To the Editor: We read with interest the recent editorial by Van Der Weyden on the issue of doctor displacement.1 We agree completely that a transparent and evidence-based approach to health care roles is essential.

In proposing a pilot program of physician assistants (PAs) in South Australia to examine the potential of “physician extenders”, we broadly used the model applied to the introduction of new therapies in medicine, including new drugs:

• Evidence of an unmet need;

• Evidence of safety and efficacy in another setting;

• A monitored pilot/trial in practice;

• Re-evaluation after a defined period with a defined process; and

• An emphasis on any ongoing utilisation being a consistent and national process.

This last point is noted in the Australian and New Zealand College of Anaesthetists’ submission to the National Health and Hospitals Reform Commission.2 We emphasised the need for any proposed future clinical role for PAs to be defined, followed by identification of the required knowledge base, training and education requirements, and certification.

Not all new health care roles have followed such a pathway, and this provides potential challenges for ensuring quality, safety, consistency and “trademark definition” (widespread understanding of the role). In the case of PAs, it was evident at a recent International Forum for Physician Assistant Education in the United States that the definition of the term “physician assistant” varies greatly internationally, potentially confusing future debate on this topic in Australia. Hence, to develop a robust Australian model, any proposals for ongoing use and training of PAs would have to be discussed at a national level.

To the Editor: The Journal’s Editor is a man of words and we love him for it, but, as Lord Tennyson said: “For words, like Nature, half reveal and half conceal the Soul within” (In memoriam A.H.H., 1850).

So what does his Christmas issue editorial1 really reveal about our man of words? He has unfortunately biased the debate about physician assistants and other alternative health care providers with his editorial’s very title: “Doctor displacement”. Doctors will not be displaced — liberated, perhaps, to concentrate on things that interest them, where their advanced skills can be best used and where they can make the most impact. This is not (nor should it be) about maintaining the status quo. The debate should be about how to provide health care to patients and the community, ensuring that they can get appropriate advice from well trained professionals when and where they require it.

Most health services are now provided by teams — no longer is it ethical to promote the idea of an autonomous practitioner, be it nurse or doctor. The great strength of the physician assistant is that it is a “delegated model”, dependent on the doctor and not, as the editorial suggests, able to practise independently. Physician assistants will never be able to practise independently; they will always have to practise under supervision and within the scope of practice of their supervisor.

Nowhere in Van Der Weyden’s editorial is the issue of preventive health, as an important physician assistant or other health professional role, raised, nor the fact that health professionals might use teleconsulting to link across disciplines and geographical areas. These are aspects that could change workforce requirements dramatically. Australia currently spends a minor fraction (less than 5%) of its $90 billion health budget on trying to prevent illness.2 We must use our health dollars more wisely and effectively.

Also absent from the editorial is mention of the current global shortage of 4.5 million health workers. On this point, the MJA should look to the Lancet to see how it has consistently run a global agenda on health services and workforce, pointing out our responsibilities to low- and middle-income countries.3 The world is divided into those with and those without effective health care. Opinions on proposed changes to health care split into those who say “why?” and those who say “why not?” Editor, you have always appeared to us to be in the latter group. Please don’t disappoint us now by becoming a nay-sayer. We want to see this Journal promoting a health system that is patient-focused and health professional-friendly, and not one that just maintains the status quo.

In reply: I appreciate the comments of Brooks and Mitchell on the importance of words to editors — they are, after all, their tools of trade. Indeed, this is no more so than in the titles of editorials, wherein their succinctness must not only encapsulate the tone and theme of the text but, having captured the readers’ attention, induce them to read on.

It seems, however, that the title of my recent editorial “Doctor displacement: a political agenda or a health care imperative?”1 has caused disquiet and prompted the accusation of “bias”. And the offending word? “Displacement”. The Concise Oxford Dictionary defines the verb “displace” as: “shift from its accustomed place”, “remove from office” and “take the place of; oust”. Given the substance of the editorial, it was my intention that all these connotations were relevant in the context of this many-layered debate.

In essence, the editorial focused on the urgent need for the profession to address, or at least debate, the increased instances of “task transfer” or “role substitution” occasioned by the escalating numbers of nurse practitioners and physician assistants. Despite Brooks and Mitchell proffering the conventional justification of this recent phenomenon as being “teamwork”, history tells us that this may well be academic double-speak. One precedent was the protracted tussle some 300 years ago between organised medicine and apothecaries, who were to eventually evolve into the progenitors of general practitioners.2 More recently, there have been well documented instances of physician assistants establishing independent practices in the United States.3

One could say that the very title of my editorial seems to have mesmerised Brooks and Mitchell, who have fixated on its seeming bias, ignoring the editorial’s subsequent exploration of current workforce issues in the delivery of quality health care and the urgent plea for the profession to have an evidence-driven debate.

On the other hand, it is easy to appreciate their sensitivity to the phrase “doctor displacement”, given their ongoing commitment to the University of Queensland’s postgraduate physician assistant training program.