Medical associate professionals in oral and maxillofacial surgery

Recent discourse around the implementation of medical associate professions (MAPs) into medical specialties has proven divisive and controversial. These roles could benefit oral and maxillofacial surgery (OMFS) departments and grant trainees increased operating experience, but their implementation could prove detrimental to training. We discuss the potential impact in OMFS.

Non-medical practitioners in the staffing of emergency departments and urgent treatment centres in England: a mixed qualitative methods study of policy implementation

BACKGROUND

Patient demand, internationally, on emergency departments and urgent care treatment centres has grown. Shortages of staff, particularly of emergency medicine doctors, have compounded problems. Some countries are pursuing solutions of including non-medical practitioners e.g., nurse practitioners and physician associates/assistants in their emergency department workforces. This study investigated at the macro and meso level of the health system in England: what the rationale was and the factors influencing the current and future employment, or otherwise, of non-medical practitioners in emergency departments and urgent treatment centres.

METHODS

Mixed qualitative methods in the interpretative tradition were employed. We undertook, in 2021-2022, a documentary analysis of national, regional and subregional policy (2017-2021), followed by semi-structured interviews of a purposive sample (n = 18) of stakeholders from national, regional and subregional levels. The data were thematically analysed and then synthesised.

RESULTS

There was general national policy support for increasing the presence of non-medical practitioners as part of the solution to shortages of emergency medicine doctors. However, evidence of policy support dissipated at regional and subregional levels. There were no published numbers for non-medical practitioners in emergency departments, but stakeholders suggested they were relatively small in number, unevenly distributed and faced uncertain growth. While the experience of the COVID-19 pandemic and its aftermath were said to have made senior decision makers more receptive to workforce innovation, many factors contributed to the uncertain growth. These factors included: limited evidence on the relative advantage of including non-medical practitioners; variation in the models of service being pursued to address patient demand on emergency departments and the place of non-medical practitioners within them; the lack of a national workforce plan with clear directives; and the variation in training for non-medical practitioner roles, combined with the lack of regulation of that level of practice.

CONCLUSIONS

We identified many features of a system ready to introduce non-medical practitioners in emergency departments and urgent treatment centres but there were uncertainties and the potential for conflict with other professional groups. One area of uncertainty was evidence of relative advantage in including non-medical practitioners in staffing. This requires urgent attention to inform decision making for short- and long-term workforce planning. Further investigation is required to consider whether these findings are generalisable to other specialties, and to similar health systems in other countries.

The influence of government policies on the nurse practitioner and physician assistant workforce in the Netherlands, 2000-2022: a multimethod approach study

BACKGROUND

Many countries are looking for ways to increase nurse practitioner (NP) and physician assistant/associate (PA) deployment. Countries are seeking to tackle the pressing issues of increasing healthcare demand, healthcare costs, and medical doctor shortages. This article provides insights into the potential impact of various policy measures on NP/PA workforce development in the Netherlands.

METHODS

We applied a multimethod approach study using three methods: 1) a review of government policies, 2) surveys on NP/PA workforce characteristics, and 3) surveys on intake in NP/PA training programs.

RESULTS

Until 2012, the annual intake into NP and PA training programs was comparable to the number of subsidized training places. In 2012, a 131% increase in intake coincided with extending the legal scope of practice of NPs and PAs and substantially increasing subsidized NP/PA training places. However, in 2013, the intake of NP and PA trainees decreased by 23% and 24%, respectively. The intake decreased in hospitals, (nursing) home care, and mental healthcare, coinciding with fiscal austerity in these sectors. We found that other policies, such as legal acknowledgment, reimbursement, and funding platforms and research, do not consistently coincide with NP/PA training and employment trends. The ratios of NPs and PAs to medical doctors increased substantially in all healthcare sectors from 3.5 and 1.0 per 100 full-time equivalents in medical doctors in 2012 to 11.0 and 3.9 in 2022, respectively. For NPs, the ratios vary between 2.5 per 100 full-time equivalents in medical doctors in primary care and 41.9 in mental healthcare. PA-medical doctor ratios range from 1.6 per 100 full-time equivalents in medical doctors in primary care to 5.8 in hospital care.

CONCLUSIONS

This study reveals that specific policies coincided with NP and PA workforce growth. Sudden and severe fiscal austerity coincided with declining NP/PA training intake. Furthermore, governmental training subsidies coincided and were likely associated with NP/PA workforce growth. Other policy measures did not consistently coincide with trends in intake in NP/PA training or employment. The role of extending the scope of practice remains to be determined. The skill mix is shifting toward an increasing share of medical care provided by NPs and PAs in all healthcare sectors.

Integration and retention of American physician assistants/associates working in English hospitals: A qualitative study

BACKGROUND

Health workforce planners in many high-income countries are considering policy strategies to retain home and overseas-trained health professionals. There is a lack of evidence on how hospitals can successfully integrate and retain skilled overseas professionals in relevant work roles. This study aimed to explore the integration and retention experiences of skilled American physician assistants/associates working in English hospitals.

METHODS

A qualitative study using semi-structured telephone interviews was undertaken in spring 2017 and spring 2018. Data were coded and analysed using thematic analysis. The study was framed within a theoretical model of role development.

RESULTS

Nineteen physician assistants/associates participated in interviews at timepoint one, and seventeen at timepoint two, across seven English hospitals. Four themes were identified in the integration and retention processes experienced by participants: motivations and expectations, seeking role identity, acceptance and integration, and establishing a niche role. Supervising doctors appeared instrumental in creating opportunities through training and system adjustment that enabled development of niche roles; offering an effective match between participant skills and interests, and medical/surgical team or organisational needs. Whether or not they had a niche role influenced the decision of participants to remain or leave.

CONCLUSION

Integration approaches that maximise the value of the skilled health professional to the medical/surgical team and support retention, including development of optimum roles, require time and resources.

Paramedics and Physician Assistants in Israel

Israeli emergency medicine is undergoing change. The paramedic is experiencing high separation rates because the position is understaffed, overworked, and underpaid. Physician assistants (PAs) were introduced into the emergency department by training paramedics and to date they seem satisfied with this new role. Experience in other countries indicates that PAs can improve access to care, reduce errors, increase efficiency and have satisfying roles in health systems. The Israeli health system will need to determine if additional roles for PAs will be accepted by the public and physicians alike.

Understanding patients' satisfaction with physician assistant/associate encounters through communication experiences: a qualitative study in acute hospitals in England

BACKGROUND

Physician assistants/associates (PAs) are a recent innovation in acute hospital teams in England and many other countries worldwide. Although existing evidence indicates generally high levels of patient satisfaction with their PA hospital encounters, little is known about the factors associated with this outcome. There is a lack of evidence on the process of PA-patient communication in hospital encounters and how this might influence satisfaction. This study therefore aimed to understand patients' satisfaction with PA acute hospital encounters through PA-patient communication experiences.

METHODS

A qualitative study was conducted among patients and representatives of patients seen by or receiving care from one of the PAs working in acute hospital services in England. Semi-structured interviews were undertaken face-to-face with study participants in the hospital setting and shortly after their PA encounter. Data were coded and analysed using thematic analysis. The study was framed within a theoretical model of core functions of medical encounter communication.

RESULTS

Fifteen patients and patient representatives who had experienced a PA encounter participated in interviews, across five hospitals in England. Four interrelated communication experiences were important to participants who were satisfied with the encounter in general: feeling trust and confidence in the relationship, sharing relevant and meaningful information, experiencing emotional care and support, and sharing discussion on illness management and treatment. However, many participants misconceived PAs to be doctors, raising a potential risk of reduced trust in the PA relationship and negative implications for satisfaction with their PA encounter. Participants considered it beneficial that patients be informed about the PA role to prevent confusion.

CONCLUSIONS

PA encounters offer a constructive example of successful clinician-patient communication experiences in acute hospital encounters from the patient's perspective. Study participants were generally naïve to the PA role. Hospital services and organisations introducing these mid-level or advanced care practitioner roles should consider giving attention to informing patients about the roles.

WORKFORCE: The career aspirations and expectations of -student -physician associates in the UK

The NHS five year forward view 1 supports the development of a flexible workforce. Expanding the traditional medical workforce using physician associates (PAs) is increasing in popularity. This study explores the career aspirations and expectations of student PAs from a large PA school in England. Thematic analysis of qualitative data from an online survey examined the personal motivations and career aspirations of student PAs. Finally, we make nine recommendations to enhancing recruitment, retention and development of PAs post qualification. Lessons learnt from this data set are generalisable.

Patients' perspective of physician associates in an acute medical unit within an English district general teaching hospital - a pilot survey study

Physician associates (PAs) are valuable members of the -medical team. However, few data are available concerning their role and contributions in acute settings from the perspective of patients. The current study explored patients' acceptance of the role of PAs in the NHS. A questionnaire was distributed to 100 patients who were under care of PAs in the acute -medical unit (AMU) of George Eliot Hospital. The questionnaire explored previous exposure to PAs, satisfaction in PA's attitude and knowledge, PA value to NHS and overall satisfaction in PA profession. Fifty women (58.1%) and 36 men (41.9%) with a mean age of 74.75 ± 10 years participated in the study. Most of the survey responders stated that the attitudes, professionalism and medical knowledge of PAs were good or very good and nearly all of respondents were satisfied or very satisfied with the role of PAs in the NHS. This pilot questionnaire survey study in the AMU of an English district general teaching hospital showed that most study participants valued the role of PAs in the NHS.

Physician associates in primary health care in England: A challenge to professional boundaries?

Like other health care systems, the National Health Service (NHS) in England has looked to new staffing configurations faced with medical staff shortages and rising costs. One solution has been to employ physician associates (PAs). PAs are trained in the medical model to assess, diagnose and commence treatment under the supervision of a physician. This paper explores the perceived effects on professional boundaries and relationships of introducing this completely new professional group. It draws on data from a study, completed in 2014, which examined the contribution of PAs working in general practice. Data were gathered at macro, meso and micro levels of the health care system. At the macro and meso level data were from policy documents, interviews with civil servants, senior members of national medical and nursing organisations, as well as regional level NHS managers (n = 25). At the micro level data came from interviews with General Practitioners, nurse practitioners and practice staff (n = 30) as well as observation of clinical and professional meetings. Analysis was both inductive and also framed by the existing theories of a dynamic system of professions. It is argued that professional boundaries become malleable and subject to negotiation at the micro level of service delivery. Stratification within professional groups created differing responses between those working at macro, meso and micro levels of the system; from acceptance to hostility in the face of a new and potentially competing, occupational group. Overarching this state agency was the requirement to underpin legislatively the shifts in jurisdictional boundaries, such as prescribing required for vertical substitution for some of the work of doctors.