The Changing Nature of the Medical Team, New Roles and Role Substitution

Like the rest of the western world, New Zealandfaces a growing shortage of registered medical practitioners. Increases in the population together with the fact that it is aging means that demand for health services will continue to increase.  Changes in work practice (e.g. the increasing emphasis on work/life balance) will only exacerbate the need for more health professionals.

As a result New Zealand is increasingly looking to new ways of meeting our population’s growing health needs. Ideas given currency include role or task substitution, and the creation of new medical roles.

This paper sets out NZMA’s position as to the changing medical workforce.

Position Statement
NZMA accepts that given the global medical practitioner shortage and the likely increase in health care needs over time, one part of the solution will be to look at how the current medical team functions with a view to improving the team’s effectiveness.

Changes to the structure of the medical team however cannot and never will be the entire solution.  Training more doctors, and taking steps to ensure that the doctors we recruit choose to continue practising in New Zealand will always be the primary action that needs to be taken if New Zealand is to meet its future health care needs.

Better Use of the Medical Care Team
NZMA believes that the current model of the medical care team, being a collaborative model which is comprised of doctors, nurses and other allied health professionals, continues to be the appropriate model for the provision of medical services.

NZMA recognises that over time the roles of doctors, nurses and other allied health professionals will evolve in response to the changes in the delivery of health care.  NZMA supports nurses and allied health staff working in expanded roles, (usually under the leadership of a medical practitioner) on the following principles:

• Proposals to expand the roles of nurses and other allied health professionals should only be considered where they will enhance patient outcomes;
• Role expansion and appropriate training programmes for nurses and other allied health professionals should be achieved by consensus, with the involvement of doctors, nurses and allied health staff in determining the need for and type of job redesign, and in the establishment of appropriate clinical guidelines;
• Rigorous and objective assessment processes are in place to closely monitor the progress and measure the impact of role expansion on patient outcomes and team function;
• A medical practitioner will usually remain responsible for coordinating the health care team  and managing the care of patients;
• There should be a strong commitment to a team based approach to health care, rather than the creation of new independent roles;
• The expanded nursing and allied health roles, and training for these expanded roles, must not interfere with the opportunities for medical students and doctors to learn and practice clinical skills;
• All health professionals should have access to appropriate administrative support services; and,
• There should be a professional and courteous relationship between doctors, nurses and other allied health professionals with mutual acknowledgment of, and respect for each profession’s contribution to patient care.

Role/Task Substitution
While NZMA supports the greater use of all members of the medical care team, it is extremely cautious about role/task substitution as a resolution to medical practitioner shortages. Medical practitioners play an essential role in formulating diagnoses, overseeing the management of patients and providing timely interventions necessary to maintain the health of the patient. Medical practitioners have a thorough appreciation of the complexity of medical decision-making and are trained to consider the whole person in developing management plans. Separating out aspects of a medical practitioner’s role and giving these responsibilities to another allied health professional without appreciating how these tasks fit into the entirety of the decision making process and/or continued oversight of these tasks by the medical practitioner has the potential to compromise the quality of care provided. It is imperative that the medical practitioner remains at the centre of the medical care team and has ultimate responsibility for the care of the patient.

New Roles – Creation of a Medical Assistant Career Pathway
Although new to New Zealand the idea of a medical assistant – variously called physician assistants (USA) and Medical Care Practitioners (UK) is not new.  They have been working in the USA since 1967 and are now being used in various guises in Canada, India, some parts of Europe and the UK. 

Defining the role of the Medical Assistant
In preparing this statement we have based our view of the medical assistant on that of the physician assistant in the USA. Thus when we are discussing the new role of medical assistant we are thinking in terms of a healthcare professional licensed to practice medicine under the supervision of a registered medical practitioner. It is not envisaged that this role is based around administrative support for the medical practitioner. It is a dependent role and works within a team environment. As to training while this is something still to be determined, our initial thoughts are again around the USA model. Under that model:

The training of a physician assistant typically consists of 25 months studying an intensive core curriculum, emphasizing a primary care, generalist approach. Most entrants have a first degree prior to entering training, and in many cases have clinical experience of some sort as well. On graduation from accredited training, PAs must pass a national certifying examination of the National Commission of Certification of Physician Assistants. Subsequently, they are required to complete 100 hours of continuing medical education every two years and to pass a generalist medical recertification examination every six years, regardless of their clinical specialty.

The NZMA believes that provided the appropriate regulatory framework is created, and the new vocation is appropriately supervised by a registered medical practitioner, the medical assistant could add value to the medical practice team. We see the following as being key principles, which should govern this role:

• The role needs to be developed with the best interests of patient care and safety in mind;
• The delegated care model as practiced in theUSAis the appropriate model forNew Zealandto look to in developing this role;
• Subject to standing orders and appropriate supervision, medical assistants should be able to prescribe;
• Medical assistants must work within the medical practice team rather than in competition with it;
• The role needs to be defined and aligned with education, training, competency and  registration requirements;
• In supporting medical assistants the government will need to set up a formal regulatory body to set standards and oversee initial and continued registration with reference to both competence and fitness to practise;
• A medical assistant’s continuing registration should be dependent on their ongoing professional development.

In creating any such role we believe that the Medical Training Board must be a key stakeholder.

As with the USA we believe medical assistants could play a role in both primary care practice and in hospitals.

Caveats
Having said the above NZMA notes the following by way of caveat:
In developing the role steps must be taken to ensure that medical trainees are not disadvantaged in terms of training (either in terms of both getting such training, as well as continuing to perform all necessary tasks in terms of that training).  In our view while medical assistants could play a part of the interdisciplinary team, any benefit they can offer our medical service would be grossly cancelled out if as a resultNew Zealandtrained fewer doctors, or doctors left the country because they could no longer get the training or experience they needed.

Nomenclature
NZMA believes the new role should be called “medical assistant” so that the public are not misled into believing the person they are seeing is a fully qualified doctor.

Next Steps
If the Government were to decide to proceed with developing this role it is the NZMA’s view that the development should be done through a steering group comprised of representatives from all the relevant medical schools and colleges, as well as the NZMA.