Physician Associate - have you come across this yet?

[ConversingWithStrangers]

On Wednesday I had an appointment at the doctors due to finding a lump on my breast. However, once in the consulting room the woman I was being seen by explained that she was a Physician Associate.

I haven't come across this before and I'm curious about what people in health care think about this. (I'm in education and wondering if it's the same kind of move as HLTAs in teaching or PCSOs in policing etc.). Curious especially about how nurses feel about it, as that seems to be the area of biggest crossover.

(I was very happy with her consultation btw. She checked my breasts and referred me to the breast clinic. Only thing that felt a bit off/unexpected was that she used the word "arseholes" at one point).

Doesn't bother me seeing a PA. Last year I saw nurse practitioner for stomach problems. She ordered blood, urine and poo tests then referred me to hossy under the two week pathway. Luckily it wasn't anything sinister. But she did nothing different to what the doctor would have done. No need to even see a doctor at all. And doctors make mistakes too. Someone i knew had their stroke missed by the doctor. They'd been to the surgery complaining about feeling unwell. Was sent home i think told it was a virus, cant remember exactly now, but they had a stroke later that day.

history taking is a skill and most appointments don’t allow the time. if PA’s are doing that and feeding back it will save so much time and money, get quicker diagnoses

History taking is absolutely a skill, but if you don’t know what the potential differentials are you won’t be asking the right questions, and won’t elicit the right information. I get a lot more information from patients about kidney disease as a consultant nephrologist than a surgical FY1 will, because I know what the potential diagnoses are and am focusing my questions to narrow down them down/exclude the most serious ones.

Somebody’s renal function is slightly abnormal? Probably not a life and death emergency. Somebody’s renal function is abnormal, they have lost weight over the past six months, have a funny spotty rash on their leg and can’t shake their sinusitis? Potential vasculitis, go straight to A&E today. Somebody with two years of training does not know to ask those questions, and merrily reports back to their supervising doctor that all is well, just mild CKD needing a recheck in 6 months.

The BMA has recently voted that the role should be phased out. I hate that GP practices try to mask that you are being fobbed off with an unqualified associate, by sticking the word Physician in front of it. I refuse to be seen by one. If I have got to the point where I am asking for a doctor's appointment, I expect to be seen by someone who is fully trained.

History taking is a hard skill to learn and part of the many years of doctor training is learning when to ask what questions.

It saves no time if the history has to be taken all over again from scratch.

They’re a cheap alternative to having enough GPs. They kill people through ignorance.

I agree with you. PA entry requirements are rock bottom. Anyone with any grade at GCSE / Alevel and at least a 3rd in a 'biomed' course can become one. The entry requirements for nursing are higher yet PAs get paid more.

I should also add that a lot of PAs in my experience as a nurse are people who failed medicine or pharmacy and so have left uni with a bachelors degree which makes them unemployable as pharmacists / doctors. Yet they're being allowed to still see patients.

This. There has been mission creep, probably as a cost saving exercise. They have been around for years but not in the way they are often being used now. And they definitely shouldn’t be diagnosing & treating undifferentiated patients.

Neither should F1 and F2 doctors be missing out on learning skills or getting theatre time because there is a PA there instead.

PAs don't even save money, the jobs they are actually useful for don't merit Band 7 pay and there are 1000s of GPs out of work as the NHS is currently funding PAs in preference

The PA degree and subsequent ‘training’ (I put training in inverted commas as there isn’t anything official, unlike the foundation program or higher speciality training) are a fraction of the costs of the public spend on medical degrees or ongoing training of junior doctors. They are a cost save overall, even accounting for the salaries.

The BMA has recently voted that the role should be phased out. I hate that GP practices try to mask that you are being fobbed off with an unqualified associate, by sticking the word Physician in front of it. I refuse to be seen by one. If I have got to the point where I am asking for a doctor's appointment, I expect to be seen by someone who is fully trained.

Yes, I was certainly under the impression from the receptionist that I was seeing a GP.

I’m thought they were supposed to have stopped doing that and should be making clear they aren’t doctors.

Mind you the big give away I got the other week was ‘I’m one of the anaesthetics team and I’ll be doing your procedure today.’ Tell me you aren’t an anaesthetist while not telling me you aren’t an anaesthetist. The fact she cocked up some basic physiology during the pre-op didn’t help much either.

I've seen one once for a breast lump, two or three years ago. When I made the appointment the receptionist was very clear with me who the appointment would be with and that she wasn't a doctor but would be able to refer me on if she felt it was necessary. Then for the actual appointment she did a very thorough check and referred me to the breast clinic on the two week wait pathway (turned out to be a massive cyst, nothing sinister). So all in all a good experience. My surgery is utterly awful in every other way possible but I can't fault them on this.

We've seen one. Ds2 had an infection and it was very obvious. She prescribed antibiotics, all good.

We saw a specialist consultant a few months ago who kept dismissing me when I questioned him because I didn't think his treatment plan for my 11 year old with complex needs was right. I ended up talking to a nurse about it and she agreed with me and got it sorted.

I know this is anecdata but some PA's are perfectly capable of dealing with uncomplicated cases and some highly qualified drs don't listen and think they know everything.

They should be doing medical admin and task as suggested by the pp above.

Id probably refuse to see one tbh unless I already knew what I needed and just needed sign off.

PA's can't prescribe in the UK and aren't nurses so it sounds like you probably saw specialist nurses/nurse practitioners (completely different roles).

Is that how it plays out at the system level though? (I'm genuinely asking). You can improve a system by adding worse, cheaper elements to it, and presumably that's the logic behind it.

e.g. 10 consultants, vs 8 consultants and 10 Physician Associates.

Wouldn't the second configuration offer better care overall?

I realise the above numbers are not real -- but isn't this, at worst, a good idea that is being implemented poorly?

I once read a piece written by a PA who realised the limitations of their training, their own lack of knowledge and understanding in treating patients. They applied to medical school to do it properly. That says it all.
The fact that a PA missed the red flags for the blood clot in Emily's case is a classic example of why 2 years training is not enough.

And what makes it even worse is that PAs are paid more than F1 doctors. It's crazy.

I saw a PA the last time I had a routine blood test and prescription renewal. When the nurses did the blood test I had to make a separate appointment with the doctor for the renewal, but the PA could do both (and was better at the blood taking than most of the nurses at my surgery who seem to have trouble finding my veins - once it took five goes over two visits, I felt like a pincushion, PA managed it first time). So it felt much more efficient.

I think their remit needs to be clearer but doctors can also be dismissive /bad at “missing” what should be obvious cancer referrals or cardiac issues.

I wouldn’t have an issue at all. Not all treatment is or needs to be carried out by a doctor, and so long as they are used appropriately, a PA should be no different to a nurse or psychologist providing treatment.

In my view a lot of the manufactured opposition is coming from the BMA who want to preserve doctors’ scarcity and bargaining power (remember they have previously opposed increasing medical school places!)

Mistakes and errors are not unique to PAs and there is no evidence that PAs make a higher number of errors than other healthcare professionals.

Most (all) doctors are firmly against it for many many reasons. The main one being that they’re not safe.

If you saw the app for a lump in your breast, I’d have another appointment with a GO to confirm. Already quite a few cases where they ‘made a mistake, oops’….

There is a world of difference between a PA and a NP. PAs have 2 years training. A NP will have done a nursing degree and many will have years of experience in general nursing plus further post grad qualifications.

I doubt that qualified nurses are doing blood samples in surgeries these days.

Exactly.

Why would she need to see a gp when the person she saw was able to refer her to the specialist she needed to see?