A worrisome phenomenon currently sweeping the world is that of physician burnout, which has been recognized and defined as a clinical condition with actual symptoms. Resulting from multiple factors that include overwork and a change in physician-patient relationships, including a perceived lack of trust and appreciation, this can, frighteningly, result in suboptimal quality of patient care and an increased risk of medical error while simultaneously impacting on the physician’s quality of life and well-being.
We live in an era of crippling doctor shortages (for example there are just 4,000 cardiologists in India, but the actual projected need, given the size of our population, is of a whopping 88,000). Further, it is estimated that 89% of rural patients have to travel a minimum of 8 km to access any kind of healthcare. Such gaps are not going to be easy to fill and there is evidently a need for out-of-the-box approaches. This article explores one potential solution, namely the use of physician assistants or surrogates to support and supplement overworked physicians who are in short supply.
A growing role globally
The concept is not a new one. Since the early days of medical science it has been recognized that a physician cannot always provide comprehensive medical care in isolation, and the nurse, for instance, has always been an integral part of the healthcare delivery paradigm. In India since the 1970’s, provision was made in national healthcare planning for a cohort of trained midwives (called Dai’s or traditional birth attendants) meant to assist rural women in childbirth, realising that in the rural setting access to a physician, let alone an obstetrician, can be a challenge. In China, the barefoot doctors have from the time of Mao Zedong provided a healthcare alternative to physicians trained in the allopathic system.
When I moved to the U.S. in the 1990’s to train there as a radiologist, I was intrigued to see that ultrasounds there were performed by sonographers, which was entirely different than what I had been exposed to during my earlier years in India, where radiologists performed the sonograms. The distinction is subtle yet profound. A radiologist has completed (at least) four years of medical school, one of internship and four more of radiology residency before being permitted to scan a patient (other than in the on-call emergency setting in which residents participate). A sonographer on the other hand has undergone a 2 year course in radiography (the science of performing radiographs) followed by an additional year of specialised ultrasound training. Three years of training instead of nine. It was revealing to see the symbiotic relationship between these two cadres, each understanding and respecting the role and contribution of the other, with patient care as the focus. It was clearly understood that the sonographer was the person who acquired the images, and that the radiologist was the person who did the analysis/interpretation/reporting. No overlap and no conflict.
Two decades later, it is interesting to see the growing cohort of physician assistants that have entered the healthcare workforce in the US. Over 200 such training programs currently exist in the United States. A physician assistant undergoes 2-3 years of medical education, and is trained in all the subjects that allopathic physicians are. At the end of the course, the PA is licensed with a clearly defined scope of practice, based on collaboration with a licensed physician. As of 2016 there were over 100,000 physician assistants in the US. Further training in specialties such as Neurology, Trauma Care, Critical Care and Oncology allow for additional skills to be imparted in these specialties which face physician shortages providing an additional line of support for overworked specialists.
Similarly in the UK a cohort of Physician Associates was conceptualised and implemented in 2014-15. As observed by the then secretary of state Jeremy Hunt “The NHS is treating record numbers of people. That is why we are growing the workforce further with a new class of medic so busy doctors have more time to care for patients.”
A need for balance
In each of these examples the regulatory framework of the relationship between the physician and the assistant/associate is of paramount importance. The challenge is maintaining the fine balance in role definition where physician assistants/surrogates can add value and support physicians without posing an actual threat to the profession and practice of medicine.
In India, to achieve the required doctor-to-population ratio of 1:1,000, we will need 2.07 million more doctors by 2030, according to a study published in the Indian Journal of Public Health, in September 2017. Given that our medical colleges produce approximately 50,000 medical doctors each year, this would translate to another 750,000 doctors joining the workforce by 2030. This still leaves a huge gap of over 1.2 million doctors to meet the healthcare needs of India’s population.
Recognising the need to fill this gap, in a related development the Indian government is now making efforts to bring practitioners of alternate medical systems such as Ayush and Homeopathic doctors into the healthcare mainstream. The net result of this is however an increase in suspicion and concern on the part of existing allopathic medical professionals.
Concerns and threats
Some of the concerns include lack of professional regulation, governance and supervision, concerns about the impact on physicians’ training and income and the lack of clarity about physician surrogates and their roles. Essentially the fear of most doctors is that such personnel may offer a quick and cheap substitute for fully qualified doctors and potentially replace them. Given the years of hard labour and toil that a physician currently puts into his/her medical training, this is not an unjustified reaction. Having such assistants or surrogates work under the supervision and guidance of traditional allopathic physicians is one way, it may be logically argued, to ensure that standards and expectations are simultaneously met along with the healthcare needs of the population.
In India, an additional concern is related to the fact that traditionally there is a major prevalence of quackery. According to one study, there are one million unregistered and unqualified medical practitioners (quacks) in India. Such quacks can do significant harm to patient care and expose the inability of the state to effectively regulate healthcare delivery.
In radiology in India, the issue of physician shortage is of cataclysmic proportions, with only 15,000 radiologists to serve a country of 1.3 billion people (approximately 1 radiologist for 100,000 members of the public, which is a hugely inadequate ratio). Given that ultrasound is a time consuming and labor intensive procedure, it can be argued that sonography technologists could provide a helpful cadre of assistants to radiologists. However, the issue here is related to the PC-PNDT (Pre-conception and Prenatal Diagnostic Techniques Act of 1994) regulation. Introduced to halt the pernicious and tragic practice of female foeticide, this regulation necessarily provides safeguards essential to protecting the unborn female child, however it also nips in the bud the use of sonographers in ultrasound practice.
Regulation as the key
Ultimately, however, regulation is the key. If the process of training and certification/re-certification can be properly managed and regulated in India, as it is in parts of the Western world, with allopathic physicians given the opportunity to play a leadership role in the process, a cohort of physician assistants/associates could be of tremendous value in supporting doctors and addressing healthcare gaps in this time of dramatic physician shortages and burnout.
Views are personal.
The author is CEO & co-founder of Teleradiology Solutions, a global healthcare company headquartered in Bengaluru.
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