University of London. These programs followed the Competence and Curriculum Framework for the Physician Assistant (CCF) and were taught at the master’s level, with a postgraduate diploma (PgDip) award. The CCF was first published in 2006 and was updated in 2012. , The latest edition will reflect the physician associate title.
Unfortunately, three of the first four programs closed only a few years after opening. Hertfordshire closed in 2009, followed by both the University of Birmingham and the University of Wolverhampton programs in 2011. The latter closures were the consequence of losing the original champions within the universities, as well as opposition from leadership within the regional National Health Service (NHS). Meanwhile, the St. George’s program in London had doubled its entry cohort number, and a new program was launched at the University of Aberdeen, Scotland, in September 2011 ( Fig. 6.4 ).
The 2013 title transition from PA to “physician associate” came after a recommendation from the UK government’s Department of Health. Within the NHS structure, the “assistant” title denotes less qualified, less trained individuals with few academic credentials. “Assistants” in the NHS are also paid less. The title change was also intended to differentiate the role from a group of informally trained “physician’s assistants” (“medical assistants” in U.S. terminology) who were working in some NHS hospitals.
After several years of governmental apathy, interest in the PA profession began to build in the mid-2010s. A renewed interest in PAs came from cities and regions across the entire country, especially as hospitals were feeling the strain of the work-hours restrictions on their doctors in training. All three previously closed programs reopened: the Universities of Birmingham and Wolverhampton in 2014 and the University of Hertfordshire in 2017. The number of PA programs increased from two in 2013 to 30 by late 2015. Support came from Health Education England, who hosted the first national strategic PA workforce conference in October 2014. Another significant boost for the profession was the UK Secretary of State for Health’s announcement that there would be 1000 PAs available to work in primary care by September 2020. To meet this demand, the number of universities offering PA programs increased again to over 30 by late 2018 with projected numbers near 40 programs by 2022. Also of significance is that in addition to the rapid increase of PA program numbers in England, there are now programs in all four UK nations. As of 2019, there were two programs in Wales and one each in Scotland and Northern Ireland. PA educators have been holding conferences since 2016. These conferences encourage cooperation and collaboration between programs and offer new PA educators the opportunity to network with more experienced colleagues.
Originally, UK-trained PAs were expected to work in primary care, which at the time was anticipating a significant shortage of workers in underserved areas. Accordingly, the Competence and Curriculum Framework (CCF) developed by the Department of Health was focused on primary care. Implementation of the European Working Time Directive, however, which limited work hours for doctors in training to less than 48 hours per week, has increased the demand for PAs to work in hospitals and specialty practices. In 2018, 28.4% percent of PAs worked in primary care. Revisions to the CCF are presently under way to reflect the shift to a broader approach, including hospital-based practice.
In 2015, the original professional organization, UKAPA, became the Faculty of Physician Associates (FPA), part of the Royal College of Physicians. The FPA holds a “managed voluntary register” as a means of identifying and registering PAs who have graduated from a UK or U.S. PA program and have passed the national examination; it provides the necessary continuing medical education that UK PAs need to maintain their qualification; and it is responsible for the UK PA National Examination. Until the profession is legally recognized, UK PAs are unable to prescribe or order diagnostic imaging, which can limit their efficiency in practice. In July 2019, PAs across the UK celebrated the government’s announcement that PAs would be regulated by the General Medical Council, the same council that regulates doctors. It is expected that statutory regulation will be in place by 2020 or 2021. After regulation, a legal change to the Medicines Act will be required to allow PAs to prescribe medication. Despite these challenges, the demand for PAs continues to increase. As of October 2019, there were about 1800 PAs in the UK, with approximately 900 to 1000 new PAs graduating per year ( Fig. 6.5 ).
As in the United States, new graduate PAs must pass an initial qualifying examination. The UK’s version is a two-part process, with both a 200-question multiple-choice examination and a 14-station Objective Structured Clinical Examination (OSCE). Of potential interest to American PAs is that at present, PAs who hold NCCPA certification are able to apply to become members of the Managed Voluntary Register (MVR) without first having to undergo the UK examination process. This policy is under review, and it is possible that U.S. PAs who wish to practice in the UK in the future may have to pass the UK PA National Examination.
The PA profession in the Netherlands developed after the government predicted upcoming shortages in the medical workforce. To address the imbalance between the demands and supply of Dutch medical care providers, the PA role was first introduced in 2001. Since then, five Master Physician Assistant (MPA) programs have been started at universities of applied sciences. The first MPA program started at the University of Applied Sciences Utrecht in 2001 and was followed by a program at the HAN University of Applied Sciences in Nijmegen in 2003. Then, in 2005, three more MPA programs opened at the Inholland Graduate School in Amsterdam; the Hanze University of Applied Sciences, Groningen; and the Rotterdam University, University of Applied Sciences. From 2005 to 2009, the Rotterdam program had a primary focus on clinical midwifery. Since 2009, however, Rotterdam University has run a regular MPA program and maintained the midwifery program. In total, the five Dutch MPA programs have an annual enrollment of approximately 250 students. Enrolling students must meet the admission criteria of: (1) holding a bachelor’s degree in either nursing or paramedicine and (2) having a minimum of 2 years of relevant professional, clinical experience after their undergraduate training.
The MPA program is a 30-month curriculum, which awards a Master of Science (MSc) degree. The curriculum is based on the National Training and Competency Profile MPA. This profile is tailored to the professional roles of the PA outlined in CanMEDS, including: (1) medical expert, (2) communicator, (3) manager, (4) collaborator, (5) scholar, (6) health advocate, and the overarching role of (7) professional. These seven professional roles are described by a definition, delineation, and related competencies. Each of these professional roles is linked to the task areas as defined within the Professional Profile Physician Assistant by the Dutch Association of Physician Assistants. According to the Framework for Qualifications of the European Higher Education Area, the MPA programs in the Netherlands are designated as second-cycle programs and entail a total study load of 150 European Credits, equal to 4200 clock hours. PA training in the Netherlands differs from other traditional international PA models in the integration of their didactic and clinical education, known as a “dual program . ” Upon enrollment to the MPA programs, the students are also employed as paid PA trainees. Although students on campus are learning the core medical and scientific knowledge and skills required for all PAs (1 day per week), each student simultaneously receives additional clinical expertise in a designated medical specialty by actually working in that area the rest of the week. Students are contracted through a “training and employment contract” with a minimum of 32 hours per working week. Students are also expected to engage in further study on the evenings and weekends. As a result, PA students have both didactic education days (to acquire generic competencies, modeled to the medical curriculum) and clinical days (to acquire specialty competencies, analogs to that of training medical residents) interspersed throughout the duration of their training. Fully qualified PAs are known as Master Physician Assistants (MPAs). Dutch PAs work across all areas of medicine, including general practice, and because of their unique approach to training, are found in subspecialty areas in greater numbers than PAs elsewhere. ,
The Dutch PA development and movement is in its second decade, and many professional milestones have been reached. The profession has grown to almost 1400 clinicians. Under the leadership of the NAPA, the Dutch PA profession has made significant advances. The most substantial professional milestone was reached in 2018 as PAs were incorporated as an article 3 profession within the Individual Health Care Professional Act. This registration involves authorization to practice medicine independently, albeit at all times in collaboration with a medical doctor. This legislation granted rights that previously only belonged to the realm of medical doctors, including medical procedures such as catheterizations, surgical procedures, injections, lumbar punctures, the prescription of drugs, endoscopies, electrical cardioversion, and defibrillation.
At the time of graduation, PAs can voluntarily enroll in NAPA’s Quality Register. The Quality Register contributes to ensuring the quality of professional practice by keeping track of developments in the profession (i.e., by means of continuing medical education [CME]). Being enlisted into the Quality Register indicates the PA is a graduate of a Dutch Flemish Accreditation Organization–accredited MPA program and was clinically active at the time of registration. The registration period covers a term of 5 years, after which reregistration is required. Only those who have been practicing as PAs for a minimum of 16 hours per working week and have completed CME totaling 200 hours (40 hours per year) in the last registration period of 5 years are considered for reregistration.
The first German PA program opened its doors at Steinbeis University Berlin (SUB) in 2005. SUB is a private university, and the PA program established an official relationship with the German Society for Orthopedic and Trauma Surgery. Until recently, there were just three programs in Germany. The total number of graduates from 2005 until 2016 was 269. Whether these graduates have remained active as PAs in clinical practice is unknown. Currently, German PAs have a relatively limited scope of practice, requiring direct supervision by the attending medical doctor. Germany’s medical hierarchy has been generally reluctant to entrust any significant aspects of medical practice to nonphysicians. Despite this barrier, the German PA profession is steadily growing because of access and efficiency pressures within the medical system.
Similar to the Netherlands, PA programs in Germany are offered through universities of applied sciences. All PA programs offer bachelor’s degrees because the majority of health professionals are trained at a vocational level. By 2015, two of the original PA programs (SUG and the Baden-Wuerttemberg Collaborative State University) in Karlsruhe remained open. The third program, through Mathias Hochschule Rheine University of Applied Sciences, has been restructured through the Praxis Hochschule University of Applied Sciences.
Beyond the original three programs, four other PA programs currently enroll students and were expected to graduate their first classes sequentially in 2017, 2018, and 2019. These programs include the University Medical Center Hamburg-Eppendorf, the Fresenius University of Applied Sciences in Frankfurt am Main, the State Academy Plauen, and the Fresenius University of Applied Sciences in Munich. It appears that PA training in Germany largely relies on the initiative of private universities. The absence of a national accreditation process means that there is not yet the assurance of a standardized curriculum across schools. Future challenges to PA practice are upcoming because of the governmental structure of Germany. Similar to the United States, Germany has a federal system of government, with 16 separate states, each with its own constitution and regulatory processes. Despite a recent resolution by the Germany Medical Association to call PA “a profession,” the nationwide establishment of the PA profession in Germany will not be complete until all 16 states have “signed on.”
Republic of Ireland
The Republic of Ireland is a more recent entry into the developing PA role in Europe. Ireland, like other European countries, has a combination of factors that make it fertile ground for the introduction of the PA role. Ireland is faced with a recovering economy, an aging population, recently enforced work-hour restrictions on doctors in training, and the emigration of many of its qualified doctors and surgeons. With the goal of achieving improved service delivery and better continuity of care, the Department of Health approved a 2-year pilot project with four expatriate PAs, three Canadian and one American, employed in surgical subspecialties in Dublin in July 2015. Anticipating a favorable environment, an Irish PA training program awarding a 24-month Master of Science in Physician Associate Studies degree was established at the Royal College of Surgeons in January 2016. By December 2018, the number of program graduates grew to 18 PAs, who were practicing throughout Ireland in general practice and multiple specialty areas. The program welcomed its fourth cohort of students in January 2019. Although the initial pilot project produced promising results, the Department of Health initiated a second pilot with expanded scope to evaluate the impact PAs have on the health care system from a wider stakeholder perspective and to assess the need for regulation. The Irish Society of Physician Associates was registered as an official organization in late 2016, with full activation in the spring of 2019 when election of the first officers and board of directors took place. Although the PA profession has gained a foothold in the Irish health care system, it remains to be seen how PAs will be used to meet the ever-increasing patient care needs of both primary and secondary care.
The Republic of Bulgaria is a country situated in the Balkan region of Europe. Since 2007 it has been a member state of the European Union (EU) and has a total of 7.2 million inhabitants. With an outdated health care system inherited from the former communist era, Bulgaria began a process of health care reform in the late 1990s to address lagging health indicators. Although the ratio of health professionals to citizens is similar to other EU nations, health professionals are not evenly distributed throughout the country. Most medical staff are located in urban regions, resulting in limited access to medical care services in the rural and remote areas of Bulgaria. Despite the main goal of the medical schools in Bulgaria to prepare a cadre of physicians who will stay in Bulgaria, emigration of physicians to other EU member states with greater resources persists. Emigration of doctors, combined with the increasing health care needs for an aging population, has made Bulgaria more interested in adopting the PA role. Bulgaria has a 130-year history of using feldshers—medical professionals trained at the secondary school level—to meet the medical needs of their communities. In 2014 the PA profession was formally started with the establishment of a PA education program at Trakia University in Stara Zagora. As of 2017, three cohorts with 90 students each have enrolled. This program is a 4-year bachelor’s degree program, which is followed by a year-long internship. PAs are included in the register of regulated professions and are incorporated into the national classification of occupations. Bulgaria hopes to have trained at least 1000 PAs by 2025.
Established in 1965, the first and only Liberian PA program at the Tubman National Institute of Medical Arts grew from a collaboration between the national government, the World Health Organization (WHO), and the United Nations Children’s Fund. Liberia had a 14-year civil war, which caused the decimation of its health care system. At the end of the war, in 2003, a survey of health resources found that there were only 30 doctors left in Liberia. The political instability, civil wars, and public health crises have resulted in intermittent disruptions to the PA training program. Nonetheless, the PA model remains integral to health care delivery, especially in rural and remote areas of the country. Of particular note, although the nation’s resources were otherwise overwhelmed, Liberian PAs played a major and essential role in the treatment centers for the Ebola outbreak in 2014 and 2015; as a result, many PAs became infected, often because of lack of proper protective equipment, including 14 who died in service to their country.
In 2009, the medical assistant (MA) profession in Ghana celebrated the historic landmark of their workforce’s presence in the health care system, spanning 4 decades. Initially, the program was designed for nurses as an advanced study lasting 18 months. Enrollment was open for nurses who had at least 3 years of work experience. Because of an increasing demand of MAs, the program was redesigned in 2007 to enable high school graduates and other health workers to enter MA training, parallel to the existing program. This new “direct admission program” offered via the Kintampo Rural Health Training Center is a 4-year curriculum that includes intensive clinical internships in the last year. After completion of the training, most MAs are deployed in primary health care centers in rural areas. The workload of MAs is heavy, with an average of 90 to 150 consultations per working day. Because MAs supervise nurses, midwives, and community health workers, they are the key figures in their health center. In 2005 the very first bachelor PA programs were initiated at Cape Coast University and Central University College. Now, after more than a decade, universities offer PA education programs, often referred to as a “BSc Physician Assistantship.” The PA profession in Ghana is known to have three types of PAs—namely, PA Medical (composed of the earlier known medical assistants and graduates of the “new” PA programs), the PA Dental (formerly Community Oral Health Officers), and PA Anesthesia (also known as Nurse Anesthetists). As of 2015 the Ghanaian PA workforce included 2500 clinicians, of whom more than 70% were registered as PA Medical. After graduation, PAs can obtain a license to practice through the Medical and Dental Council, designated by the Ministry of Health as the regulatory body to regulate PA training and practice in Ghana. To get licensed, PAs have to sit for the Licentiate Examination. The PAs Medical are predominantly stationed in primary care settings, with the majority serving communities in the rural and remote parts of Ghana. Given the content areas assessed in the Licentiate Examination, the PAs Medical appear to be trained to the medical curriculum and can be considered fellow PAs, as adapted to meet the local needs of the Ghanaian health care system.
The PA equivalent in South Africa is the “clinical associate” (CA), a concept first developed by the National Health Council in 2002. CAs were formally introduced by the Health Ministry in 2008 as a means to address chronic health workforce shortages, especially in rural and otherwise underserved areas of the country. The “brain drain” of the medical workforce of South Africa had resulted in a loss of almost 40% of their doctors through immigration in the preceding 15 years.
Three South African programs were created simultaneously to bring significant numbers of graduates into the workforce in multiple sites throughout the country. Programs at Johannesburg’s University of the Witwatersrand, the University of Pretoria, and Walter Sisulu University in the Eastern Cape Province are all offered in partnership with national and provincial departments of health. All of the CA programs follow a 3-year curriculum, which is competency based and delivered in a variety of formats. This leads to a bachelor of clinical medical practice degree. The first cohorts of CAs graduated in December 2010 and are working in various clinical settings, in both hospitals and primary care and in both the public and private health sectors. More than 1070 qualified CAs were registered with the Health Professions Council of South Africa in 2018. , A final scope of practice, including prescribing rights, was signed off by the Minister of Health in 2016.
Clinical officers in East Africa
For more than 50 years, nonphysician clinicians called “clinical officers” (COs) have been educated and deployed throughout East Africa, including to Kenya, Tanzania, Uganda, Malawi, Rwanda, Mozambique, and Zambia, to address a shortage of doctors. In countries such as Tanzania, which has approximately 2300 doctors for a population of 58 million people, COs are meeting the needs of patients who would otherwise receive no medical care at all. , The educational process for these clinicians differs from country to country, with some requiring only a secondary school education plus an apprenticeship, and others requiring formal, university-level training. Some of the clinicians are trained specifically for surgical tasks, including surgical obstetrics, because of the lack of available surgeons and obstetricians. Others are educated in general medicine. Although accurate numbers are difficult to obtain, Kenya has at least 1300 COs and Malawi has approximately 900. The means of licensing and regulating clinical officers in East Africa are heterogeneous and not described in detail within the scientific literature. In the early 2020s, increasing efforts are being made to standardize educational practices among COs. Further research is needed to better understand the contribution of COs to the health systems and population health outcomes of East African countries.
Until the first scholarly article in 2012 that reported on the Indian PA educational system and professional workforce, the Indian PA movement remained largely invisible. The first PA training program began in 1992 under the auspices of the Madras Medical Mission and the leadership of Dr. K.M. Cherian, a renowned cardiac surgeon. Dr. Cherian had worked with American PAs during his training in the United States. Almost 25 years later, there are more than 3000 qualified PAs in India nationwide; however, many of them work with pharmaceutical or medical device companies or have taken up other health care related jobs rather than work as clinical PAs. Graduates of PA programs pursuing higher education in health sciences is another reason for the attrition of PAs in clinical practice.
The Indian programs are hosted by training institutes and facilitated by affiliated universities granting the degrees. Similar to the American experience, a range of academic credentials are associated with Indian PA training. Programs range in length from 2 to 4 years. They also vary from baccalaureate to postgraduate diplomas, such as that offered by British PA programs. Master’s degree level programs were in existence in the earlier days but were downgraded because of a lack of applicants. There is no formal accreditation or program quality assessment, which has led to varying quality in the new programs being developed.
Under the purview of the Indian Ministry of Health and Family Welfare, the National Initiative for Allied Health Sciences (NIAHS) was established in 2012 to formulate a proposal to bring in regulation in the education and practice of all allied and health care programs, with a long-term vision of creating a governance council. It is envisaged that all allied and health care professionals (PAs included) would be governed by this council except for medicine, nursing, and pharmacy, which are already governed by their respective councils. The Allied and Healthcare Professionals bill brought out by the NIAHS was debated in Parliament in January 2018 and has been forwarded to the Parliamentary Standing Committee for its review. The report of the Parliamentary Standing Committee is expected. Alongside standardizing the curriculum and acquiring governmental recognition for the PA profession, title protection of the different professions is also sought. In line with several other nations, the Indian PA workforce has opted to change the title of assistant to associate . The current definition of a physician associate in India, as laid down by the Taskforce, is as follows: “Physician associates are health care professionals trained in a medical model who practice medicine as part of the health care team. They are qualified and competent to perform preventive, diagnostic, and therapeutic services with physician supervision.”
Although the lion’s share of the Indian PA workforce has its roots in cardiothoracic surgery and cardiology, a shift to other disciplines is occurring, such as emergency medicine, general medicine, general surgery, obstetrics and gynecology, and orthopedics. The role of PAs in primary care is yet to be explored in India. There is huge potential to strengthen the delivery of the primary care landscape in India with the introduction of PAs. Because PAs are employed exclusively in private practice, they are therefore barely visible to the public, government, and health administrators responsible for planning primary health care. The introduction of PAs in primary care within the public health system is expected with the passing of the Allied and Healthcare Council’s bill.
Since 1984, Australia has had a publicly funded universal health care scheme called Medicare. Health care services are provided via a complex mix of government and private financing and service provision. The Commonwealth (federal) government funds the bulk of public hospital services, but the public hospitals are controlled and operated by the six state and two territorial governments. The Medicare Benefits Scheme (MBS) heavily subsidizes out-of-hospital services for primary care and specialty services and pays for free universal access to public hospital care. Primary care services are privatized and provided by general practitioners (GPs) who function as sanctioned gatekeepers. Specialists who work in both public and private health settings may only be accessed with a referral from a GP. The federally funded Prescription Benefits Scheme (PBS) subsidizes the cost of medications. Approximately 55% of the total population of 23.9 million is covered by optional private health insurance that affords beneficiaries access to private hospital care and flexible ancillary services.
Although Australia generally ranks highly in international comparisons of health care quality and health system efficiency, the fragmented system does have some difficulties. Urban public hospitals tend to have fewer resources than needed to meet their mission; Australia is facing an aging population; the health indicators for indigenous Australians lag behind those of white Australians; and there is a significant health professional maldistribution problem.
Proponents of the profession believe that PAs could make significant contributions to patients in a number of underserved areas, including rural and remote regions, primary health care services, Aboriginal medical services, and struggling urban public hospitals. Nevertheless, after a promising start, the implementation of the PA role has slowed.
The lack of acceptance of PAs partially stems from circumstances not common to the United States. In contrast to the United States, Australia does not have a shortage of doctors. According to the 2019 WHO update, in 2016, Australia had 3.6 doctors per 1000 people compared with 2.6 per 1000 for the United States, but significant problems with underutilization and misdistribution negated the oversupply. Furthermore, the number of medical schools has increased from 10 to 19 since 1999, and class sizes have ballooned over the same period. The Australian Medical Association (AMA) and the Australian Medical Students Association (AMSA) have opposed PAs over perceived competition for clinical training resources and potential jobs. Nevertheless, compared with more than 3400 medical school graduates annually, the small number of PA graduates is scarcely noticeable. Major nursing organizations also oppose including PAs in the Australian health system. Nurse practitioners in particular view PAs as redundant and as a direct threat to their employment opportunities. In 2019, nurse practitioners pushed for an expansion of their Medicare billing items and independent practice rights, which led to fierce opposition from the Royal Australian College of General Practitioners and the AMA. In their statements, they instead advocated for more team-based care. This approach aligns more with the PA model of practice.
Two Australian states, Queensland and South Australia, completed PA pilots between 2009 and 2010. Four years after the release of independent evaluations containing mostly positive outcomes, the Queensland government became the first to develop significant policy changes enabling PAs to practice within the public health system, Queensland Health. The South Australia state government has yet to record any forward momentum.
The first PA program in Australia began at the University of Queensland (UQ) in Brisbane in 2009. The 2-year master’s degree program graduated two cohorts totaling 34 students before it closed in 2012. There is now a single educational program at James Cook University (JCU) College of Medicine & Dentistry in Townsville, Queensland. The 3-year bachelor of health science (PA) course has been adapted specifically for mature age students with previous health care and tertiary academic experience living distantly. Similar to UQ, the average age of students to date at JCU is approximately 36. Paramedics account for the largest group of students enrolled, followed by nurses. Nine students graduated from the first JCU class. Cohort sizes remain relatively small. The JCU course is a fully integrated component of the College of Medicine & Dentistry. The JCU College of Medicine & Dentistry strongly adheres to a philosophy of social accountability and focuses on supplying medical and PA graduates to underserved populations and, in particular, to rural, remote, tropical, and indigenous Australia.
The emerging PA profession has received essential but incremental support from certain segments of the medical profession and health care advocates. The Australian College of Rural and Remote Medicine (ACRRM) became the first major health care profession organization to champion the PA model with a formal policy statement in 2011. This policy statement was reaffirmed in 2014. The Rural Doctors Association of Australia (RDAA) has endorsed the ACRRM policy. Despite these champions, the profession has struggled to gain a foothold. The Australian Society of Physician Assistants has continued to function even though the number of PAs in Australia is small. They continue to lobby at the state and federal level on behalf of PAs and the potential role PAs could play in Australia.
As in Australia, New Zealand faces an aging population, maldistribution of doctors, an extremely high rate of obesity, and challenges in providing culturally competent and accessible care for the native peoples of New Zealand, the M¯aori and Pasifika. Development of the PA profession in New Zealand was influenced by the earlier development of the profession in neighboring Australia, and by the positive experiences of some New Zealand doctors who worked with PAs during their U.S. residency training.
New Zealand PA development began with two pilot projects funded by Health Workforce New Zealand (HWNZ). The first trial in 2010 was a 1-year project at Middlemore Hospital in Auckland, part of the Counties Manakau Health services. Two U.S.-trained surgical PAs were hired to provide pre- and postoperative care in a busy surgical teaching service. Of note, the PAs were not permitted to participate in operative cases because of the Health Practitioners Competence Assurance Act, which restricts surgery to registered health practitioners.
The second pilot was intended to expand on the first by adding more PAs and by employing them in general practice to demonstrate their impact more broadly. For this demonstration, seven U.S.-trained PAs were recruited from 2013 to 2015. Six of the PAs worked in primary care settings in small cities or rural communities on the North Island, and one PA worked in a rural hospital on the South Island. Funding for each demonstration project included an evaluation process and written report summarizing the activities.
The first pilot, the surgical trial, demonstrated that PAs increased productivity on teams with a PA compared with those without, freed up house staff to spend more time in theatre, and improved continuity of care. There were no patient safety issues; on the contrary, the evidence suggested the safety was enhanced by having a PA on the team. PAs were noted to have good organizational, interpersonal, interprofessional, and patient communication skills, as well as good alignment with the medical model practiced by physicians. Nevertheless, the surgical trial was too short in duration to maximize the potential impact of the PAs, because it took some time for the PAs to be oriented and for other staff to become familiar with the new role on the team.
The evaluation of the second primary care demonstration was more robust. It was designed with mixed methodology to evaluate the PA role in multiple settings and to provide guidance to HWNZ on future directions for the PA profession in New Zealand. The report found that 30,000 patients were seen by PAs over the demonstration period with no safety concerns. Overall, PAs were found to make a valuable contribution to their practice settings in areas such as improved patient flow and throughput and in reduced workload for existing staff. PAs also had no negative effects on the training of junior doctors and were found to enhance training opportunities. They were found to work well with nursing staff, and nurses appreciated the contribution of the PAs. PAs were found to be cost-effective in their ability to deliver quality of care similar to physicians at a lower cost. Patients were very satisfied with the care rendered by PAs.
Although the demonstration evaluation reports were overwhelmingly positive, as of July 2019, PA regulation by the Ministry of Health has made little progress. This next regulatory step is the key to increasing PA scope of practice and efficiency, including prescribing authority. The New Zealand Medical Association (NZMA) strongly supports PAs. NZMA requested that the Medical Council of New Zealand, the regulatory body for physicians, take on the responsibility of regulating PAs. In 2015 the Medical Council sent a letter to NZMA indicating their willingness to provide regulatory oversight for PAs. An application for regulation was submitted to the Ministry of Health in February 2017, but no decision has been made. In the meantime, by request of the Ministry, the New Zealand Physician Associate Society (NZPAS) has created and maintains a voluntary national registry of PAs, which would provide minimal title protection.
By 2019, there were 6 U.S.-educated PAs employed in New Zealand. To work as a PA in New Zealand, NCCPA certification is required. PAs certified in other countries, such as the UK, Canada, or the Netherlands, therefore, cannot work in New Zealand. The rationale is to maintain the standards set by the successful demonstration project and to avoid introducing additional variables at this precarious period in the profession’s development.
NZPAS, with its small membership, advocates for the advancement of the profession, especially for regulation. PAs in New Zealand, a Commonwealth country, have chosen to use physician associate as their profession designation, in line with the UK approach, despite the fact that the first practicing PAs were U.S.-trained physician assistants.
Many of the early demonstration sites are eager to hire more PAs, having seen the advantages of having PAs as health care team members. NZPAS leaders regularly present to hospitals, health care services, and medical conferences throughout the country, advocating the advantages of implementing PAs, especially in general practice and in rural settings. NZPAS also receives frequent inquiries from PAs worldwide interested in living and working in New Zealand because of its natural beauty and high quality of life. Recently, discussions have emerged between New Zealand and Australia regarding cooperating in the development of common education and accreditation standards. The goal for the future of the profession in New Zealand is to achieve regulation for the profession, hire more U.S.-trained PAs in the short term, and develop education, accreditation, and regulatory processes to allow a future cadre of home-grown PAs.
The Middle East
The first Israeli PAs graduated from their education program in October 2017. The Israeli Ministry of Health started exploring the PA role in the early 2010s to address medical workforce shortages in emergency medicine, surgery, internal medicine, and pathology. This interest was especially encouraging given the initial opposition from many in the Israeli physician community, including the Israeli Medical Association. With the urgent need to alleviate health workforce needs, however, physicians and policy makers now acknowledge the need for PAs.
The factors that contribute to the demand for PAs in Israel include chronic overcrowding in hospitals, an aging population, an increase in chronic diseases, and a shrinking, overworked physician workforce. The large cadre of physicians who arrived from the former Soviet Union in the 1990s will soon retire. Additionally, Israel suffers from so-called “brain drain,” with educated professionals, including physicians, emigrating to countries with better professional and financial opportunities. Some specialties, such as those previously identified, have more significant gaps, in part because of preferences in specialty selection by physicians in training. Israeli physicians are facing stress and burnout. Many physicians are beginning to recognize the urgent need for PAs to ease their burden.
A shift in attitude within the government came in 2013 with the publication of a report from the Israel Ministry of Health’s (MOH) health care workforce committee, recommending exploration of the PA model in Israel. The MOH’s training department started the first PA training course in 2016, based at Sheba Medical Center in Tel HaShomer, with clinical training sites in emergency departments throughout the country. The 9-month training course in Emergency Medicine is open to paramedics with at least 5 years of experience and a bachelor’s degree. The course graduated its second cohort in June 2019, with the third course scheduled to begin in September 2019 ( Fig. 6.6 ).