Giving doctors a "doctor's assistant", the United States has been doing it for 56 years, can we too?

There is no vertical development channel for the assistant doctor, nor can he become a doctor, but only needs to specialize in his own medical process.

Written by | Ling Jun

Source | "Medical Community" public account

summary

Physician assistants have a history of more than 50 years in the United States, saving doctors many basic diagnosis and treatment links that do not require hands-on work, so that doctors can focus on the most core medical practices and concentrate on cutting-edge medical research.

China's private hospitals and doctor groups have taken the lead in the emergence of doctor assistant positions, but the positioning is diverse, which is very different from the concept of professional and homogeneous career development of doctor assistants in the United States.

A steady stream of doctors have become the largest "talent pool" for doctor assistants in public hospitals, although they have saved costs, but they have undertaken too much primary medical work and clinical chores, which is contrary to the original goal of "training".

Doctors in the United States earn $200,000-$500,000 a year, and physician assistants earn $100,000 a year. With China's current industry access and treatment standards, is there room for doctors' assistants to live?

Or maybe the establishment of a physician's assistant is more than just about a job adjustment. It requires us to re-examine the core medical values: is the focus of medical work on cost performance in the short term, or on the development of medical care in a long-term virtuous cycle?

The increasing number of patients, scarce expert resources, and the current heavy medical work often make doctors cry out, experts in clinical, department, teaching and research, exhausted but unable to work efficiently. Even so, most patients still feel that there is a lack of sufficient and effective doctor-patient communication time, and it is difficult and expensive to see a doctor.

As early as a few decades ago, overseas doctor assistant positions have been set up, aiming to more rationally and efficiently lay out medical resources. So what exactly is a doctor's assistant? Is it the doctor's secretary? In the exploration of deepening medical reform, can doctors' assistants also enter China's medical history, and what kind of changes will they bring?

What exactly is a physician assistant?

If you have a medical condition in the United States and want to see the attending doctor as soon as you enter the hospital, it is not so easy. American doctors are like being born in a "deep boudoir compound," and the doctor's assistant is probably the first person to respond when you "knock on the door."

In 1965, Duke University opened its first training program for Physician Assistants.PA, a profession that officially entered the history of human medicine.

After World War II, the number of patients in the United States increased, the number of general practitioners fell sharply, and the poor people were difficult to obtain medical resources, and because the training cost of doctors' assistants was relatively low compared with doctors, the establishment of this position effectively alleviated the shortage of resources for American doctors at that time.

Zheng Ting, a Chinese doctor in gastroenterology at the Mayo Clinic in the United States, introduced that the positioning of American doctor assistants is a middle-level medical staff with medical background, but it needs to be attached to a doctor's name to practice medicine.

In the process of diagnosis and treatment, the doctor's assistant is first responsible for collecting and judging the basic information such as the patient's signs, medical history, and medication history, and then chooses whether to formulate the examination and treatment plan by himself or to further notify the doctor according to clinical experience. However, procedurally, the decision of all doctor assistants needs to be confirmed by the superior doctor.

Taking general outpatient clinics as an example, since most of them are relatively "healthy" patients, the whole process of diagnosis and treatment of many people can be completed in the doctor's assistant link. In the fields of gastroenterology and neurosurgery, the patient's condition is relatively complex and serious, and most people eventually need to see the attending doctor.

In terms of staffing, surgery usually requires more physician assistants. Zheng Ting told the "medical community": "For example, in the department of orthopedics, because doctors need to be busy with surgery and the diagnosis of the patient's condition is relatively simple, the doctor's assistant can complete a series of tasks from diagnosis to preoperative guidance, and the doctor directly handles the most core medical links." ”

Under state law, physician assistants now practice almost the same scope as doctors in the United States, including evaluating diagnoses, developing treatment plans, prescribing, and assisting with surgeries. According to the National Council on Physician Assistant Certification, there were 123,089 physician assistants in the United States at the end of 2017, compared with more than 985,000 practicing physicians in the United States during the same period.

In the United States, the training of doctors is based on the elite education 4+4+X model, that is, 4 years of undergraduate study, 4 years of medical school, 3-7 years of residency training (according to different professions), after becoming a professional doctor, the average income ranges from 200,000 to 500,000 + US dollars.

"This positioning makes the United States set the standard of serving patients very high, often resulting in doctors not being able to see several patients a day." Zheng Ting said, "The existence of doctor assistants is to set up a relatively 'cheap' group of professional medical workers, save the basic diagnosis and treatment links for doctors without personal efforts, and save medical costs." ”

"At the same time, physician assistants have also done a good job of improving the uneven distribution of medical resources." In villages and community hospitals with fewer doctor resources, as well as small-scale private clinics where cost control is required, it is common for one doctor to be staffed with multiple physician assistants. ”

Physician Assistant,

"Miscellaneous", or "professional"?

According to statistics, in the United States, Canada and other medically developed countries, the average communication time between doctors and patients is 17.6 minutes, while in the top three hospitals with better conditions in China, due to too many patients, the average consultation time of each patient is only 5 minutes.

Under such circumstances, the establishment of doctor's assistant professions and posts in Our country seems to be one of the effective ways to rationally allocate medical resources.

But in fact, the position of "doctor's assistant" already exists in China, and it is piled up in private hospitals and doctor groups. The "medical community" searched through a recruitment website and found that more than 100 private medical institutions of various types have recently provided doctor assistant positions.

Zhang Qiang, founder of Zhang Qiang Doctor Group, believes that high-end private medical institutions and doctor groups have taken the lead in the demand for doctors' assistants because they employ top doctors, have high medical service positioning, and have strong autonomy.

In dr. Zhang Qiang's group, there are about 20 doctor assistants, all of whom have professional education backgrounds in nursing, and their main functions include assisting nurses in nursing work and helping doctors with patient management, including Internet information appointments, triage follow-up, and managing electronic medical records.

"Our physician assistants have a wide range of responsibilities and are flexible to adapt to the situation, which not only facilitates the process and service, improves the comfort of the patient, but also shares the trivial work for the doctor, so that they can concentrate on providing quality medical services to the patient."

"But unlike in the United States, our physician assistants are unable to perform the medical practices prescribed in the Practicing Physician Act, make a diagnosis, let alone prescribe a prescription." Zhang Qiang said.

In the Zhang Qiang Group, the identity of the doctor's assistant is more inclined to be "assistant". For Zhu Yan, a pediatrician at Shanghai Jiahui International Hospital, the situation is diametrically opposite.

Before coming to Shanghai Jiahui International Hospital, Zhu Yan has accumulated rich clinical experience in the Children's Hospital affiliated to Shanghai Jiao Tong University. At present, in addition to being the deputy chief physician of pediatrics in the hospital, she also has another function - the assistant doctor of dr. Teng Guoliang, the director of pediatrics.

"Some patients are unable to make a thorough diagnosis or formulate a treatment plan during Dr. Teng's 30-minute consultation, at which time the patient will be transferred to me and I will perform the various examinations prescribed by Dr. Teng. At the same time, I will also 'check the gaps and fill in the gaps', and finally discuss with Dr. Teng to formulate a corresponding diagnosis and treatment plan. ”

"And some patients who can't 'solve' in the outpatient clinic will also be transferred to me, and I will judge based on clinical experience, choosing whether to deal directly or further transfer to doctors in different subdivisions." Zhu Yan said.

In essence, although the development of social medical services has given birth to the position of doctor assistant, its positioning is various, on the recruitment website, the function of doctor assistants in different institutions ranges from appointment reception, brand promotion, instrument maintenance and cleaning, to auxiliary diagnosis, rounds and follow-up, which is very different from the professional and homogeneous career development concept of American doctor assistants.

Wang Yue (pseudonym), a Chinese student studying for a doctor's assistant master's program in the United States, told the "medical community" that in the United States, doctor assistant is a popular profession, its work intensity is not as high as that of doctors, and the difficulty of education, time and economic cost are far lower than that of doctors, but the income is considerable, and the average annual salary after entry is about 100,000 US dollars.

To apply for the doctor assistant major, you need to accumulate a certain amount of hospital internship experience (ranging from 500-2000 hours), and after the end of undergraduate studies (regardless of major), you will be admitted to the two-year doctor assistant master program.

In terms of career promotion, the doctor assistant has no vertical development channel, nor can he become a doctor, but only needs to specialize in his own medical links, which ensures the accuracy of his first diagnosis in different departments, especially in areas that need to be further subdivided according to the condition. For an experienced physician assistant, clinical diagnostic experience may even exceed that of a doctor.

Wang Yue introduced that for the daily work of some other non-diagnostic and therapeutic behaviors, there is also a special position in the United States, called medical assistant (MA, Medical Assistant), whose job responsibilities include answering patients' inquiries and appointment services, entering patient medical records and information, etc. Practitioners do not need medical background, after three months of training can be hired.

"For doctor assistants, there is no need to consider too much high-end medical technology and scientific research, nor to consider other clinical 'trivia', neither to do 'deep', nor to do 'miscellaneous', just to do 'special'." Wang Yue said.

There are rules for Peisheng,

Do I still need a doctor's assistant?

In the world, the training and use cost of doctors are high, and how to optimize the structure of medical manpower is a topic that requires long-term research and development.

China's private medical institutions and doctor groups of "doctor assistants" do not form a consensus industry standard, but more according to the size, positioning, concept, medical saturation of different hospitals to develop their own recruitment and responsibility standards.

The situation in public hospitals is more complicated. From the perspective of hospital administrators, there is no doctor assistant profession in China's medical education, and the establishment of new positions requires additional staffing and economic costs, while a steady stream of medical trainees have both professional knowledge backgrounds and low "use" costs, which seems to have become the largest "talent pool" for doctor assistants.

The clear purpose of residency training is to cultivate senior talents with high theoretical professional knowledge and operational professional skills through clinical practice. However, in practice, in the top three hospitals in large cities where the medical run phenomenon is the most serious, the actual role of regulating doctors after joining is more to alleviate the heavy workload of doctors.

According to the feedback and discussion of different resident medical trainees on social networks, the actual work of different departments and hospitals includes from writing medical records, night shifts, assisting doctors to assist in operation...

Zheng Ting told the "medical community" that young resident medical trainees in the United States also have duplicates with the work of doctor assistants, but the doctors mainly have to focus on the practice and learning and discussion of cutting-edge medical treatment. "Their goal is to become an elite doctor, and taking on too many primary care jobs may seem to save costs for the hospital, but it is not conducive to personal career development."

Sun Yuqiang, attending physician of the First Affiliated Hospital of China Medical University, believes that for public hospitals, the regulation trainees can indeed share some basic work, but the increase in doctor assistants should not only be for the consideration of "lack of work", but need to think about the core values of the entire medical system.

In 2018, Sun Yuqiang went to the Mayo Clinic in the United States to participate in clinical research as a visiting student. He told the "medical community" that the american doctor assistant is only one part of the system, and everyone in the medical system has clear job responsibilities, works according to the established procedures, and ensures homogeneous medical services.

"And long-term practice also makes every link relatively reliable, forming a relationship of trust between medical staff and doctors and patients at all levels." Sun Yuqiang described an observation he had seen in a U.S. hospital:

A patient with an accidental fracture is directed into a special consultation room after registration, where a doctor's assistant first conducts an initial examination and asks if pain relief is needed.

If necessary, the nurse will come to make a second judgment based on her clinical experience, and if agreed, the doctor's assistant will prescribe painkillers, and then make an appointment for imaging and refer it to an imaging doctor.

Immediately after that, a financial officer will come to the docking to discuss specific payment methods, and finally meet with the attending doctor.

"It takes about 2 hours from the time the patient enters the hospital to the time he sees the attending doctor, and there will be different contingencies according to the priority of the patient's condition." Sun Yuqiang said, "Although not all hospitals are so detailed, this is a general framework for medical care in the United States." ”

"But China's national conditions are different, on the one hand, patients can not accept such a long medical time, and Chinese patients generally rely on expert doctors, even if it is a minor disease, they do not trust medical personnel other than doctors. Sun Yuqiang said.

Sun Yuqiang believes that doctors' assistants are only a microcosm of medical reform, and in the short term, such a refinement of positions and processes does look "inefficient" and "high cost". But once this system is gradually improved, doctors can be liberated from complicated work, have more time to practice cutting-edge medicine, and middle and low-level medical personnel can also ensure the accuracy of medical behavior within the scope of professional authority, and patients will gradually adapt to this system.

"What is the focus of medical work on cost performance and efficiency in the short term? Or is it the medical development of a long-term virtuous cycle? This involves a question of core medical values. Sun Yuqiang said.

Does China have the conditions to set up doctor assistants?

Looking at the conditions for the development of doctor assistants in the United States, it is because the United States first established the elite status of doctors, and then made a clear distinction between the academic background, professional responsibilities, and remuneration of personnel at all levels of the medical system, refined the positions, and formed a clear vertical career echelon. In this model, the doctor's assistant is an indispensable link.

In China, as Sun Yuqiang said, the establishment of doctor assistant positions is not only a one-sided "demand" problem, but also the need to refine the position and process, requiring managers to take the lead in making a more forward-looking top-level design.

Teng Guoliang, director of the Department of Pediatrics at Shanghai Jiahui International Hospital, believes that the model of american doctor assistants is worth learning, and in China's current medical practice, there are actually similar models explored.

"It is not that there is no concept of a doctor's assistant in China, but it is often implemented in the way of a team of doctors, such as a director with 2 to 3 attending doctors, and then with 5 to 6 residents, responsible for a whole group of patients, forming a grading in the treatment process." Teng Guoliang said, "Including our graded diagnosis and treatment, the three-level rounds system, in fact, are all aimed at using medical resources more efficiently." ”

"But unlike in the U.S., our 'physician assistant' is not a definitive medical worker position. Since China currently does not have a practice license corresponding to a doctor's assistant, there is a lack of corresponding laws and regulations to clearly divide its diagnosis and treatment functions and responsibilities. ”

In this regard, Teng Guoliang believes that the premise of establishing a doctor's assistant is to have a corresponding practice license, and the scope and responsibility of the doctor's assistant are divided first. In addition, since China's medical students have learned the basic medical knowledge in the training of undergraduates, this resource should be effectively used, and young graduates are free to choose to obtain a practicing physician qualification certificate or a "doctor's assistant qualification certificate".

"Resident doctors and regular training doctors are going to develop to the 'upper' after all, and after the next batch of personnel comes in, senior doctors have to train new people from scratch." Teng Guoliang said, "But if you can make the doctor's assistant a fixed position with medical background talents, you can form a talent echelon in depth, and doctors can also 'delegate power' in primary diagnosis and treatment work to alleviate pressure." ”

Zhang Qiang believes that in the "under" of doctors to set up a middle-level medical worker position, industry positioning and treatment standards are the premise to determine whether employment channels can be formed.

The "medical community" launched a survey on the current status of doctors' salaries in China in 2019, and the data shows that in 2018, the average annual income of doctors before tax in the country was 117,000 yuan, while the income distribution was concentrated in "60,000 to 100,000" and reached 42%. In addition, Academician Wang Chen pointed out at the 2020 Zhongguancun Forum that 40% of China's occupational doctors still do not have a bachelor's degree.

Zhang Qiang told the "medical community" that the current average treatment level of doctors in China is too low, which is one of the objective factors restricting the formation of doctor assistant positions. The academic qualifications and income standards of doctors' assistants need to refer to doctors, and for most ordinary medical institutions, it is almost impossible to recruit an "assistant" who has received professional training and even has a master's degree with an income lower than the salary of a general doctor.

On the other hand, Zhang Qiang believes that under the existing medical education system in China, there is no need to open a special "doctor assistant" major for the time being.

"Compared with the United States, the entry threshold for doctors in China is too low, and it is very difficult for a large number of graduates of general medical schools to become a top doctor in the future." Zhang Qiang said, "We can directly take the lead in the talent reserve of medical students who are specialized and undergraduate as doctors' assistants." Once the corresponding positions emerge, these students can also have more career options: whether to go back to being a grassroots doctor or to become a doctor's assistant in a 'high-end' hospital. ”

Source: Medical community

Editor-in-charge: Ling Jun

Proofreader: Zang Hengjia

Plate making: Xue Jiao