Smith and Tevis have provided a helpful comparative overview of the background, training, and practice environment of physician’s assistants (PAs) working in US and UK emergency departments (EDs).¹ However, they leave unanswered a number of questions about the role and relative value of PAs. This commentary highlights many of the issues that remain to be addressed and their wider implications.

As an emergency physician who has practised in EDs for nearly 30 years, I have witnessed the evolution of emergency medicine as a specialty in the USA and observed the more recent introduction of physician extenders (nurse practitioners (NPs) and PAs) in ED practice.^2–4 The notion of physician extenders has important implications for meeting workforce needs, specialisation within ED practice, and defining the specialty. The comments that follow are based on more than seven years of work with physician extenders in the Oregon Health and Science University (OHSU) ED and five years as a lecturer for the OHSU PA training programme.

WHAT ARE “PHYSICIAN EXTENDERS”?

The underlying concept of a physician extender is that of a non-medical healthcare provider who sees patients on behalf of or in conjunction with a lead physician or physician(s). This provider generally has a narrower knowledge base and skill set than the lead physician. In the USA, the commonest types of physician extender are PAs and NPs. The PA generally completes a 2+ year programme, including up to 14 months of clinical rotations, after receiving a college undergraduate degree. The NP generally completes a two year master’s level course after a four year registered nurse degree programme. Clinical exposure is generally interspersed with didactic courses during the second year of the NP …