Instituting the Role of Physician Assistants in Emergency Departments

Background

In 2016 Israel’s Ministry of Health (MoH) embarked on a multi-dimensional initiative to improve the level and quality of service of emergency departments (EDs). This initiative included a decision to institute the role of physician assistants (PAs) in EDs as an aid to physicians in the performance of their varied activities. Although discussed previously, the establishment of the role in Israel only matured in 2016. In 2012, the Director-General of the Israeli Ministry of Health (MoH) assembled a committee to examine the need for PAs (the Physician Assistant Committee, 2013). The committee concluded that the health system could benefit from the addition of PAs. It recommended that the first such roles be created on the basis of an existing profession and regulated by the Physicians Ordinance. In May 2016, a specific course began at the Sheba Medical Center to train PAs for EDs. Another recommendation by the committee was that the process of PA integration be supported by accompanying research. As a result, the MoH asked the Myers-JDC-Brookdale Institute to evaluate the integration of PAs into EDs.

The goal of the study was to evaluate the integration of PAs into Israeli EDs from the perspectives of hospital directors and ED managers, as well as ED physicians and the PAs themselves.

Methods

The study was divided into three parts to permit an examination of the perspectives of each of the parties involved in the integration process. In the first part, there were two rounds of in-depth interviews with hospital deputy-directors, and ED managers and physicians where PAs had been introduced (33 interviews). The first round took place from May to December 2016, the second – from May to November 2017. In the second part of the study, an on-line survey was conducted of 129 members of the Israeli Association for Emergency Medicine (IAEM – June to August 2017). The survey dealt with the PAs’ duties and the extent of their assistance. The third part contained two questionnaires administered to participants of the first PA training cohort, one at the beginning of training (May 2016), the other a year later (June 2017). At the start of training, respondents were asked about their motives for choosing the PA profession, and their expectations of the new role. At the end of training, they were asked about the difficulties and challenges of the role, and the extent to which it had met their expectations.

Findings

In the in-depth interviews, all the ED physicians and managers stated that they were highly involved in integrating the PAs into EDs. The expectations of the ED managers concerning the new role were varied. Some managers compared it to the PA position in the US, which is an established profession with PAs there permitted to perform a variety of medical interventions. Others failed to understand the need for the new role or to distinguish it from nursing. Hospitals in which the managers had set high expectations regarding the new role tended to grant the PAs broader authority. The integration of the role into EDs differed in form by hospital and was adapted to each. Most ED managers said that the PAs assisted only physicians, whether out of principle or necessity (because of opposition to the new role from nursing staff). Most managers reported that the PAs had integrated successfully with the ED staff and workwise, on both the professional and interpersonal levels. However, at most hospitals, we did hear of opposition, to varying degrees, from the nursing staff. Other difficulties concerned the definition of the role, the level of training, and low remuneration.

According to the survey of IAEM members, some 60% of the 70 physicians who worked in an ED with PAs ranked the extent of the assistance they provided for various ED duties as great or very great. Nonetheless, there were considerable differences in the degree of autonomy granted to the PAs in the different hospitals. The overriding majority of physicians (23) from EDs that had did not have a PA (altogether 27 physicians) said that they were interested in adding this type of role to the ED.

In the PA survey, respondents were asked to rate the degree to which each factor (from a pre-prepared list) had attracted them to the new role. We found that between the beginning and end of the course, there was a substantial decline in how they rated the factors of attraction. The most prominent decrease concerned the chances of better remuneration or career advancement.

Relatively few PAs reported difficulties in working with physicians or integrating with the ED team; 44% reported very little or no resistance at all from the nursing staff while 25% reported that they did feel resistance to a great or very great extent when working with the nursing staff. Satisfaction with the decision to become a PA was very high at the beginning of the course. A year later, satisfaction had decreased considerably though it remained high. A negative correlation was found between the PAs’ level of satisfaction and their sense that the new role had not met their expectations.