There has been a lot of controversy in recent years around the role of physician associates (PAs) in UK primary healthcare, or GP practices. A key concern is how their role impacts on the safety of patients, who many general practitioners (GPs) say are being put at risk.
A letter by NHS England states that “PAs are not doctors, and cannot and must not replace doctors”. It maintains that they must not practice independently but under the supervision of doctors. However, there have been reports that patients are not always informed about who they’re seeing. And the burden of responsibility and supervision is causing alarm among GPs.
Training physician associates over medical students
In a survey by the British Medical Association, over 60% of GPs said their workloads had increased since associate professionals were employed in their practice. Because of an apparent shortfall in education and training for physician associates, some supervising doctors don’t feel comfortable signing off on their PAs’ work unless they re-do it themselves.
GPs question whether this is a good use of their time. They could instead be supervising and training junior doctors. Dr Peter Burke, semi-retired GP and examiner for the Royal College of General Practitioners (RCGP) says: “for doctors-in-training the time spent for supervision is an investment because they’re going to become the doctors of the future. Whereas with PAs essentially what you’re doing is providing lifelong supervision to somebody who isn’t qualified to work unsupervised.”
Dr Burke also points out that doctors are “investing considerable amounts of time providing supervision at the expense of time they could be spending face-to-face with patients”. What’s more, “there’s never been any serious evaluation on whether PAs improve patient care or not”.
Patient awareness and safety
The Faculty of Physicians Associates says that:
“PAs should introduce themselves clearly and with a full explanation about their role in the healthcare team. Patients must always receive clear and accurate information about who is treating them and making decisions about their care.”
However, cases like Emily Chesterton, a patient who died after being misdiagnosed by a PA, whom she mistakenly thought was a doctor, have shown that patients are not aware of who they’re seeing. Nor are they being given a choice to see a qualified medical professional.
One problem is the job title. The word ‘physician’ is generally understood to mean a medical professional who holds a medical degree (excluding certain specialist doctors like surgeons, obstetricians and psychiatrists). Therefore, using the word ‘physician’ in the title of a professional who does not have a medical degree, especially with the word ‘associate’ implying that they are a high-level physician, very likely causes confusion.
Are physician associates’ courses misleading?
The outcry among GPs also raises the question: how do PAs feel about this themselves? Some have decided to re-train as doctors, apparently due to feeling inadequately trained.
PA-turned-medical student Adam Skeen writes in an article that his PA degree covered almost none of the essential subjects learnt by medical students before they start seeing patients in their later ‘clinical years’. “I was left academically unstimulated, with ‘we don’t need to know that’ a frequent response to my enquiries. Why if doctors need to know it, would PAs not? After all, course leaders told us we were going to qualify at a foundation doctor level.”
Professional regulation concerns
Where a PA has been responsible for the death of a patient, they may be fired from one position but then go on to work in a similar position elsewhere, without the serious consequences doctors face in these situations. PAs are not held to account because they are not currently regulated by a professional regulatory body.
Legislation has been passed that will soon require physician associates to be regulated by the General Medical Council (GMC). The GMC has only ever regulated medical doctors who have graduated from medical school after a typical five to six year medical degree.
Dr Burke explains why this raises further concerns.
“You’ve got two opposite poles of the medical spectrum; you’ve got doctors who have the most detailed training and actually the most rigorous assessment. Failure rates in medical exams are high, especially in specialist exams where in some cases you’ve got pass rates as low as 20 to 25%. So if you want to become a hospital consultant then you’ve really gone through the mill, and that’s what the GMC regulates. Then at the other extreme you’ve got people who’ve got two years training where the failure rate is close to nil. 100% pass, very easy exams.”
It could also increase patient confusion, as PAs will have new identifiers. These are their GMC reference numbers, that will be very similar to those of doctors.
Hopes for more funding for GPs and nurses
Many hope the new government will change the legislation for GMC regulation of PAs. They also hope the funding which is currently available to practices to employ PAs and other medically-associated professionals can be freed up to hire more GPs and nurses. Meanwhile, the public are advised to check who they are being seen by during an appointment at their GP practice. If you aren’t sure or you don’t understand a job title, it’s your right to ask.
