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Journal of the American Academy of Physician Assistants:
doi: 10.1097/01.JAA.0000453240.00098.83
Commentary

Physician assistants in the Netherlands

Driesschen, Quinten van den MPA; Roo, Frank de MPA

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Quinten van den Driesschen is a master PA in family practice and emergency medicine and a docent/advisor in the master PA program at Hogeschool van Arnhem en Nijmegen in the Netherlands. He is a past president of the Netherlands Association of Physician Assistants (NAPA). Frank de Roo is a master PA in pediatrics and cardiosurgery at the Academic Medical Center Utrecht and president of NAPA. The authors have disclosed no other potential conflicts of interest, financial or otherwise.

This November, the Netherlands Association of Physician Assistants (NAPA) celebrates its 10th anniversary with a 3-day international symposium in Amsterdam (http://www.pa-invest.nl).

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The first four PAs were introduced in the Netherlands at the end of 2001; this year, the number of Dutch PAs will exceed 1,000. In each of the next few years, 150 to 200 PAs will complete their program. Unlike in other countries, the Netherlands was not prompted to introduce PAs by a shortage of physicians or rural areas lacking healthcare facilities. This country of 17 million has about 60,000 physicians, and all inhabitants are covered by healthcare insurance for a contribution of 360 Euros (about $489 US) per person per year. Everyone is registered with a general practitioner's office, which refers patients when needed to physicians; most physicians work in hospitals, as do about 75% of Dutch PAs.

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HISTORY OF THE PROFESSION

The Dutch PA profession traces its history to the late 1990s, when the Dutch ministry of health foresaw a future shortage of all healthcare workers and studied different solutions to keep costs in control and find new career opportunities for healthcare workers. Physicians thought that PAs could help alleviate problems with continuity of medical residents on hospital units and in outpatient clinics. Experts also visited the United States to learn from the experience of the American PA profession.1 The first PA program, which was not accredited, was organized in Utrecht in 2001 by a few physicians and was led by cardiothoracic surgeon Aart Brutel de la Riviere. The first students graduated in 2004.

The first accredited Dutch PA programs began in 2003 in Nijmegen and Utrecht. Three new PA programs were started in 2004 in Amsterdam, Groningen, and Rotterdam, bringing the total number of PA programs in the Netherlands to five. These programs are accredited at the master's level by the Accreditation Organisation of the Netherlands and Flanders.

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PA EDUCATION

Dutch PA programs are 30 months long and educate students in a broad range of medical care and competencies. PA students must have a healthcare-related bachelor's degree and at least 2 years of clinical work experience in the healthcare domain.2 The programs incorporate a dual work-education model, which means that students are employed within a particular medical specialty 2 days per week, under the supervision of a mentor physician, while enrolled in the master's PA program.2 The students undertake didactic and clinical education within this medical specialty from the beginning until the end of the curriculum. This model is very successful because in addition to teaching students it assures them of a job after graduation.

Dutch PAs conduct low- to moderately complex medical tasks within certain specialties, both in primary and secondary care.2 Since January 2012, PAs are authorized to indicate and perform predefined medical procedures and prescribe medications without supervision.2 The scope of practice will be reevaluated in 2017.2

“Physician assistant” is a protected title by law, under the Dutch Individual Health Care Professions Act, meaning that all registered Dutch PAs are licensed to practice.2

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PROFESSIONAL ASSOCIATION

NAPA has played an important role in the success of the Dutch PA profession. Founded by students in 2004, NAPA collaborates with PA programs, government, and medical professional organizations to promote the PA profession. Registration was introduced by NAPA in 2009 following the same rules as physician registration; both professions require continuing medical education as a condition of licensure.

NAPA also provides a successful model for other European countries that are considering developing a PA profession, and has collaborated with the United Kingdom and Germany.

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WORLDWIDE COLLABORATION

Studying the different PA curricula in the United States, Canada, United Kingdom, and the Netherlands, and the different job descriptions, we see that the profession is performed at the same level in these countries. But can PAs practice in a country other than the one in which they were educated? What are the obstacles? How can these be solved? Is there a mutual interest to look for means to prove equality?

We found no documents about special regulations on employability. However the Dutch PA title is protected in the Netherlands, where the government decides whether to recognize foreign diplomas. International collaboration by PA professional organizations (such as that being considered by the American, Canadian, United Kingdom, and Netherlands PA associations) may help expand employment opportunities for PAs across borders.

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RESEARCH OPPORTUNITIES

Few studies have been done on PAs in the Netherlands.3-7 More studies are in development or in progress on the cost-effectiveness of PAs, billing by PAs, best practices, and which procedures should be reserved for physicians. Additional studies are needed to strengthen the position of PAs in the Dutch healthcare system. Here, too, collaboration is needed on international professional and educational standards.

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REFERENCES

1. Harbert K, van den Brink G, Smith R, van Bergen B. Best practice approach to the development of an international physician assistant program: the University of Arnhem-Nijmegen model. JAAPA. 2004;15(2):115.

2. Timmermans MJ, van Vught AJ, Wensing M, Laurant MG. The effectiveness of substitution of hospital ward care from medical doctors to physician assistants: a study protocol. BMC Health Serv Res. 2014;14:43.

3. van Vught JAH, van den Brink GTWJ, Wobbes T.Implementation of the physician assistant in Dutch health care organizations. Association for Medical Education in Europe conference, 2013.

4. Tromp Meesters RC, Hettinga AM, van den Brink G, et al. Task shifting and quality of care in practice; physician assistants compared with anaesthesiology residents in the preoperative anaesthesiology outpatient clinic. Ned Tijdschr Geneeskd. 2013;157(19):A5518.

5. Kuilman L, Nieweg RM, van der Schans CP, et al. Are Dutch patients willing to be seen by a physician assistant instead of a medical doctor. Hum Resour Health. 2012;10(1):28.
6. Merkle F, Ritsema TS, Bauer S, Kuilman L. The physician assistant: shifting the paradigm of European medical practice. HSR Proc Intensive Care Cardiovasc Anesth. 2011;3(4):255-262.

7. Spenkelink-Schut G, ten Cate O, Kort H. Training the physician assistant in the Netherlands. J Physician Assist Educ. 2008;4:46–53.

© 2014 American Academy of Physician Assistants.

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