Journal of Health and Medical Sciences

Objective: The objective of this study was to examine if patients, visiting a hospital outpatient’s clinic, were satisfied about the care delivered when a PA instead of a doctor is the provider. Methods: The study methodology was a descriptive quantitative approach using an eight-item survey and an option to include free text comments. Results: There was no difference in satisfaction levels between consultations with doctors or PAs, as part of a pilot project introducing the PA role. Conclusions: In Ireland, patients are just as satisfied with the care they received from PAs and doctors. Findings are consistent with findings in other countries where the PA role is embedded. In meeting the patient's needs, an important aspect of care given by both doctor and PA seems to be keeping the patient informed and behaving in a professional manner.


Introduction
Healthcare in Ireland has a two-tiered system of public and private services.The government-funded public hospitals are owned and run by the Health Service Executive (HSE) or are voluntary public hospitals, which may be privately operated but funded by the government.The public system, although providing similar quality care to private hospitals, is overbooked and waiting lists can be long, even for operations that demand some urgency.In fact, Ireland, together with the UK and Sweden, had the worst patient feedback on accessibility/waiting time problems among the 35 countries ranked by the EHCI, Ireland coming in at 21 st place (Health Consumer Powerhouse (2016).The fact that Ireland has the highest percentage of the population (> 40 %) purchasing duplicate healthcare insurance could be regarded as an extreme case of dissatisfaction with the public system.
During the Irish recession, it is suggested that resources were not well deployed and cost savings were, in fact, 'false economies' (Williams & Thomas, 2017).According to these authors, the claimed financial savings was offset substantially by overtime payments, and the need to rely on more expensive agency workers.While a key focus in many countries during the time of austerity was to move away from a reliance on doctors in primary care, Williams & Thomas (2017) suggest that this was not a policy focus for Ireland.It seems that staff nursing numbers fell during the period monitored (2008 -2014), but there was an increase in nurse specialists and therapists.In summary, a more efficient use could have been made of the resources, in particular, those deployed on agency staff and retirement packages offered.The opportunity of considering a Physician Associate/Assistant (PA) role to address the shortfalls in staffing is opportune.The challenges to meet health targets, shortage of doctors, over-reliance on secondary care without investment in primary care, have been political issues tackled by several Irish governments.The focus on healthcare can be seen to change, depending on which political party is in power.In 2016 the opportunity to form a committee across the political spectrum was provided.This committee developed consensus on a long-term policy direction for Ireland's healthcare system, to ensure that, in future, everyone has access to an affordable, universal, single-tier healthcare system, in which patients are treated promptly on the basis of need, rather than ability to pay (Houses of the Oireachtas, 2017).
Alongside these challenges and developments, a pilot project was set up with the Department of Health, in Ireland, to introduce the role of the PA in 4 surgical services in one large urban teaching hospital in Dublin.As part of an evaluation of a two-year pilot project (Joyce et al., 2019), the team undertook a study on patient willingness to be seen by a PA with surrogate patients who were not yet familiar with the role in Ireland (Joyce et al., 2018).The findings of the latter study suggest that patients are willing to see a PA, if they can be seen quicker than any other clinician.In other words, expediency is a primary motivator.The study presented here formed part of the overall evaluation of the pilot project and followed the focus of a study in the US (Hooker et al., 1997) comparing clinicians.Patient satisfaction was measured in two of the surgical services in a hospital where the PA role was being piloted.While the project commenced with 4 PAs (recruited from North America) across four services, there were two PAs in two services, in the second year of the project, when this data was collected.The other PAs returned to their country of origin.The aim of this study was to examine whether patients, visiting a hospital outpatient's clinic, were satisfied with the care delivered when a PA instead of a doctor was the provider.Embedded in this study is whether there is a correlation between the patient satisfaction and socio-demographic factors.

Methods
The study methodology is a comparative quantitative approach.There was an option to include free text comments at the end of the survey.During the four weeks of the study, there were 285 patients booked to attend the out-patients' clinics, sampled.Using convenience sampling, all were invited to participate in the study.

Data Collection
Data was collected via survey, with eight items, examining the effectiveness of communication of doctors and PAs with patients.A Likert-type scale was used, measuring agreement with statements from strongly disagree to strongly agree (on 5 levels).Using an instrument already tested (Counselman et al., 2000), communication and interpersonal skills were viewed as core attributes contributing to patient satisfaction.Patients were invited to complete the survey after their consultation with the PA or the doctor.The sample site is a training hospital with the supervising physician and trainee doctors attending to patients in the clinics.Some patients did not complete the survey.In some cases, this may have been due to the outcome of their consultation, for example, in the breast clinic, patients have an initial consultation with the doctor or PA.A follow-up mammogram is sometimes ordered, which necessitates the patient going to the radiology department and returning later to the clinic.Some of these patients may not complete the survey if they receive bad news, or they are stressed after the consultation.When it was noted by the researcher that patients seemed upset or stressed, they were not reminded about the survey on checking out.

Results
Data was analysed by descriptive statistics, and free text comments were analysed using content analysis.During the four week period of data collection, 260 patients attended the outpatients' clinics across the two services sampled (15 patients in total did not attend their appointment as scheduled).Seventy-four completed surveys were returned (28% response rate), out of which 22 (30%) were seen by the PA and 52 (70%) by the doctor (supervising physician and/or trainee).Where patients saw both supervising physician and doctor/PA, they completed the survey for the first clinician encountered.Table 1 shows the characteristics of the survey respondents.As the clinics surveyed included a breast clinic, it is not surprising that the majority of the patients were female (77%) with 58% of the age group between the ages of 31-50 years.Both groups of patients were compared on age and education in addition to gender.

Differences in patient satisfaction
Overall there was no difference in the satisfaction rating with doctors and PAs (Table 2).Consultations with the PA were equally positive as indicated with this sample of comments: A well-planned clinic.Very satisfied with service.(P10) I was very nervous.All the staff were friendly and put me at ease.Thank you.( P70) Out of all the appointments, this one has been the most informative and put me at ease.(P33)

Z was very nice and helpful. (P44)
Where improvements were indicated, the following comments were volunteered by two patients: With respect to organising the appointment, it was a little unclear that I should have come in earlier to get the blood tests done.(P15) Extremely slow.Waited 2 hours for appointment.People with later appointment taken before me.(P41) While both patients (P15 and P41) were seen by a doctor, these comments relate to administration issues in organising the clinic and have been communicated to the appropriate staff.It is interesting to note that another patient had a very positive experience around wait time in the clinic:

So efficient, thank you. (P69)
There were no significant differences found between satisfaction levels and age, gender, or education.

Discussion
Numerous studies (Hooker et al, 1997;Counselman et al, 2000;Hooker, 2001;Freeborn et al, 2002;Roblin et al, 2004;Hooker et al, 2005;Cipher et al, 2006;Budzi et al, 2010;Berg et al, 2012;Dill et al, 2013;Johnson, 2016;Kurtzman & Barnow, 2017;Meijer & Kuilman, 2017) have found that care given by the PA is at the level of that given by doctors with high levels of satisfaction.Patient satisfaction is believed to be an important component of healthcare because satisfied patients are more likely to seek medical advice, follow through with treatment recommendations, keep their follow up appointments, and maintain a good patient-doctor relationship (Levesque et al., 2000).This study found similarities with previous studies in that, once patients' needs are met and in particular, that they are communicated with, and informed of their health status, they are satisfied.For Ireland, this is the first study on patient satisfaction with a PA and a doctor because this is the first project piloting the PA role.Being a small exploratory study, it draws on previous studies and an instrument already tested.One study in the US compared the level of patient satisfaction with the PA and NP in people aged 65 years and older (Cipher et al., 2006) while an earlier study (Hooker et al., 1997) added certified nurse midwives and physicians as providers.There was no difference in patient satisfaction levels regardless of provider.Conclusions reached for both studies are that patients do not generally distinguish preferences for types of providers once communication and interpersonal care needs are met.However, one study (Budzi et al., 2010) suggests that patients prefer to see NPs as compared with PAs and physicians because they focus on health promotion, disease prevention, health education, and counselling.
The PA development drive emerged from a scarcity of doctors, and the process for filling the void varies among countries (Ballweg & Hooker, 2017).The PA profession has emerged as a reasonable strategy for augmenting a stretched doctor cadre.According to a recent Irish report (Walsh & Brugha, 2017), there are three main medical workforce stressors that continue to undermine Ireland's ability to achieve medical workforce sustainability and compliance with the WHO (2012) Global Code on recruiting international health personnel.These include high rates of emigration among Irish medical school graduates, the need to comply with European Work Time Directive (restricted work hours for doctors), and increasing demand (Walsh & Brugha, 2017).The resulting dilemma is that the increased domestic supply of doctors is not sufficient to keep Irish hospitals staffed (Pflipsen et al., 2019).These findings support the consideration of a PA role to meet some of the current challenges to a sustainable medical workforce.
The small sample size is the main limitation of this study.The restriction to two services was due to there being a PA in each of these services, as part of a pilot project.The data collection timeframe coincided with the first national patient experience survey in Ireland (HIQA/HSE/Department of Health, 2017).Some of the patients had already received an invite to take part in the national survey if they had been inpatients in the hospital during the month of May.This confusion may have reduced the response rate.Where the patient was seen by a trainee doctor/PA and supervising physician, they may have evaluated their overall satisfaction with the consultation.Furthermore, unless the PA introduced themselves, the patients were not aware of been seen by a different provider.The researcher noted that some patients marked 'doctor' on the survey even though they had their consultation with the PA.Lessons learned from the study included the importance of having a researcher (who is not a clinician) on-site in the clinics to check the surveys following its completion, and to remind the patients, on checking out, to return the survey if they were willing to complete it.Further research is needed with a larger sample of patients over a longer timeframe.Data was collected the month prior to doctors in training rotating to different services.Clinical rotations occur in these services three and six monthly.
This study suggests that patients, in Ireland, are just as satisfied with care they received from PAs and doctors.Findings are consistent with those in other countries where the PA role is embedded.In meeting the patient's needs, an important aspect of care given by both doctor and PA seems to be keeping the patient informed and behaving in a professional manner.Although the findings are based on a small pilot study, where patients are unfamiliar with the PA role, it is encouraging for the introduction of the role in Ireland.It seems that the provider of care is less important than meeting the interpersonal needs of patients.The qualitative data (via free text) supports the importance of professionalism and good communication skills with patients, including putting patients at ease and communicating in a method that is understandable to them.Although the pilot project focused on specific areas of surgery, feedback is positive from colleagues in medicine and primary care where Irish PA graduates have now secured a role, as per the global trend.The opportunity to expand the PA role across the broader health system in Ireland is being considered, and the future is hopeful for further expansion of the role.