Saturday, November 27, 2010

A PA's Perspective on the Future of Medicine

The rumblings are getting louder.  The undertow is getting stronger.  It seems every medical team member is unhappy.  The hospital administrators are trying to cut down on costs, the government is trying to change the health care in the U.S. over to a nationalized system (quantity and quality unknown at this time), the physicians have left primary care in droves, the NPs are trying to say they can totally take the reigns of primary care over, and the PAs are trying to determine a new name for themselves. Why is everyone so unhappy?  Could it have something to do with our own unmet needs, or our perception that others are trying to be more than they are, or our misunderstandings of how healthcare is administrated, or deceiving ourselves into thinking that we can do more than we are trained to do, or of feeling as though we are not perceived correctly by patients, the public we have taken an oath to provide care to?  Or maybe it also has to do with the overseers of healthcare, those giant insurance companies who we believe are being greedy and not responsive to our patient’s needs?
First, let’s take a step back.  Let us take an honest look at who we are and what we all bring to the table. 
Who are the hospital administrators and what do they bring to the table of health care?  They are those people who are responsible for taking care of the bottom line, the financial line of the hospital.  Yes, they have to make some decisions which are not pleasing to us, the healthcare providers on the frontline.  Yes, they have to cut nursing staff, or say ‘no’ to our budget increases, or say ‘no’ to the hospital buying a new CT Scanner.  But we have to remember that they are there to keep an eye on the bottom line of the hospital so that it can continue to stay open and over time grow. 
Who and what is the government plan regarding healthcare?  There’s still too much we don’t know about Obama’s healthcare plan and potentially it still can be changed.  So what should our response be to it?  We need to be ready to change, plan, participate and be responsive to it, remembering that we are not in control of it.  But our patients are going to be affected by it, We need to be there to help them through the various gates. 
Then there are the physicians who have left primary care in droves.  They have decided that being a specialist is where the money is, and who’s to blame them when they come out of medical school with huge debts.  They deserve to have a life they have spent years in training for. 
Then there are the NPs.  Where do we start?  The physicians are upset at them for their believing they can take over primary care and for their believing that they don’t need to collaborate with the physicians in taking care of patients.  How wrong can they be?  First off, the NPs (whether they want to admit it or not) are not well enough trained to take over primary care for patients.  They don’t have the education or the clinical experience to take care of ALL of the patients who come into a primary care setting.  And until they are capable of doing so, they cannot say, or believe they can step into these shoes.  The shoes are too big to fill.  They need to quit fooling themselves in believing otherwise.
Then there are my PA colleagues.  Yes, we need to change our name so that the media and patients perceive what we do appropriately.  But in reality there is more.  We need to step up to the plate, take the helm of leadership onto our shoulders and truly help our colleagues in shaping the future of medicine.  Now is our chance to bring about the necessary changes for our patients.  Now is the chance to bring about compassionate care.  Now is the chance for us to shine.  And for us to shine, we need to strengthen our relationships with our physicians, not weaken it.  They need to know that we truly are team members in every way.  We are there to work together for the betterment of our patients. 
Our patients need the skills, experience and education of both the physician and us (whether that is the PA or the NP) involved in their healthcare.  They need both of us involved in taking care of them, seeing them in clinic, seeing them as a hospitalized patient, ordering their medications, assessing their response to treatment.  We all have something to bring to patient care, we all have certain expertise.  Just as two strands of rope intertwined together is stronger than a single strand alone, so are we acting as team members for our patients.  Standing alone we can never be as good as standing together. 
Let us respect each other.  The physicians need to be respected for their training, expertise and education.  And due to their training and education they have earned the right of being the ‘leader’ of patient care.  Why can’t we all act as a team?  Let’s all take the reigns of leadership (that do belong to us) and move forward by forming ‘patient homes.’ This is the future of medicine. 
Being involved in ‘patient homes,’ is the wave of the future with primary care.  If done correctly, ‘patient homes’ allows everyone to put forth information regarding a patient, for the betterment of the patient.  Everyone acts as a team member (this includes the physician, the NP/PA, the social worker, the psychologist, the clinic nurse, etc.) But for the patient home idea to work, we need to put our egos aside and respect what everyone (and I do mean everyone) can and does bring to the table of healthcare. 
Let’s stop this antagonist attitude we have towards the physicians.  Let’s stop the backbiting and bullying the NPs have towards their nursing colleagues.  Instead let’s appreciate what we do have, appreciate what we can bring to the table of healthcare.
Let us start now.  Start with respecting our colleagues and start with laying down our egos.  Let us begin tomorrow with an attitude of teamwork.  And let’s do it now for the betterment of every patient we see.  Then and only then can we bring about the future of medicine in ‘patient homes’ all over the country. 

Tuesday, November 23, 2010

Polypharmacy

I was working at a rural health clinic seeing patients one afternoon when I picked up an intake questionnaire on a new patient waiting to see me in the exam room, I was outside of.  It stated that he was an African-American male, 48 years old, slightly obese, and 6’4” tall.  He was coming into the clinic to be seen as a new patient due to his hypertension and diabetes. 
I walked in and introduced myself.  “How can I help you?”
“I’m here because I’ve tried 3 other medical practices in the past 6 months and all they have done is add on medication on top of medication and none of them have made any difference to me.  So I’m hoping you’re different.”
“Well, I’ll certainly try.  What medications have you been put on for your hypertension and type 2 diabetes I see listed here on your intake questionnaire?”
With that, the patient lifted up a grocery sack and spilled all of them out on the exam table.  My eyes popped open.  There were at least 20 medicine bottles there, and upon inspection they had several different physicians names on them who had clinics locally. 
“Do you know which medication to take for your blood pressure and which ones for your diabetes?”
“No, that’s part of the problem, no one really explained anything to me.”
“I see.”  I took a look at his blood pressure reading the medical assistant got for me.  Whoa, I said to myself, it was 280/170.” 
“Are you having any symptoms like headache, dizziness, blurriness, numbness, blood in your urine, anything?”
“Nope, I feel my usual.”
“I see.  When was the last time you took any of these medications?”
“About a week ago, I don’t like taking meds I don’t understand the reason for.”
“Well, why we’re figuring out all your medications, I need you to take some of this long acting cardizem you have here, as well as 2 of these 50 mg tabs of tenorectic.  Both of these blood pressure meds will help bring your pressure down.  I also need you to take one of these metformin and glyburide tablets.”
“Do you have any health insurance?”
“No, that’s probably why the other medical clinics just gave me all of these drugs and then didn’t schedule a follow-up appointment for me.”
“Okay, well I’ll work with you, but first I need you to lay down here on the exam table quietly for about 30 minutes until the meds you just took begins to work and then I’m going to have to get some blood drawn on you, a urinalysis and an EKG.  But that will wait until your pressure is down.”
While he was laying quietly in the exam room, I went ahead and did my physical exam, listening to his lungs, heart, doing the abdominal exam, making sure I didn’t hear or feel a possible abdominal aneurysm.  I felt for his distal pulses in his feet and wrists, also listening in on his carotid arteries for any bruits.  Nothing was abnormal so far on his physical exam. 
“Would the patient be able to dodge the bullet after all?” I thought to myself.

Working in a rural health clinic on a patient who didn’t have any health insurance and worked as a day laborer precluded my calling an ambulance on him to have him transported south to Galveston (90 minutes by car) to be admitted to the in-patient unit at the public hospital for a medical work-up.  Instead I would have to do the best I could at the clinic.  
So I would have to check his kidney function due to the hypertension he had.  The increased blood pressure had the potential for causing renal insufficiency or failure.  He would also need to have an electrocardiogram done to check his heart function for any heart failure, or previous unsuspected history of heart disease.  Blood work would need to be done to check for his sodium levels and potassium levels.  His urine would need to be checked for any protein, infection or possible blood.   

I went back into the patient’s exam room where he was laying quietly in a darkened room.  I re-checked his blood pressure, thankfully it was coming down.  It was now 240/135.  I had the medical assistant come in and draw the necessary blood work on him.  I also had him use the restroom facilities so that we could acquire a urine sample which the medical assistant immediately did a urine dipstick on. 

His dipstick showed 1+ protein, 2+ glucose, no ketones, no blood, no white blood cells.  The medical assistant took the EKG machine into the patient who by this time was laying back down on the exam table.  About 10 minutes later the medical assistant came out and gave me the EKG reading. 
I looked at the EKG, no Q waves, no elevated ST waves, with normal sinus rhythm.  In addition, there wasn’t any signs of cardiac disease.  I thought to myself, “maybe this patient is going to ‘miss the bullet’.  I certainly hope so, he’s tried to be seen by physicians in the recent past regarding his elevated blood pressure readings, but no one has ever followed up with him.”

I continued to have the patient lay quietly in the darkened exam room resting for 2 hours while the medical assistant went in every 30 minutes to get his blood pressure readings.  Finally, 2 hours after he took his blood pressure meds in my presence, his reading was 150/85.  With this reading I let him go home and made him an appointment to come back in the morning to see me again.  I advised him to re-take the cardizem, tenorectic again in the am.  I kept the remaining medications he had come in with, all 18 bottles of them. 

I walked back into my office and went through the various medication bottles.  The patient could almost stock a pharmacy with all of the medicines he had.  There were 5 different medications for his diabetes, 8 different blood pressure medications, several of which were the same medications, just prescribed with different strengths.  No wonder the patient couldn’t keep any of his medications straight.

The following morning the patient returned for his 9 am appointment.  I had scheduled him for a full hour.  The medical assistant took his blood pressure reading and lo and behold it was 135/80.  I was estastic!

I knocked on the exam room door and then walked in.  I gave the patient a ‘high five’ with my hand for his wonderful blood pressure reading.  That morning I had also received his blood work back and his renal function showed a BUN of 23, and a creatinine of 1.1 (normal).  His sodium and potassium were fine, his glucose was understandably high at 320. 

I spent the next hour going over his three blood pressure medications I wanted him to stay on, how frequently per day to take them and how they would complement each other.  I then explained to him the diet he needed to adhere to, the amount of calories he could eat per day, that he needed to begin an exercise program of walking every day, as well as the two diabetic medications he needed to take, one of which was metformin and the other was glyburide.  I gave him a pill box so he could sort out the 5 medications he would need to take every day, with only having to remember to take his meds twice a day.   

The medical assistant came in and showed him how to do his finger sticks for his daily blood glucose levels.  We sent him home with a blood glucose machine and plenty of chemsticks to use with it.  (We had recently done a community health screening clinic sponsored by some of the local drug reps who had paid for the medical equipment we would need to use.  Hence we gave him one of these leftover glucose monitoring machines.)  Then we sent the patient home with a food chart, a blood glucose chart, as well as a blood pressure chart.  The patient was advised where he could go and get his blood pressures taken without having to own his own blood pressure machine.

By the time the patient left the clinic he had all sorts of patient informational material to read at home from the American Diabetic Association, and the American Heart Association.  It was in an easy to read format.  I had him come back in and see me in a week.

Patients can be non-compliant with their medical regimens due to many reasons.  One of those reasons is the patient’s lack of understanding about their disease, the medications and/or lifestyle changes they need to take to control their disease.  Patients need  to be educated on a level they can understand (usually on a 6th to 8th grade level). 

Many chronic diseases do not have any symptoms initially, so patients think that they don’t need to do anything about it.  Unfortunately, with some patients by the time they have symptoms it ends up being too late.  Patients end up having end stage organ disease or organ failure.  So we as clinicians have to be vigilant with our teaching of our patients, continually reviewing the importance of taking their medications, continue their lifestyle changes and stay with their medical regimen long-term.  We have to continue to remind our patients of the long-term complications they are facing due to their chronic disease, otherwise we are doing them a disservice.        

During the week at work, the medical assistant and I both made bets as to whether the patient would adhere to all of the teaching I had given to him.  The medical assistant didn’t think he would be able to stick to it, I hoped he could. 

The week went by before I knew it.  I walked out of one of the exam rooms after seeing a patient and the medical assistant walked up to me with a thin chart in his hands.  He slapped it into my hands as he said, “you won!”

“I won what?” 
“Take a look at the name on the chart.  You won, his blood pressure is normal and he has all of his readings for his glucose, blood pressure readings and what he’s eaten with him.  You won!”

"Really, you’re kidding?”
“Nope, he’s even got a big grin on his face, he’s so pleased with himself.”
“Wow, I’m amazed!”

I walked into the patient’s exam room and sure enough, I had never seen such a wide grin on a patient’s face as I had with him.  I gave the patient a double ‘high five’ with my hands for what he had been able to accomplish in the past week.

I went over his charts, his blood pressure readings on three medications were finally staying in the normal range.  His food diary showed that he was really trying to switch over from processed foods to more chicken with fruits and vegetables.  He had stopped eating (at least for the past week) all of his snack foods (potato chips, cheese on crackers etc).  I could tell we still needed to work on his blood glucose levels, they were tending to stay in the range of 180-200, but that was so much better than the 320 from a week ago. 

“My girlfriend and I are walking every night for 30-45 minutes.  We decided that we like taking a stroll around the lake out where we live.”
“Wonderful, I replied.  You’re even getting your exercise in.  I’m very impressed with your progress.”
“I’m really trying doc, I am.  You’re the first person who has even worked with me to get me better, so I thought the least I could do in return is do as I was told.”
“Well, I’m very pleased with your progress.  I’m going to increase your metformin dose as well as your glyburide dose and this should bring your sugar levels down to near normal range.  Other than this, everything else will stay the same.  I’ll also get your cholesterol levels drawn when you come back and see me.  So come in on the morning before you see me and have them drawn by the medical assistant.  Have them drawn before you eat or drink anything.  I want you to come back in and see me in a month.  Keep up with your food diary, getting your blood pressure readings and doing your glucose readings twice a day.  Any questions?”
“No, I’m just happy that I finally found someone who’s willing to work with me.  Thanks, Doc.”
“You’re welcome.”

Seeing this patient in the rural health clinic reveals major problems with patient care,  they’re unable to get the medical care they need due to a lack of health insurance.                                                                                                                                                                                                                                                                                                                                  Sometimes inappropriate medical care is also due to physicians having a preconceived idea that the patient really doesn’t care about their health, so they don’t want to work with them.  There is also a problem with racial inequalities.  The medical literature is replete with journal publications documenting patients of another culture or ethnicity are not given the same medical care patients would receive if they were Caucasian.

Will the new health care reform bill address these problems?  I wonder.  It will address the lack of health care insurance, but it’s not going to do anything to change physician’s perception of patients they see, nor change the disparity in racial inequalities.  These are problems that go deeper than their lack of health insurance.   

 

A Case of Flesh Eating Bacteria

After I finished seeing the patient I was with, my medical assistant told me that he had my next patient ready to be seen.  I quickly scanned in intake questionnaire where I read the patient was 43 year old female who had come in urgently with a skin infection.  Her temperature was 100.5 F.  My medical assistant warned me before I went in to hold my nose, the smell would overwhelm me. 
Taking his advice, I put on my best ‘pucker face’ appearance and walked into the exam room.  He was right, the putrid smell in the exam room was overwhelming.  Keeping my pucker face on, I asked the morbidly obese diabetic patient what had brought her in. 
She replied, “I have an infection on my backside that won’t go away.”
I asked, “When did it start appearing?”
The patient replied, “I noticed it about 3 days ago.  I tried to keep it clean and put some neosporin ointment on it, but it hasn’t gone away.  Now it’s spread and it’s draining fluid.  So for the past 2 days I’ve had to keep a bandage over it, which gets soaked through every day.”
“Okay, let me take a look at it.”  With that, I reached for a pair of exam gloves to put on.  
The patient proceeded to take the tape off of her skin on the front of her leg.  She then turned over to let me remove the wet bandage over her posterior inner upper right thigh.   Once I removed the bandage a strong noxious smell hit my nose. 
The area of her skin involvement was pretty impressive.  She had erythema (redness) over her inner thigh that reached halfway down to her knee.  It stretched from her the edge of her buttock all the way to her front side of her thigh.  Towards the center of this erythema was a wound that was about 3 x 4 inches in size.  It was mean looking, ulcerated, swollen, and upon palpation caused exquisite pain for the patient.  I could see that the wound extended down to her muscle and possible also involved the muscle lining (fascia).  
Seeing this, I knew she could have streptococcus that was known as ‘flesh eating bacteria’, My background working as a PA in an infectious diseases practice immediately came to mind and I got on the phone to get a hold of a general surgeon.
“Hello, this is Dr. Stevens, I’m answering your page.”
“Dr. Stevens, this is Sharon, I’m a PA out at the rural health clinic west of town.  I have a patient I need you to see immediately.”  I then explained to him her physical findings and what I thought it was, necrotizing fasciitis.   
“Sharon, you’re probably right about the diagnosis.  But I’m not equipped to deal with necrotizing fasciitis.  She’ll have to go to the teaching hospital down in Galveston.  The surgical service down there will be able to deal with her condition.  Send her by ambulance if you have to, but get her down there right away.”
I went back into the patient after hanging up the phone.  I explained to the patient that she needed to go immediately to John Sealy Hospital in Galveston, about 1.5 hours driving time south of us.  I told her that I thought she had necrotizing fasciitis and she would need to be taken to the operating room immediately by the surgical service upon arrival.  They would have to remove all of the infected skin and then she would be put on IV antibiotics.  I advised that I could call an ambulance for her or she could have her spouse take her who was waiting out in the waiting room. 
The patient decided that she would have her husband take her right away.  They quickly left after the wound was re-wrapped.

Necrotizing fasciitis is a condition that is caused by group A streptococcus and is typically accompanied by an anaerobe such as clostridium, bacteroides, or peptostreptococci.  There are many risk factors for this condition.  They include diabetes, obesity, depressed immune system, recent viral infection which caused a rash, or recent intake of steroids. 
Patients typically present with erythema (redness) at the site of the infection, swelling, increased heat, pain out of proportion of what a clinician would expect to have given the wound size, crepitus (air under the skin), elevated temperatures, elevated white blood cell counts and bacteremia (bacteria in the blood stream) or sepsis.
Necrotizing fasciitis has a high mortality rate.  If a patient just received IV antibiotics without prompt surgical debridement the mortality rate approaches 100%.  By giving the patient prompt surgical debridement as well as bacterial specific IV antibiotics the mortality rate still hovers around 20%.
Patients can receive hyperbaric oxygen therapy.  Patients are put into a sealed chamber where a high concentration of oxygen is pumped in, which the patient breaths.  This increased concentration of oxygen then reaches the infected skin site and due to the high oxygen concentration is toxic to the bacteria and they die.  Many facilities will use these chambers so as to expedite the healing process and address the anaerobic bacteria (bacteria that live in the presence of no oxygen) which thrive in the presence of low to minimal oxygen saturation. 
       
Two weeks later I received a fax in the clinic from John Sealy Hospital in Galveston.  It advised me that the patient I had sent down to them with necrotizing fasciitis was being discharged and they wanted me to call them. 
After finishing seeing a patient in the clinic, I picked up the phone and called the number listed.  It was a pager of one of the surgical residents there.  He immediately called me back and informed me that the patient I had sent down to them was now ready to be discharged and she would need to be followed up. 
He proceeded to inform me that she had been taken to the operating room twice, the day of her admission and then again 3 days later.  She had a large area of surgical debridement which extended from her perineal area halfway down to her knee.  She had a surgical mesh dressing over it and would have to return to them for skin grafts, but they wanted her to finish out the six weeks of IV antibiotics first. He needed me to set up out-patient IV antibiotics and daily dressing changes done by the visiting nurse association.  He wanted me to see her in clinic every week to assess that everything was healing up the way it should.  She would then come back and see them in a month so they could schedule her for the needed skin grafts. 
I asked the resident what had grown out on her microbiology cultures.  He informed me that she had group A streptococcus, peptostreptococcus, as well as pseudomonas.  So she was on two IV antibiotics, Unasyn as well as Rocephin.  He gave me his pager number in case there was any problem with her, otherwise I could expect her back in the community by morning. 
I set up her out-patient nursing care, IV antibiotics and scheduled her for her first out-patient clinic visit with me.  I called the resident back and gave him this information which he put on her discharge papers.

Patients with necrotizing fasciitis are given IV antibiotics so as to make sure there is a high concentration of antibiotics within the blood stream which will then reach the infected site.  The choice of which antibiotics they are given is based upon the microbiology culture results which are done in the operating room. 
Patients are initially given a broad spectrum IV antibiotic (to cover for the typical streptococcal and staphylococci found) as well as a IV antibiotic to cover for anaerobes (bacteria who live in the presence of no oxygen).  Cultures are then sent to the microbiology lab and the results are known in 3 days.  Information consists of what the bacteria is, as well as which antibiotics it is sensitive to.  Based on these results the patient’s IV antibiotics are changed (as needed) to acquire the quickest kill of the bacteria involved.
Surgery keeps an eye on the patient and makes sure that once they have debrided (removed all of the infected skin and surrounding tissues) the patient does not need any further debridements (i.e. there isn’t any spread of the infection beyond the original site). 
     
I didn’t hear about her again for a few days until I received a call from the visiting nurse association who had a question about her IV antibiotics.  I took care of her question and then the following week in clinic I picked up a intake questionnaire to see the patient’s name on it.  She was waiting for me in the exam room.  I knocked and went on into the exam room. 
“How are you doing?” I asked.
“Much better.  My wound is healing, it’s looking so much better, my pain is almost gone.” 
“Well, I see here that you’re remained free of any temperatures, how’s your IV site?”
“The visiting nurses change the site every 3 days, so it’s fine for now.”
“Okay, well then let me take off your bandage and see the surgical area and how well it’s healing.”  I reached for a pair of exam gloves.
The patient rolled over on her stomach and I removed the almost dry bandage.  Lifting it up off of her skin, the first thing I noticed was the total absence of any noxious smell.  The skin looked healthy, there was minimal erythema, no swelling, and she had an intact surgical mesh over her underlying muscles.  The surgical defect was large so I could easily understand why she would need skin grafts once she finished out her regiment of antibiotics.  I replaced the surgical dressing and then taped it back to her skin. 
Three weeks later she returned to John Sealy Hospital for the first of several skin grafts she would receive.  Six months later I saw her again in clinic and everything was healed up, the skin grafts had taken.  She informed me that the whole episode had really scared her and she wanted to lose weight because she knew that her obesity had partially been a reason she had come down with the infection to begin with. 
So I discussed with her an exercise program as well as the needed dietary changes.  I advised her to keep an eye on her blood sugar levels and to test herself at least four times a day.  I gave her information on Weight Watchers, as well as a nutrition consult.  On the way out of the exam room I could only wish her the best in her attempt to finally address one of her health issues which had been there for too many years.

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INTRODUCTION/DISCLAIMER

Hello, welcome to my blog about medicine.  I’ve written it for all of the various laypeople out there who need solid information on how to be the best patient advocate they can be for their family members as well as for themselves. 
At no time do I want you (my reader) to assume that the medical information contained in these real patient encounters are meant for you.  Please take the time to discuss any information contained in these stories with your physician or medical provider.  Only with their help can you determine what the best route is for you to take in addressing your own personal health issues.
Please know that I have never used the patient’s real names, or the physician's real names or given away the locations of the clinics/hospitals I saw them in.  All of the stories are real patients I’ve seen, real scenarios that happened with real endings.   I’ve written about the most interesting, informative patient encounters I’ve been involved in over more than 20 years and counting of being involved in clinical medicine as a physician assistant.  Hopefully this will also allow you to understand what a physician assistant is and what we are capable of doing.  We are as close to being a physician as we can be, without being one, our typical medical training involves an undergraduate degree with 3 additional years of graduate training. 
I hope you enjoy reading the stories, learn from them and use the information contained herein to help you become a better patient advocate for yourself and/or your family members and friends. 
I wish you the best,
Sharon




FOR MY AUSTRALIAN PA FRIENDS (COMMENTARY INTENDED FOR AUSTRALIAN FAMILY PHYSICIAN):



The Next Step
The Australian medical profession is on the precipice of a new adventure.  They are now are on the edge of incorporating and allowing a new medical profession into their midst.  Hopefully physicians and hospitals will be willing, and able to take in this new medical professional and allow them to work to their fullest potential.  But only time will tell, what the reaction will be.
Australia now has 12 newly graduated physician assistants (PA)  from the University of Queensland.  There are three other PA programs in Australia who will be graduating their own first PA classes next year.  All of these PAs are well trained and ready to go to work.  Now it’s up to you, the physicians and hospitals to employ them.  The only question is, are you willing to do so?
But before you answer that question, maybe it would help to understand who they are, and what they are capable of doing, for the Australian medical establishment.  Let me give you five important things the PAs can do.
First, PAs, due to their extensive medical training (a 24 unit Master’s degree program) are capable of seeing, diagnosing and treating patients.  In addition, they have at least one additional year of medical work experience behind them, prior to enrolling in their PA program.  They will work besides you, seeing patients, treating them, diagnosing them.  By working as a team, this increases your billing capability, thus bringing in additional monies into your practice and allows you to expand your patient base, as well as the services you offer to patients. 
Second, physician assistants are well equipped and capable of teaching patients about preventive medicine, educating patients about their disease and how to address the various facets of it.  Physicians typically don’t have the time to explain to the patient their health condition in a language they can understand.  Physician assistants are trained to do this, and do this very well.  With you patient population understanding how to handle and deal with their disease, this will decrease patient call backs to your office. Subsequently, this will make for a happier patient encounter in the future, seeing that the patient now knows they are in control of their own disease.
Third, the PA will bring ‘to the table’ experience and clinical expertise that you may not have.  They may have experience working (prior to the going to PA school) in a marine environment and therefore know marine bacteriology quite well and what to expect as far as an infection in a fisherman who has a hook caught in their hand.   
Fourth, the PA brings to the table a willingness to learn and adapt to your clinic.  For example, they could be capable of helping out with managing/supervising your front desk personnel, for instance.  This can then free you up to do other responsibilities of the practice which are more to your liking. 
Fifth, and most importantly they are not as expensive as bringing in another physician into your practice.  They typically come at ½ of the price of a physician.  So with all these benefits, won’t you give them a try?
But you say I don’t know whether they will work out or not.  That’s understandable.  Many, many physicians in the U.S. didn’t believe in the capabilities of PAs either, when we first came on the scene 40 years ago.  It took the U.S. physicians and hospitals about two decades or so before enough of them in the U.S. became used to PAs, knew what we were capable of doing and wanted to work with us. 
I can only hope that the Australian medical establishment does better than the American medical establishment did, by welcoming and allowing the newly minted Australian physician assistant a place ‘at the table.’ 
Learn from us your U.S. counterparts, PAs are a great asset to medicine.  Try one out for yourself, you won’t regret it, nor will your patients. 

Sharon Bahrych, PA-C, MPH
http://paviewonmedicine.blogspot.com