Taiwan experimented with a physician assistant (PA) model of care that was popular and growing from the mid 1980s to 2005. However, an effort to formalize the education process met resistance from the Taiwan Medical Association and organized nursing, and legislation to legalize the PA profession was defeated. All PAs in Taiwan became nurse practitioners (NPs) and assumed roles that span nursing and medicine. This article revisits the PA movement and assesses how political ideology can disrupt well-meaning and useful health policy.
The PA movement is a global one and has some presence in at least 10 countries, including Australia, Canada, Germany, Ghana, India, South Africa, Saudi Arabia, The Netherlands, the United Kingdom, and the United States.1 The development of PAs in Taiwan began in the 1980s and was sparked by shortages of skilled medical labor. After more than 2 decades of robust economic growth, Taiwan established universal national health insurance (NHI) in 1995. However, physician supply was unable to meet the demand of the newly insured.2 PAs were seen as a viable option to meet the demand for services. Many healthcare professionals, trained in the United States where the PA movement started, wanted to see a similar type of clinician in their hospitals.
Each year in Taiwan, 1,300 newly trained physicians enter the healthcare system. Most resident physicians tend to work in large medical centers in urban areas instead of mid-to-small-size hospitals in rural areas. They also choose less demanding specialties. Thus, many regional and local hospitals have a chronic shortage of primary care and on-duty physicians. Physician burnout due to the stress of high patient volume also contributes to the shortage and threatens the quality of care.3
DEVELOPING A PROFESSION
During this period of healthcare demand leading up to and after NHI implementation, many hospitals began training experienced nurses to carry out routine medical work independently and collaboratively with physicians. Because this was a decentralized effort with many variations in training and responsibility, these clinicians were called by different titles, including:
- NPs (Chang Gung Memorial Hospital, 1984)
- clinical nurse specialists (Mackay Memorial Hospital, 1986)
- PAs (Chi Mei hospital, 1992)
- advanced NPs (Buddhist Tzu Chi Hospital, 1997).
Although formally and informally trained by individual hospitals with different programs, these clinicians were never legally certified and the curriculum never standardized. By 1997, 67.1% of hospitals in Taiwan had PA-like personnel. More than 90% of these clinicians worked with physicians in hospital settings in roles similar to hospital-based PAs in the United States. Although a full accounting was not taken at the time, the number of PAs is believed to be close to 500. This number may have been larger because more than 1,650 participants sat for the first national NP examination in 2006, and many were previously PAs.4
Taiwan's physician shortage, a problem for decades, became worse after NHI implementation in 1995. The single-payer program covers 99% of Taiwan's 23 million citizens and involves 95% of its hospitals. Coverage is comprehensive and copayments are very low, so demand for medical services increased almost overnight: the average number of annual outpatient visits per person rose from 5.5 before NHI to 15 after NHI, average inpatient visits increased from 4.5 to 13, and average length of hospital stays from less than 2 days to 9 days per inpatient visit.5 Much of this was due to pent-up demand for management for chronic illnesses.
Although the numbers of physicians and nurses increased by 67.3% and 127%, respectively, from 1995 to 2012, the workload for medical care professionals outpaced this growth.6 Taiwan has 1.7 practicing physicians per 1,000 population, compared with 2.5 in the United States and a median of 3.2 for countries in the Organization for Economic Cooperation and Development (OECD). Taiwan has 4.9 active nurses per 1,000 population, compared with 11.1 in the United States and a median of 8.7 for OECD countries.7
To standardize and centralize PA training, the first PA education program was established at Fooyin University in 2002.8 The university drew on three well-respected PA consultants and developed a curriculum that emulated PA programs in the United States, consisting of 83 credits of didactic courses and 1,224 clinical hours. The founder of Fooyin University had trained as an internist in the United States and wanted to continue what he saw as a model of PA use for Taiwan. The program was operational only for 2 years. The Ministry of Education of Taiwan denied the program's accreditation when an amendment of the Medical Care Act for PA legislation failed to pass in 2004. As a result, the PA program at Fooyin University was forced to close and students were transferred to the department of nursing.
In April 2004, the Taiwan government amended the Medical Care Act and added an article prohibiting healthcare institutions from hiring clinical assistants to conduct medical practices. Instead, the government began promoting NP certification to legalize previous PA-like personnel and modified the Nursing Personnel Act to let NPs practice under physician instruction. Thus, NP has become an acceptable and unifying title and has eclipsed the Taiwan PA profession since 2006.
NP education occurs in qualified institutions, is 6 months in length, and includes 184 credit hours and 504 hours in practice. To earn an NP certificate, candidates must pass a two-stage examination; a written test and an Objective Structural Clinical Examinations skills test. The first national NP examination was held in 2006 and has been conducted annually, with an average oral test pass rate of 41% and skill test success rate of 72%. As of 2013, the number of qualified NPs has grown to 4,463 (Table 1), with 3,684 NPs still employed as of 2013.
The daily activity of NPs includes rounding wards with attending physicians, prescribing orders under the supervision of physicians, collecting and reporting laboratory data and imaging results, recording medical progress on charts, and attending medical conferences. However, some invasive procedures such as draining ascitic fluid or pleural effusions and removing stitches have not been explicitly defined in many of these settings. In retrospect, the NP role seems less broad than what was anecdotally reported by the PAs. At the same time, NPs' work stress and high burnout rate continues to be a problem.9 Most NPs work in both medical and nursing departments and the administrative requirements often increase role conflict.10
Dr. Chin-Chun Yeh, former Minister of Health, wrote about the problems of PAs working under the title of NPs.11 He indicated that PAs should be legalized because of the physician shortage. Furthermore, the government promotes putting physicians under the protection of Labor Standards Act, which would limit working hours and worsen the physician shortage. Consequently a new call for the return and legalization of PAs has gained attention in Taiwan.12
Why did the PA movement in Taiwan rise and then die? When a university president wanted to formalize a PA education program that was standardized and modeled after the US model, a strong resistance from both medical and nursing associations arose that could not be overcome. We contend that the arguments of the day were more about the shortsighted protection of the medical and nursing professions and less about the needs of society. Nevertheless, we are aware that legalizing PAs in any country is a social action that also involves political wrangling and the need for influential champions. In 2004, Taiwan's 1,000 PA-like personnel were not numerous enough or united enough to change the vested interests of medicine and nursing. Perhaps more PAs with a better communication network could overcome that resistance. Perhaps a nationally prominent physician spokesperson could have shepherded the process more adroitly.
Taiwan's population is aging, and a sustainable long-term-care system is a priority. More physicians are needed in hospitals and communities. The Taiwan PA movement, even in its brief period of existence, appears to have been successful, is missed, and is now being reviewed. Some type of PA-like clinician is needed to resolve the shortage and uneven distribution of physicians. To achieve this goal, we suggest the various models of PA programs be revisited. Furthermore, we believe the incorporation of domestic PAs needs to be developed by medical schools and not by nursing schools. At the same time, we argue from a health policy perspective that legalizing the PA profession early on in the process will provide the impetus needed to restart this vital medical labor force.
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Copyright © 2015 American Academy of Physician Assistants
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