A PA (physician associate) could be the answer to your workforce pressures

Te Awamutu Medical Centre is helping to pioneer the use of physician associates in New Zealand general practice.

The recent RNZCGP 2020 workforce survey reinforces what Pinnacle forecast some time ago – namely the shift to a part-time GP workforce and looming retirement bringing about a critical shortage of GPs. The latest survey found 31 per cent of GPs will retire in the next five years. It’s an urgent call to rethink the future of New Zealand’s primary care workforce.

Te Awamutu Medical Centre (TAMC) currently has two full-time physician associates (PAs) on staff, with a third to join the team in July. They first introduced the role in 2015.

Practice manager Wayne Lim says, “We knew about the previous pilot, so were aware that PAs had been in New Zealand and had been tested in our system. We were interested and read a report explaining how the role could be deployed in the provider mix. Our directors could see the potential. Then an opportunity to employ a part-time PA kind of landed on our doorstep, and we thought why not?”

UK trained GP Amanda Henderson was a member of the TAMC team before the PA role was introduced.

“To be honest I had never heard of a PA. Like many of my colleagues at the time, I was a little sceptical at first. I thought it might feel like having a medical student, I wasn’t sure what the supervisory role would be like. But our first PA just came in and hit the ground running. They have really good knowledge and they don’t need a heap of supervision.”

Once a sceptic, Amanda now isn’t sure TAMC would cope without the PAs on board.

“Once they get their prescribing rights in New Zealand I don’t think it will feel much different than working with a GP, we’re a collaborative practice and profession anyway - people should question and support one another,” adds Amanda.

Dr Ernst Buhrs joined the practice as a partner after PAs were already established as part of the team.

“I hadn’t heard of the role but quickly learnt what a fantastic addition to the team they are. To me they are a lot like GPs – their training is great. Probably the only minor flaw is they cannot independently prescribe in New Zealand yet. There is a bit of inbox management and process stuff to sort out stemming from that, but it’s a pretty quick and easy adjustment.”

A New Zealand Physician Associate Society (NZPAS) has been established and it has submitted an application to Health Workforce New Zealand, which is moving slowly but surely through the regulation process. Once PAs are a regulated workforce prescribing rights can follow. The hope is that a local training programme will also emerge, securing a pipeline of New Zealand trained PAs.

Scott Deaton is the newest PA to join TAMC, with just three weeks under his belt at the time of interview. Having come from the United States, where he was able to independently prescribe, he’s taken the move, including adjusting to needing GP sign off on prescribing, well in his stride.

“I’d present my cases to my supervisor anyway, so even if I was signing my own scripts I’d still be checking in, challenging my own thinking, reviewing my treatment plans and choice of meds anyway,” says Scott.

Jackie Sartorius is entering into her third year with TAMC and was one of the first 15 PAs in New Zealand. She’s proud to pioneer the role in New Zealand.

“Patients don’t really ask about the role; I’ll introduce myself as a physician associate, but I don’t think I’ve ever had anyone ask me ‘what’s that?’ Most interactions I’ve had with other providers have been great too. I’ve had one consultant say ‘I don’t consult with nurses or PAs’ and hang up the phone, but that was definitely a weird exception and not the rule,” laughs Jackie.

Jackie was previously a high school science teacher, with a Bachelor of Science (Honours) in biology before completing her Master’s in Physician Assistant Studies. Scott was also a biology major and went straight into his master’s programme. Both are PA-C, meaning they are nationally board certified through the NCCPA in the United States.

A PA is trained as a generalist, in the medical model, receiving over 2,000 hours of clinical rotation. Versatility and collaboration are key outcomes sought in the training programme.

Most PAs in New Zealand are currently US trained. It is an intensive master’s level qualification, and to be a candidate for the programme you must have a bachelor degree, complete pre-med prerequisite courses and direct patient contact experience. Professions such as paramedics, nurses, pharmacists and radiology technicians are often found going down the PA route.

“I volunteered with a local hospital to gain my patient contact experience. I’d always contemplated the choice between medicine and teaching, my mum is a teacher which probably initially swayed me that way. Working as a volunteer affirmed my love for medicine and I know I’m in the right career for life now,” adds Jackie.

To remain board certified, PAs need to complete 100 hours of continued medical education every two years, and re-sit their board exam every 10 years. With PAs working in many countries worldwide there is a pilot programme to conduct recertification online, so hopefully by the time Scott or Jackie need to take the exam again they will be able to attend a New Zealand-based testing centre.

“Keeping up our certification can be a bit challenging, but online training definitely helps and the New Zealand Physician Associates Society is doing a lot of work with our regulating body in the United States, finding ways to credit training we complete in New Zealand,” she says.

Wayne believes adding the PA role in a part-time capacity at first was a good way for everyone to gradually adjust.

“Our team needed to assess a PA’s clinical ability, to see the role in action. Within two to three weeks we were all wondering why we worried.

“I think the really big bonus of PAs is they are GP extenders; the PA mindset is to extend the GP capabilities.

“PAs are used to reporting and calling on someone – they are trained to ask for help when they need it,” says Wayne. “That makes them really good team players, and all the PAs we’ve had here have consistently fit that mould.”

“We had to figure out some new processes, particularly with how to manage test results coming back. Using the PAs in our casualty department has been quite useful in smoothing those things, as there is often less follow up for those patients.”

Wayne explained TAMC’s strategy is to start with strengthening its drop-in service, extending into the PAs having booked appointments, and then experimenting with using PAs in outreach roles.

“We’re using the PAs time as best as possible, deploying where we’d have sent GPs and maximising the time GPs have for booked appointments.

“If you are short of providers and their books are full it can be hard to figure out how to implement new ideas for outreach or mobile services that might really make a difference in improving access and equality,” says Wayne.

“PAs, at just over half the cost of a GP, mean you can experiment a little more with new ideas. PAs add clinical capacity and can help improve continuity of care too, with a lower level of financial risk. The same opportunities are less available when using higher cost locums, so PAs just make good business sense.”

There are established channels in place to help recruit a PA from overseas, and due to GP shortages in New Zealand – and beyond – it’s a different experience from trying to find a GP.

“In our last round we had seven really high-calibre PA candidates who all wanted full-time work. We got to choose not just on experience and competency but also personality and team fit,” shares Wayne.

“When recruiting a GP, we are usually working via agencies and we get candidate options presented to us one-by-one. They are often only seeking part-time work and you have to assess just the one person; you don’t know when the next person might come along and if that person will be a better fit or not.”

TAMC believe by embracing the PA role they’ve increased patient access to primary health care while making the working conditions more attractive for GPs, actively reducing stress, overwhelm and burnout. Being cost effective, they’re increasing the efficiency and sustainability of their general practice too.

“With two full-time PAs here now and a third coming, we’ve made the call to staff our casualty department with PAs, rostering one GP to be available to them for a half day shift at a time,” says Wayne.

“Across the 8am-6pm day our PAs typically see 20-25 patients each. We hope this new system will give our GPs some time to spend on paperwork and telehealth while acting as the supervisor for the PA team.”

Of course, the PA is just one of the new roles we must urgently look at to increase the adoption of – others such as clinical pharmacists, primary care practice assistants, nurse practitioners and primary care paramedics all add additional capacity and capabilities to the general practice team.

These new roles, together with the extended care teams we have in Lakes, Taranaki and Tairāwhiti, along with the introduction of non-clinical roles supporting health coaching and social care, will help to ease the pressures felt by general practice and primary care.

We’re grateful to the team at Te Awamutu Medical Centre for so generously sharing their experience with the network.

If you would like to discuss how the PA role might fit into your practice, we’ll arrange a Zoom session with Te Awamutu GPs, PAs and business manager. Register your interest and we’ll confirm a date soon.

Alternatively, you can reach out to NZPAS, or GPB Solutions which recruits PAs.

You are also welcome to contact the practice directly. Please ask to speak to Wayne Lim, general manager, in the first instance.