Who is at Stake?

In Puerto Rico, medical doctors' predominant views on the PA profession give the profession an unconventional definition and show their own lack of understanding about it. For instance, an MD who graduated from Guadalajara, Mexico, and holds a PA license in PR was interviewed⁴. The MD stated that a PA is just like a 4th-year medical student doing rotations and that in the United States a PA is a person certified to practice medicine but who never studied medicine. The president of the Surgical College of PR also declared that PAs do not have the preparation needed to practice medicine⁴. It is important to clarify that the PAs educational curriculum is modeled after the American Medical Education, and students must perform over 2000 hours of clinical practice after didactic year⁷.

As represented above, views by many MDs on PAs are unfounded, and their weight affects the profession's future. As a PA from PR that is NCCPA certified and holds licensure in New York and PR, these views directly impact my success and put me in a disadvantageous position in the Island when it comes to obtaining a job in the profession. As an attempt to help advocate, regulate, and legislate for the PA profession, my duty has become to complete a Doctor of Science in physician assistant studies while volunteering as a fellow PA-C member of the Academia de Asociados Médicos de Puerto Rico/ Physician Associate Academy of Puerto Rico (AAMPR). It is my due diligence to consider this matter a practice problem in the Physician Assistant profession of the Island.

In addition to other trained physician assistants who want to serve the Island and encounter a disadvantageous start, patients with government-based insurance plans, especially those in rural communities, who experience health care needs are also at stake. PAs effect on rural health has been demonstrated through effective, safe, and economic care provision². Unfortunately, rural communities in PR have not yet benefited from access to this profession. The geographic maldistribution of physician clinics, continued medical specialization, and decrease in physician working hours have caused primary care shortages and longer wait times as reported by Doan et al.⁷ Granted, it is a personal preference whether a patient wants to see a PA or an MD regardless of location. However, Halter et al.⁶ found that willingness to be seen by a PA was directly proportional to the patient's assessment of the severity or complexity of their problem. In addition, a Canadian study indicated that mothers who were unaware of the PA profession would accept their child to be seen by a PA over an MD if it meant shorter waiting times, depending on the gravity of their children's case⁵.

Contributing Factors to the Dilemma

A series of socio-economic and political factors have historically prevented the Island from evolving with modern society, especially in healthcare. For many years, budget cuts have been implemented, threatening healthcare provision. According to the Visit Report from 2017, cited in Lafarga Previdi & Vélez Vega⁸, issues like economic instability and high cost of living have contributed to the healthcare system's frail structure and its difficulty in addressing health needs. They state that the healthcare system has been poorly coordinated for decades, making obtaining referrals difficult and contributing to months of waiting time⁸. The overseeing committees of healthcare in PR have a lot on their plates. To remedy the lack of access to doctors, former Governor Ricardo Roselló signed the bill to introduce the PA profession. Although well-intentioned, implementing an unregulated profession has led to distrust, a lack of Puerto Rican understanding about PAs, and an imbalance between qualifying professionals.

Proposed Resolutions

In May 2021, the national professional society for PAs in the United States, the American Academy of Physician Assistants, avowed the new official title to change from Physician Assistants to Physician Associates; it is currently under implementation¹. A proposed resolution stems from the fact that a new title is being implemented. Instead of legislating to change the already introduced profession on the Island, a new law could be legislated to introduce the physician associate's profession instead (Physician Assistants for Puerto Rico, Zoom Meeting, July 13, 2021). It is adequate to state that resolving the credentialing process to become a PA in PR will be greeted with confusion and resistance., and thousands of MDs who hold a PA license will have to go through a certifying process. However, in a constant havoc world, PAs must be regulated by the same governing bodies in the United States to ensure competence, especially on an Island with a crippled economy.

Evidence-based practice will undoubtedly be needed to investigate the PA profession's degree of knowledge and acceptance in PR. Evidence-based advocacy will hopefully render success. According to Zimbabwe AIDS Network¹², for advocacy to be achieved, evidence must be used to portray professionalism, credibility, reliability, relevance, create interest in decision-makers, and accurately represent needs. Advocacy through evidence becomes an opportunity to influence policy, reform¹², behavior, and social- economic factors⁸.