Inter-professional education and training is a way of educating health
professionals on the roles of each discipline, and in 2.6.3, I provided
particular examples based on rural practice. Multidisciplinary training
however, may have implications of ‘task substitution’ for health care
disciplines. In order to address the effect these implications may have on
education and training for rural health practitioners I now examine the
literature for current viewpoints on the subject of ‘task substitution’.
With a shortage of General Practitioners (GPs) in rural areas, one solution for
this shortage is the training of other health practitioners to partake in some of
the duties of the rural GP. As an example, rural nurses in Australia are seeing
legislation changes to allow formalization of such extended practice
(Sullivan, Dachelet et al. 1978: 973; Roberts 1996: 174; McCann and Baker
2002: 176; Plager, Conger et al. 2003: 407; Usher and Lindsay 2003: 84;
Bagg 2004: 4). One overseas study found that more than two thirds of the
medical visits in rural areas were for acts that nurses can carry out. Common
medical visits were for conditions such as respiratory tract infections,
prescription of drugs for chronic diseases and blood pressure, and diabetes
mellitus. The study looked at two remote areas in Crete over a year, and
suggested that legislation should change to allow replacement of junior
doctors with properly trained nurses (Vlastos, Mpatistakis et al. 2005: 361-
A comparison of the practice of rural and urban paramedics: bridging the gap between education, training, and practice. Peter Mulholland
57 Internationally, the Physician Assistant (PA), or Non Physician Clinician
(NPC) role is one particular way in which other disciplines assist in dealing
with this shortage of rural GPs. In one example from Africa, some physicians
and nurses raised the concern of professional dilution of skills with the
introduction of Non Physician Clinicians however, the NPCs did play an
important role in HIV/AIDS treatment programs (Mullan and Frehywot 2007:
2158, 2161-2162). Physician assistant roles in the UK are developing in a
way similar to that of doctors working in the primary care, and accident and
emergency settings, and by creating a separate discipline, nurses are left to
nursing duties (Parle, Ross et al. 2006: 13-17). In the United States one third
of Physician assistants work in areas of primary health care shortage
providing comparable services to a GP (Drozda 1992: 46-48), and tend to be
used in otherwise underserved rural populations (Staton, Bhosie et al. 2007:
32). PAs increase productivity of rural practices in terms of number of
patients seen, and both improve the workload and income of the employing
doctor. In California PAs and Nursing Practitioners rank ahead of primary
care physicians in the likelihood of working in rural locations (Hooker 2006:
5).
The Royal Australasian College of Physicians (RACP) supports task sharing
and the development of a team-based approach to patient care. Sewell (2006),
A comparison of the practice of rural and urban paramedics: bridging the gap between education, training, and practice. Peter Mulholland
58 offer specialist care and that diagnosis and development of management plans
is not easily shared. However, the implementation of plans, specific tasks,
and working within community based teams will be avenues of patient care
that are increasingly shared (p. 23).
Development of extended scope of practice, or indeed new disciplines such as
Physician Assistant in rural areas can face political challenges despite support
of organizations such as the RACP. The Australian Medical Association
(AMA) takes the stance that any reforms must improve what doctors and
other health professionals do, and not risk any reduction in care. The AMA
supports synergy of health professional skills rather than creating competition
between overlapping clinical roles. The AMA does not support the
Productivity Commission view that task substitution is a solution for medical
shortages, their arguments being that it could very well lead to a two-tiered
system that takes from one profession to create another. The example of the
practice nurse is given, where, a short term rise in this new position is created
by taking from nurses in hospitals and nursing homes (Yong 2006: 27-28).
At a more elementary level, doctors may value some of the tasks proposed for
handling by other professions. Removal of more simple tasks may affect the
sense of connection between the doctor and patient, and there is suggestion
that quick tasks such as medical certificates, immunizations, and repeat
A comparison of the practice of rural and urban paramedics: bridging the gap between education, training, and practice. Peter Mulholland
59 Kidd, Watts et al. (2006) suggest various safeguards should task substitution
be implemented. These involve areas such as informed consent, so that
patients know exactly who is treating them, effective medical indemnity
insurance, and appropriate financing to ensure viability (pp. 20-21).
The presence of rural specialties and multidisciplinary practice in rural areas
leads to questions of how health disciplines view the possibility of task
substitution among health care professions in these areas. Internationally,
appropriately trained specialist disciplines such as Physician Assistant or
Nurse Practitioner are appearing as means by which to deal with shortages of
General Practitioners. In Australia, levels of support for such practice vary
between organizations such as the Royal Australasian College of Physicians
and the Australian Medical Association. However, by regarding such
specialist or multidisciplinary practice as task sharing, or synergy of
professional skills, rather than task substitution, there is some common
ground between organizations.