Physician associates as a potential win for the Aotearoa New Zealand healthcare workforce

As of July 2023, a proposal to regulate the physician associate (PA) profession under the Health Practitioners Competence Assurance Act (HPCAA) has been put forth by Manatū Hauora – Ministry of Health.¹

This proposal coincides with a much-lamented crisis in the Aotearoa New Zealand healthcare workforce as severe acute-on-chronic staffing issues plague both primary and secondary health sectors.² Mental health and addiction care in Aotearoa New Zealand is particularly vulnerable, with a dire urgency to both retain existing tertiary educated workforce and add new qualified clinicians.³

PAs are licensed clinicians who practise across all specialties of medicine under physician supervision. PAs conduct physical examinations, diagnose and manage illnesses, order and interpret laboratory tests and imaging, counsel on preventive health care, assist in surgery and write prescriptions. While PAs practise primarily in the United States, 15 other countries utilise PAs including the United Kingdom, Canada and Germany. Because of their close relationships with physicians, PAs train in the medical model at the Master’s level, typically at an established medical school. Entrants to PA education typically have over 3,000 hours of hands-on patient care experience such as paramedic, surgical technician, nursing, or medical assistant. Most PA programmes are approximately 27 months (3 academic years) and include classroom instruction followed by 2,000 hours of supervised practicum in the core disciplines of medicine. PAs work across all medical specialties in a complementary role to a supervising physician or group of physicians and share panels of patients to expand clinical workforce. A key aspect to PA training is knowing the limits of their medical knowledge and to seek help when needed. Supervisory requirements for PAs typically vary by region; most American state laws dictate the physician must either be available on-site or by phone for consultation, and a small percentage of the PA’s charts are reviewed per year.

Adding qualified PAs to the Aotearoa New Zealand healthcare workforce under HPCAA could potentially reduce dual burdens of patients awaiting medical care and physicians struggling to meet their needs. A mixed-method study of PAs in 15 countries concluded “the utilisation of PAs, particularly in primary healthcare roles, increases access to services, is cost-beneficial, and shows a physician-equivalent quality of care”.⁴ Given their physician-dependent role, PAs are largely introduced successfully into existing health systems as non-threatening to physician practice. PAs have been well studied to decrease acute care utilisation and hospital length-of-stay, improve patient safety and quality of care, increase access to services and may help decrease physician burnout.⁵ PAs frequently deliver care to populations that are traditionally under-served or rural.⁶ Patients are overall satisfied by PA care.^5,7

While PAs are not a one-size-fits-all response to the Aotearoa New Zealand healthcare workforce crisis, they can perhaps be part of the solution. A struggling mental health and addiction sector in Aotearoa New Zealand could certainly stand to benefit from an influx of experienced foreign PAs. In the United States, the National Commission on Certification of Physician Assistants (NCCPA) offers an optional specialty certification in psychiatry⁸ and PAs play a crucial role in treating substance use disorders, particularly in rural locations.⁹

Introducing foreign-trained PAs to Aotearoa New Zealand’s workforce must be given rigorous oversight and input from all key stakeholders. Māori cultural competency education with guidance from Te Aka Whai Ora – Māori Health Authority would need to be incorporated into the PA licensure process. Supervisory regulations under HCPAA, particularly for rural locations, should be established with input from both physician and PA organisations. Research on introduction of PAs in the United Kingdom notes that their lack of ability to prescribe and order radiographs limits their ability to ease primary and secondary care pressures if they are not able to fully utilise their skillset.¹⁰

Once structures and regulations are in place for foreign PAs to join Aotearoa New Zealand’s healthcare workforce, partnerships with existing PA programmes and organisations from overseas could be a means to introduce qualified clinicians. Rotations in under-served regions of Aotearoa New Zealand would introduce PA students until a local PA programme is established. A registry (such as through the New Zealand Physician Associate Society) that lists interested PAs by medical specialty could be a means to link under-staffed clinics and hospitals with new, qualified clinicians.

While introducing foreign-trained PAs under HCPAA would also introduce new sets of concerns and considerations, deployment of PAs globally into the healthcare workforce is largely considered a success. Aotearoa New Zealand’s struggling healthcare workforce could certainly stand to benefit from an influx of well-educated clinicians as a means to improve access and equity of care for patients. Evidence supports the introduction of PAs as beneficial to patients, physicians and healthcare systems worldwide, and Manatū Hauora – Ministry of Health would be wise to move forward with their proposed regulation.