The concept of a nontraditional clinician is not new or unique to the United States. At the same time, the US was creating the Physician Associate, the Chinese were developing the “barefoot doctor”. Growing in popularity across the globe, Physician Associates are now gaining ground in New Zealand, home of the Kiwis and Land of the Long White Cloud.
Like many areas around the world, including the United States, traditionally trained doctors are in short supply. The shortage of general practitioners (GPs) is said to be at a breaking point in New Zealand. Many of those general practitioners that are still in practice are burned out or set to retire. In New Zealand, where almost half of the general practitioners are foreign-trained, practices are closing and some rural patients are unable to find any type of health care at all.
Training Physicians and their Associates in the Pacific
Similar to the United States, New Zealand underpays its general practitioners relative to specialists. Yet most of the medicine practiced in New Zealand is considered primary vs secondary care. Nearby Australia also attracts NZ-trained physicians with promises of a more lucrative practice.
In New Zealand, prospective physicians earn a 6-year Bachelor of Medicine and Bachelor of Surgery (MBChB). This is compared to a 4-year bachelor and 4-year doctorate in the US. American physicians then usually complete a 1-year internship after which most go on to a 3+ year residency. After their medical bachelors, New Zealand physicians then complete a 2-year stint at the hospital before more specialized training can be pursued.
Physician Associate vs Bachelor of Medicine and Bachelor of Surgery
Physician Associates, also known as PAs, have been a critical part of the US healthcare system for nearly 60 years. For a time, they were unsuitably known as Physician Assistants. They train in rigorous 2-3 year graduate programs followed by optional residency training. They are particularly suited to primary care positions. New Zealand currently has no official registration for Physician Associates but that hasn’t stopped some intrepid pioneers.
Lisa deWolfe has been practicing medicine as a PA for over 30 years. “Physician Associates are medical practitioners trained in the medical model like doctors,” she said in a recent webinar. “PAs have the reputation of putting patients first, working hard, and playing key roles on health care teams,” she adds.
Physician Assistant, as the profession was previously known, was recently named the U.S. News and World Report’s 2021 Best Job in America. Forbes magazine has rated the PA profession “one of the most promising jobs for millennials”. And it’s a good thing, too, because there is a global shortage of healthcare providers to the tune of 7.2 million. It’s expected to increase to 13 million over the next 10-15 years. Yet PAs are still a relatively unknown entity in New Zealand.
“PAs do not replace doctors, nurses, nurse practitioners, or other health professionals. They complete the team and add to the team,” says PA deWolfe. deWolfe supports bringing in American-trained PAs to help relieve New Zealand’s massive doctor shortage. The PAs are purposefully placed in areas where the workforce shortage is most severe. Long-term placement is prioritized.
What Can a Physician Associate Do in New Zealand?
Because physician associates are still unregulated in the country, they do not have the ability to prescribe medication or order labs and images. Yet, clinics are still eager to utilize them. “The satisfaction rate is about a hundred percent. Most practices are wanting to hire another PA shortly after the first PA begins to work at their clinic,” says deWolfe.
The Physician Associate profession was first introduced to the island nation through two pilot programs with Health Workforce New Zealand in 2013. The pilot focused on rural emergency medicine. It showed that PAs were not only competent clinicians but that they also improved throughput and reduced the overall workload. Earning half of what a doctor does, PAs were especially noted to be cost-effective. One staff member at the pilot site pointed out that a clinic comprised of a GP physician, nurse practitioner (NP), and a Physician Associate could care for a population of 6,000 and still be profitable while also employing both an administrator and social worker.
The major difference between New Zealand PAs and their American counterparts is that the Kiwi PAs are still unable to sign their own orders. They otherwise practice independently. PA deWolfe explains that while certainly inefficient, it’s not an insurmountable barrier. “As soon as the doctors here got to know how we work and that we know all the medications and we know how to prescribe, we all worked out a way to move smoothly on a busy clinic day,” she says.
Most of the PAs coming to practice in New Zealand have had about 10 years of experience on average. A total of 30 Physician Associates have ever lived and worked in New Zealand. This makes the transition relatively painless notes PA deWolfe. The long-term goal, however, is to train PAs right in New Zealand which currently has two medical schools. Of the 30 PAs that have ever worked in New Zealand, only 12 are currently practicing. Demand is growing, however. There are apparently 30-40 PAs awaiting placement while 100 or so have recently expressed interest.
New Zealand Loves Physician Associates
Te Awamutu Medical Centre, on New Zealand’s North Island, cares for 14,000 patients. Opening in 1970, the clinic now employs 10 general practice physicians, a nurse practitioner, and one physician associate. PA Scott Deaton is a recent arrival to the Te Awamutu Medical Centre but is not new to medicine. Practicing since 2005, his experience is in urgent care and rural medicine.
Wayne Lim is the general manager at the clinic and shares his thoughts on PAs: “In 2015, we took on our first part-time physician associate and very soon after we tried out and got used to our first PA, we went looking for a full-time one.” Lim values PAs because they are trained just like physicians. “We really love physician associates because essentially they are trained in a similar diagnostic model to GPs and so communication amongst the PAs and the GPs is very, very good.”
At Te Awamutu, the PAs run the urgent care seeing 60 to 70 patients a day. Sometimes the PAs deliver traditional family medicine via booked appointments as well. “They fit in very well,” says Lim. “We’re so happy to have them as part of our provider mix and would actually be really stuck without them.”
From the Gem State to Aotearoa
PA Jackie Sartorius is another US-trained physician associate who has decided to call New Zealand home. Graduating from Idaho State University’s PA program in 2013, PA Sartorius began her medical career in Wilmington, North Carolina. She practiced geriatric and internal medicine before moving to South Lake Tahoe to work with the indigent community. She first came to New Zealand on a surf trip in 2017 and returned to stay only a year later.
“PA programs are an intensive 2-3 year Master’s degree,” says Sartorius. Prerequisites usually include a bachelor’s degree and typical pre-med coursework such as biology, microbiology, biochemistry, anatomy and physiology, abnormal psychology, and statistics. Required testing often includes the GRE and CASPER. Competitive applicants also have 1,000-2,000 hours of direct patient contact, often in the form of nursing or paramedicine.
Admission to PA school is notoriously competitive. For example, during the 2016-2017 application cycle, only 31% of applicants were accepted into PA training versus 41% of medical school applicants. After 3-4 semesters of medical didactics, PA students obtain clinical training in family medicine, emergency medicine, obstetrics and gynecology, general surgery, internal medicine, and psychiatry. Most programs allow one or more elective rotations where students can train in dermatology, orthopedics, or something else. PA Sartorius chose to do her elective rotation in oncology.
Your New Zealand PA Can
Contrary to the notion that PAs manage less complex patients, PA Sartorius explains that physician associates do it all. “We see any kind of patient: any acuity, any complexity. We’re not just there to pick off the easy ones and leave the harder ones for the GPs. We’re trained to know our limitations and work within our scope,” she says.
Over on the eastern coast of the North Island, you’ll find Hastings Heath Centre where CEO Andrew Lesperance sees physician associates as a potential solution to the growing physician shortage. “We have a significant shortage of GPs. More than 20 of the workforce will be retiring over the next 10 years–that’s quite substantial. We need to be thinking about how we find substitutes for that.”
Lesperance, a nurse, worked in Washington state in the intensive care unit where he always found the PAs to be helpful. “They work well as part of an integrated health team and actually provide quite a lot of cohesiveness. They have great hands-on experience as well and they do more than talking–they do the work,” he says.
PA Andie Cook is the only PA at Hastings Health. She graduated from the University of Utah PA program in 2010 and worked in urgent care and emergency medicine at a level 1 trauma center while commissioned with the Utah Air National Guard. Also an educator, PA Cook has returned to her alma mater to lecture on emergency medicine topics. She left the military at the rank of Captain in order to relocate to New Zealand.
Locums Tenens: A Temporary Solution
To address the staggering shortage of health care providers, New Zealand clinics turn to expensive locums tenens doctors. Cheryl Britton, office manager at Te Hiku Hauora, notes that temporary or locums physicians, make up 70% of their general practitioners. Locums contracts typically last 6 months. “This is not ideal for continuity of care and providing good long-term primary care to our community,” she says.
Just three years ago, Britton recalls all of the medical practices in the town of Kaitai where Te Hiku Hauroa is located were forced to close due to a lack of medical personnel. As a result, physician associates have been welcomed with open arms in Kaitai where Britton says that they are treated as colleagues.
“PAs are amazing clinicians,” she says. “Their ability to take responsibility for clinical decision making is very comparable to the GPs. But unfortunately, New Zealand’s government has yet to officially recognize physician associates as a profession. I’d really like to see that change,” states Britton. “It would provide an opportunity to optimize that workforce for us to then recruit more [PAs].”
Nurse practitioners entered New Zealand in 2001 and now number over 200. “Nurse practitioners were hailed as the solution to the GP crisis,” recalls Britton, “However, my experience in employing nurse practitioners is that they’re a nice supplement to the general practice workforce but they’re not a replacement for the doctors.” Britton implores the Ministry of Health to endorse and support physician associates in order to shore up the healthcare workforce in New Zealand.
Moving now to New Zealand’s South Island, we meet Karl Metzler, the CEO of Gore Health. “I cannot recommend PAs highly enough,” he proclaims. “We’ve had really good fits and matches for rural settings. Often the PAs have worked rurally and in a solo manner in the far reaches of the United States.” Metzler also points out that PAs train in the medical model as opposed to the nursing model favored by NPs. “They have single-handedly ensured the sustainability of our emergency department in a small rural area,” he adds.
According to Metzler, a South African native, PAs are a tailor-made solution to New Zealand’s workforce woes. Like Cheryl Britton, Te Hiku Hauora’s office manager, Metzler feels that the central government should look at the Physician Associate workforce seriously.
Shoring Up the Workforce
PA Tiffany Hodgson has lived in New Zealand for 10 years. In addition to working clinically, she works to get more American PAs in the country. Hodgson is the PA Liason at GP Business Solutions Limited. “We are looking for experienced PAs from the US and Canada that want to help pioneer the profession, want to live in New Zealand long term, and don’t mind a pay cut in exchange for better work-life balance in a beautiful country,” she says. The average wage for a Kiwi Physician Associate is $50 an hour. Although Hodgson helps to import American PAs, she supports the end goal of training New Zealand natives in New Zealand. The aim would be to help them return to their communities to provide high-quality healthcare.
American PAs earn $60-70 on average but Hodgson is betting that a pay cut won’t be a dealbreaker. “New Zealand’s an amazing place to live,” she says. “Why wouldn’t you want to trade that for the lifestyle here?”
Interview with NZ Physician Associate Society VP Shelly Collins, PA-C
How do you get through the day without being able to sign your own orders?
Once your supervising doctor is comfortable with your level of competence, you just put the orders under their name and then “co-sign” the order. Nurses can even do that with lab orders. Most prescriptions are sent electronically now without a wet signature anyway, so that is just a matter of sending it under the doctor’s name (controlled meds still need to be printed and signed by the Dr. ) Really the biggest pain in the neck are paper forms that have to be completed like driver medicals, some disability applications, etc. For those, I just complete the form/visit and then have to stand outside my doc’s door until he can sign right quick for me. GP’s aren’t allowed to order all the same things that GP’s in the US can. For example, the only imaging tests I’m allowed to order without talking to a specialist first are X-rays and ultrasounds. And then I have to follow an algorithm of specific criteria to get it covered. The health system here (once you understand how it works) is pretty straightforward with specific rules/criteria to follow. If I’m not sure if a certain issue needs imaging or not, I just look it up under “Health Pathways” and it tells me exactly which criteria would necessitate which imaging or if it really just needs a referral to a specialist.
What is an NZ paid? Are benefits included?
All PA’s in NZ right now are working in either GP, UC, or ED. Salaries range between $50-$70 per hour depending on expected hours, experience, clinic willingness to pay, etc. In my GP clinic, I am making $60/hr and work 32 hours per week. The only benefits included are CME re-payment, yearly licensing fee payments, etc. There is no health insurance benefit as there is Universal Healthcare and everybody has access to free or cheap healthcare regardless of their employer. Things like dentist and optometrist are out-of-pocket expenses. Health insurance is available which includes dental/vision, etc if you want to pay for it. Having insurance is helpful if you have a non-emergent issue and would be waiting for several months in the public system to be seen by a specialist. If you can pay privately, you can get seen much quicker. But I have not found a difference in the quality of care between the public and private sectors. All accidents/emergencies are covered by the government, even for tourists who are just visiting.
Are you still paying US taxes?
We still have to file US taxes, but since all of our income is from NZ now and we pay taxes here, we can deduct all the NZ taxes we’ve paid and don’t owe anything to the US. NZ taxes are an absolute dream. If you are an employee of a company (not a contractor, etc), the IRD (NZ version of IRS) keeps track of all your income and taxes you’ve paid and at the end of the tax year, just sends you an email saying you either have a rebate or you owe. There’s no form you have to complete or anything. And all your past income/tax info is easy to find on the IRD website. It’s so nice.
How is work-life balance different in NZ?
It’s a general sense that family/personal life comes first above work. There’s never a question of should you come to work vs stay at home with your sick kid, it’s assumed you will stay home. There are a bazillion federal holidays with Mondays off and EVERYONE takes them off. Other than the bigger fast-food chains and grocery stores, all other businesses are closed. There’s no shopping to be had on federal holidays. No one feels bad or guilty for taking a holiday/vacation. It’s expected that you take all your vacation days and enjoy them. I told my current supervising doctor that most employees in the US get about 2 weeks’ vacation per year (if you’re lucky) and he said “I’d die”.
Where are you at in the regulation process?
We are about 2/3 of the way through the regulation process. Our application to become a regulated profession has been accepted by Work Force NZ. The big hang-up right now is convincing the Medical Council to become our regulatory body. If they will agree, then we can move forward with getting a scope of practice set up, regulations to practice, etc. That does require us to pay an initial start-up fee to the Medical Council, so we will be doing some fundraising at that point. We should have an answer from Medical Council this year, but I”m not sure how far off actual Regulation with an NZ medical practitioner number would be. Things tend to move slowly.
What are some of the common questions you get from interested PAs?
We get a lot of questions from overseas PAs from various countries about how to become a PA in NZ. Until we are regulated, only PAs who hold national certification (US and Canada) are allowed to work in NZ due to an agreement we have with Workforce NZ and the Ministry of Health.