At the turn of the century, the need for more medical doctors (MDs) in the Netherlands was predicted because an aging medical workforce and an aging population were constraining access [1
]. One solution to this alignment problem was to redefine professional roles in health care and introduce a new professional: the physician assistant (PA) [2
]. PA education in the Netherlands is a 30-month university program at a professional Master’s degree level. Graduates practice medicine in collaboration with and alongside MDs [3
]. In the last decade, Australia, Canada, the Netherlands, and the United Kingdom have introduced PAs into their health-care system and the number of graduates is increasing steadily [4
]. The health-care system of the United States introduced PAs in the late 1960s and in Canada in the 1990s [5
]. How patients accept this new kind of health provider in these countries has been only partially explored.
Since the implementation of Dutch PA training in 2001, this workforce has grown from three in 2002 to over 650 by 2012. PAs work in a variety of medical specialties including general practice. There are approximately 65 000 registered physicians [6
], serving a total population of 16.5 million. The PA cadre is small but expected to grow and supplement some portion of the medical service. While patient acceptance of Dutch PAs is only marginally known, some information exists outside the Netherlands. For example, a Scottish pilot study undertook patient acceptance interviews about the services they received from American PAs. One outcome was that all patients were willing to be seen by that PA again [7
]. In another British study, most of the patients were satisfied with the PA’s care and only 7
% of the 167 interviewed patients opted to be seen by a doctor [8
]. The perceptions of all 24 patients treated by the PAs in a Canadian orthopaedic surgical service were very positive [9
]. These studies suggest that patients are generally accepting of services provided by PAs.
A report by the Dutch Council for Public Health and Healthcare (2002) suggested that acceptance of PAs should be a focus of research [10
]. In 2008, the Health Council of the Netherlands reported observations of patients’ acceptance of non-physicians. The Health Council report indicated that patients are somewhat reticent towards non-physicians but are as accepting of the services of non-physicians as they are MDs [11
]. Specific data regarding patients’ acceptance of PAs in the Netherlands has not been reported.
Since the 1970s, a few studies regarding patient acceptance of PAs have been undertaken. Nelson et al. [12
] surveyed a total of 835 patients’ acceptance by these factors: latitude of delegated tasks, interpersonal manners and technical competence of PAs. Regarding technical competence, 89
% of patients reported their PAs being competent to very competent, and 86
% found their interpersonal manners to be professional. For routine technical procedures (e.g. injections, recording vital signs), 98
% of patients highly agreed that the tasks were delegable. Task acceptance such as first visit evaluations, house calls, and minor surgery ranged from 63
% to 75
% patient approval. However, 58
% of patients opposed to PAs providing prenatal care. Two-thirds (69
%) of the patients in the Nelson study agreed that the PA was able to take care of the patient if the doctor was out of town. Among all 449 respondents, only 20
% reported any negative attitude toward the PA.
PA acceptance appears to be influenced by many causes as outlined in an exploratory study undertaken in a rural American community. In a qualitative study, Baldwin et al. [13
] found that community acceptance of PAs and nurse practitioners depended on satisfaction and willingness to seek care from either one. This was based on the perceptions and opinions of focus groups composed of four to nine community members. In general, it was concluded that community acceptance could be achieved if certain conditions were met. These conditions were personal factors that mainly embraced provider characteristics (e.g. friendliness and competence) whereas systemic factors covered conditions such as the need for collaboration between PAs and doctors, accessibility of care, and cost-containment. The systemic factors were mentioned as conditional acceptance and matched with the acceptance factors as studied by Nelson in 1974.
In an ethnographic evaluation of rural Texans [14
], patient acceptance of single practice PAs was investigated using focus groups of citizens in small towns with a clinic; in all instances the townsfolk had positive feelings toward the PAs. The authors concluded that acceptance depends on the patients’ willingness to seek care by PAs and the feelings regarding the PA. One observation was that the PA and clinic reputation within the community had a predictive effect on acceptance.
Based upon these studies, we suggest that patient acceptance depends on multiple factors. Next to the conditional properties, such as personal and systemic factors, it appears that acceptance depends on the patients’ willingness to seek care when this new type of medical care provider delivers it.
Since the PA workforce in the Netherlands is early in development, we suggest that measurement of patient willingness towards PAs can be investigated as a precursor of patient acceptance, from a theoretical standpoint. An Australian-based study examined female willingness to choose care from PAs. In an outpatient clinic in Northern Queensland, women between 20 and 45
years old were screened for lack of knowledge about PAs. When presented with one of three scenarios, involving either a PA or a doctor with time choices, they chose care by the PA over 90
% of the time, regardless of decreasing time differences [15
]. The findings of the Queensland study were limited in external validity due to the location and the restriction to women of childbearing age.
The primary objective of this European study is to investigate whether Dutch patients, recruited in a specialty care setting, are as willing to be treated by a PA instead of an MD. Because the Australian study lacked broader generalization, we included both genders in our study with a wider age base. Based upon this, a secondary outcome was if parenthood might influence the willingness of those patients where a scenario includes a mildly injured child. Finally, we have opted to also include male participants to see if patients’ willingness will reveal gender differences. By including both genders, our hypothesis is that the willingness of the patients to be seen by a PA will be significantly lower when compared with the Australian sample.