| Popis: |
Puerto Rico is the last large jurisdiction in the United States without enabling legislation for physician assistants (PAs). This qualitative inquiry seeks to characterize the barriers to, and potential facilitators of implementation of physician assistants in the Commonwealth of Puerto Rico, and recommend strategies for implementation. Twenty-five semi-structured interviews were conducted in Puerto Rico in January 2008, from a purposeful sample of practicing physicians, medical educators, members of the legislative and executive branches of government, health system executives, and physician assistants with knowledge of Puerto Rico. Interviews were conducted in English and Spanish and digitally recorded and transcribed by the investigator. Analysis of the transcribed interviews identified themes which were coded and grouped for convergence and divergence of perspectives. Antagonist themes asserted there is no shortage of physicians, that geographic and primary care access is good, that patients will not accept PAs, and PAs will experience a negative practice environment with respect to malpractice and reimbursement, as do physicians. Proponent themes argued there are transportation barriers to care, delays in access to specialist care, substandard primary care by generalist physicians, the majority of whom are international medical graduates, elite physician flight from the island, and PA-like roles that have been created "below the radar," demonstrating the need for PAs. Cross-cutting themes include organized medicine and nursing opposition, overall loss of physicians from the island, increasing health care costs, lack of unanimity and policy action by organized medicine, and poor understanding of PAs. Strategic recommendations include a public relations campaign targeted at physicians and legislators, and a dedicated lobbyist located in Puerto Rico. An initial pilot implementation is recommended in the medical and surgical subspecialties at the University of Puerto Rico Medical Center, with future primary care demonstration projects on the islands of Vieques and Culebra and in the rural community of Castaner. Pilot projects should include prospective evaluations, including cost, quality and patient satisfaction outcomes. |
