The Royal College of Ophthalmologists workforce census, published in 2023, highlighted serious staff shortages in National Health Service (NHS) ophthalmology services.1 The census warned that, without immediate action, the trend of a dwindling workforce is predicted to worsen.
With the number of patients awaiting their first ophthalmology appointment exceeding 600,000 in January 2023, the need to proactively address staff shortages to meet growing demand has never been greater. A pilot program to introduce physician associates (PAs)—also known as physician assistants—to ophthalmology is underway, but questions remain regarding their potential role and impact on the specialty (for more on addressing the ophthalmologist shortage, see the sidebar).
Addressing the Ophthalmologist Shortage With the OLEID Model
By Richard L. Lindstrom, MD
As the US population ages and new eye care treatments are introduced, the demand for ophthalmic services is escalating rapidly. The AAO reported a shortfall of approximately 150 ophthalmologists annually, a significant gap that underscores an urgent need for effective solutions.1 A promising approach to address this challenge that I support is the ophthalmologist-led integrated eye care delivery (OLEID) model.
In the OLEID model, a collaborative team comprising optometrists, physician assistants (PAs), nurse practitioners (NPs), certified ophthalmic medical technologists, certified ophthalmic technicians, ophthalmic assistants, nurses, opticians, and anesthetists works together under the strategic direction of an ophthalmologist to meet the growing demand for eye care.
Successful Integration of PAs Into Ophthalmology
At Minnesota Eye Consultants (MEC), we employ three PAs/NPs, one of whom is a former ophthalmologist from another country. This PA now sees patients independently within the same scope of practice as our optometrists. The other two PAs/NPs primarily support our ambulatory surgery centers by performing preoperative health and physical evaluations. They also manage the everyday health care needs of our team by providing services similar to those of a school or college nurse. This arrangement ensures efficient preoperative preparation and fosters a supportive work environment for our staff.
The Expanding Role of PAs in Ophthalmology
In some specialties, such as cardiology and orthopedics, PAs are entrusted with significant responsibilities. Although we do not currently delegate surgical or laser procedures to PAs at MEC, Minnesota law allows PAs—under MD supervision—to perform office-based laser procedures and Light Adjustable Lens (RxSight) adjustments as well as to assist in cataract and IOL surgeries.
PAs have the potential to take on more significant roles in ophthalmology as the demand for services grows.
Training and Regulatory Considerations
Currently, there are no US programs specifically designed to train PAs in ophthalmology—a gap in the educational landscape. Most PAs in this field receive on-the-job training, which, although effective at individual practices such as MEC, may not be scalable nationwide. Moreover, the legal scope of practice for PAs varies by state, which can restrict their roles in ophthalmology unless regulatory changes are made.
Looking Ahead: Strategic Integration of PAs
The long-term benefits of integrating more PAs/NPs into ophthalmology are clear. These professionals can help extend the reach of ophthalmologists, enhance practice revenue by billing for services, and improve patient care by reducing wait times and increasing patient access to specialized treatments. To plan for this integration strategically, practices can visit established OLEID model sites.
1. Terveen DC. Ophthalmology numbers cause for concern. EyeNet Magazine. August 19, 2022. Accessed May 9, 2024. https://www.aao.org/young-ophthalmologists/yo-info/article/ophthalmology-numbers-cause-concern
AN INTRODUCTION TO PAS
PAs have become an integral part of the multidisciplinary health care team in many countries around the world. They were originally introduced in the United States during the 1960s as a way to mitigate physician shortages, but the UK National Health Service did not adopt PAs until 2003.
Two decades later, more than 2,000 PAs are working across hospital and primary care settings in England. PAs can perform clinical assessments, interpret diagnostic tests, and implement management plans under a doctor’s supervision or with semi-autonomy, provided they have received appropriate training and support.
Limitations exist, however, notably PAs’ current inability to prescribe medication or request ionizing radiation procedures, such as chest X-rays or computed tomography scans in England.
WHAT ROLE DO PAS PLAY IN OPHTHALMOLOGY IN THE UNITED STATES?
The United States currently has more than 150,000 PAs in practice. Only 0.1% of newly-certified PAs entered into ophthalmology, according to the 2022 annual report of the National Commission on Certification of Physician Assistants.2 The potential reason for such low representation is that ophthalmology remains a fairly niche specialty, with minimal exposure in the PA curriculum. The need for intensive in-house training, limitations on scope of practice, and the higher salary of a PA for duties that could be delivered more cost-effectively have limited wider adoption in the United States.
The pertinent question of scope creep was explored in a national survey of PAs in ophthalmology published in the American Journal of Ophthalmology in 2020.3 Lee et al reported that 65% of respondents performed roles that included assisting with ophthalmic surgery and procedures such as intravitreal injection and chalazion drainage. Less than 25% performed intravitreal injections on their own. Only 4% had performed Nd:YAG laser capsulotomy, and none had performed laser iridotomy, laser trabeculoplasty, or panretinal photocoagulation. The number of PAs currently performing procedures is therefore relatively low, and any significant risk of scope creep remains limited.
THE PA OPHTHALMOLOGY PILOT IN ENGLAND
In November 2023, NHS England, in collaboration with the Royal College of Ophthalmologists, launched a 12-month pilot to assess the integration of PAs into ophthalmology.4 This initiative aims to evaluate the viability of the PA role within the specialty.
Although there is no commitment yet to integrate the role permanently, the Royal College of Ophthalmologists’ involvement is seen as a positive step. It allows the College to develop a framework for the pilot and potentially standardize the role of PAs in ophthalmology nationally. The pilot will involve recruiting up to eight PAs across five NHS Trusts in England to measure their impact, performance, and outcomes.
A unified approach led by the College could clarify the scope of practice for PAs while considering the views of ophthalmologist members. This strategy ensures the maintenance of safety and practice standards within the field. Moreover, the College plans to organize 8 training days that will cover both theoretical knowledge and practical skills over the course of the pilot.
Although there is a possibility that the College may eventually decide against supporting the integration of PAs into ophthalmology, the decision to adopt this model will rest with individual NHS hospitals. These institutions may choose to incorporate PAs into their teams to bolster their workforce.
THE POTENTIAL IMPACT OF PAS ON SURGICAL TRAINING
Trainee ophthalmologists in the United Kingdom have encountered increasing challenges to surgical training in recent years, including the impact of the COVID-19 pandemic, the greater complexity of case mix and the rapid growth of independent sector providers performing the majority of routine cataract operations. The adoption of PAs into NHS hospital trusts, where training primarily takes place, is likely to raise further concern, but is this concern warranted?
The Royal College of Ophthalmologists has emphasized that the introduction of PAs should not detract from surgical training opportunities for trainees. PAs will not undertake intraocular surgery such as cataract surgery but may perform procedures such as intravitreal injections.
Annual national trainee surveys serve as a key indicator of a hospital’s commitment to training, underscoring the importance of meeting trainee surgeons’ needs. A structured approach, ensuring that both PAs and trainee surgeons receive adequate training, is seen as viable, provided that departments and trainers engage in careful planning. The question still remains, however, as to who will ultimately be responsible for training PAs.
A mixed methods exploratory study in the United Kingdom assessed the impact of PAs on postgraduate medical education.5 The study revealed mixed views on their integration but found no overall negative effect on surgical training. In fact, the addition of PAs appeared to alleviate pressure on existing staff, which allowed for more focused learning opportunities. This relief could, in theory, enable trainee ophthalmologists to pursue advanced training opportunities that might otherwise be limited by routine service provision or administrative burdens.
Given the administrative intensity of the specialty and the absence of scribes in the NHS system, PAs have the potential to reduce the burden on trainee ophthalmologists significantly. By taking on routine clinical and administrative tasks, PAs could free up valuable time for trainees, allowing them to engage more deeply in advanced surgical instruction and educational opportunities.
REGISTRATION AND REGULATION CONCERNS FOR PAS IN THE UNITED KINGDOM
The debate surrounding the role of PAs in the UK health care system has been intensified by concerns over their registration and regulation. Despite international evidence suggesting PAs can provide safe and cost-effective care,6 a tragic incident involving a misdiagnosed case of deep vein thrombosis and pulmonary embolism by a PA has cast a shadow over the profession. The incident raised questions about patient awareness and the transparency of health care providers regarding who is delivering their care.
A recent editorial in The British Medical Journal highlighted the absence of statutory regulation for PAs in the United Kingdom, with registration remaining voluntary through the Faculty of Physician Associates.7 This situation is complicated by the growing recruitment of PAs trained in various international programs, leading to concerns about the consistency of skills, competence, and scope of practice across the NHS.
In response to these governance challenges, the General Medical Council will oversee the registration of PAs commencing in 2024, with regulatory requirements focused on training and development, revalidation, and fitness to practice. Still under development, this regulatory framework aims to address safety and trust concerns. Its creation is an acknowledgment of the importance of establishing robust oversight mechanisms before further integrating PAs into the health care system.
Whether this new regulatory landscape will strengthen safety and trust remains to be seen, but it does highlight the importance of not putting the cart before the horse, so to speak, where patient safety is concerned.
ASSESSING THE NEED FOR PAS IN OPHTHALMOLOGY
The public health service is under increasing financial pressure and subject to growing demand, necessitating the creation of cost-effective models supported by a rapidly trained and adaptable workforce.
Ophthalmology benefits from a well-established multidisciplinary team that includes nurses, optometrists, orthoptists, and technicians, each offering a unique set of skills. The current diversity prompts a critical evaluation of the real need for PAs within the specialty and whether existing health care professionals should instead be better utilized.
The experience in the United States suggests that PAs are unlikely to assume a substantial role in ophthalmology in the United Kingdom. These professionals could, however, provide unique support thanks to their general medical training. A shift toward incorporating PAs reflects a broader transformation in ophthalmic care delivery, one that is essential for meeting demand and ultimately reducing the burden of preventable blindness.
1. Royal College of Ophthalmologists. Census report – facing workforce shortages and backlogs in the aftermath of COVID-19: the 2022 census of the ophthalmology consultant, trainee and SAS workforce. March 2023. Accessed April 10, 2024. https://www.rcophth.ac.uk/wp-content/uploads/2023/03/2022-Ophthalmology-census-Facing-workforce-shortages-and-backlogs-in-the-aftermath-of-COVID-19.pdf
2. National Commission on Certification of Physician Assistants. Statistical profile of recently board certified PAs, annual report. 2022. Accessed April 10, 2024. https://www.nccpa.net/wp-content/uploads/2023/11/2022-Recently-Certified-Report-11_8-final.pdf
3. Lee B, McCall TC, Smith NE, D’Souza MA, Srikumaran D. Physician assistants in ophthalmology: a national survey. Am J Ophthalmol. 2020;217:261-267.
4. Royal College of Ophthalmologists. Scope of practice for a physician associate (PA) working in ophthalmology. 2023. Accessed April 10, 2024. https://www.rcophth.ac.uk/wp-content/uploads/2023/11/Physician-Associates-Ophthalmology-Scope-of-Practice-211123.pdf
5. Roberts S, Howarth S, Millott H, Stroud L. Experience of the impact of physician associates on postgraduate medical training: a mixed methods exploratory study. Clin Med (Lond). 2019;19(1):4-10.
6. van den Brink GTWJ, Hooker RS, Van Vught AJ, Vermeulen H, Laurant MGH. The cost-effectiveness of physician assistants/associates: a systematic review of international evidence. PLoS One. 2021;16:e0259183.
7. Rosen R, Palmer W. Physician associates in the NHS. BMJ. 2023;382:1926.
