To think Physician Associates are (mostly) a false economy?

[bumblenbean]

I know there have been a few threads about PAs lately and I’ve shared concerns about how well equipped they are to diagnose/ treat patients. After my experience today, I really feel they are (at least in some cases) something of a false economy.

Filled in an appointment request at my GP surgery recently due to breast symptoms (nipple pain, possible small lump). Receptionist called back and said ‘the doctor has reviewed your form and wants you to come in within a week’. Appointment made for today.

Upon arrival, the clinician introduced herself as a physician associate which was the first time I was aware our surgery even used them, let alone that I was seeing one for a supposedly urgent appointment- but hey ho, didn’t have much option but to go ahead.

Tbf, the PA was very friendly, thorough and tried to put me at ease, and she listened attentively to everything I said about my symptoms. However, the breast exam took a very long time as she seemed unsure if she could feel a lump and she kept checking and rechecking. She also didn’t know what the glands on the areole are (I’m not sure what they’re called either, but I know what they are!). Eventually she said she’d refer me for an ultrasound just to be sure - fine. I came away feeling satisfied it had been dealt with.

Few hours later, I get a call from the PA saying she’d checked with a GP colleague for a ‘second opinion’ and the Gp doesn’t think a referral is likely to be needed but wants me to come in again so she can repeat the exam. So I now have to return in a couple of days for a repeat appointment.

I mean - I’m not messing around with my boobs so am happy to go back, but it’s frustrating to take time off for two appointments and to be told something will happen which then doesn’t, and basically have the same appointment twice.

It surely would have been a hell of a lot quicker and more cost effective for me to just see the GP first time around (as I was expecting)?! If the doctor has to give a second opinion on everything the PA does then surely the PA should only be doing routine things like UTIs, skin conditions etc?

I understand cost saving measures are needed, but I do think surgeries need to be more open about when a PA is assigned to an appointment and ensure that they are fully equipped to actually deal with the presenting issue.

Anyone had any experiences with a PA, either positive or similar to mine?

There's a nice PA at our surgery. He was very good when I saw him last month for a chest infection in pregnancy. I'm asthmatic and get a lot of chest infections and he took plenty of time to listen to my chest, give me advice on when to come back if I needed to etc. His bedside manner was great and he put me at ease (some of the GPs could take notes from him about bedside manner).

The downside with the PA was that I saw him in the morning (just before 11am) but by the time the doctor had prescribed the antibiotics, the pharmacy was shut for the evening and I had to wait until the following day to get them. Normally I see an Advanced Nurse Practitioner for chest infections and UTIs and they can prescribe.

I could have done without the extra trip out in the cold weather when feeling unwell and the delay in starting treatment. If I'd seen a doctor or an ANP I would have had the antibiotics the same day.

I follow a US pa and he's qualified to do minor surgery, like cyst removal perhaps someone got the idea from the States but failed to realise what they do.

OP I'm sorry to hear about your lump but if you're not sure about it may be too small ATM so a short wait may give it time to grow big enough to be felt,if it is there and not a minor change to the shape

Some Pharmacists can prescribe as can some nurses so it's not always a GP that's needed for a prescription

I agree that I don't think PAs should work seeing an undifferentiated caseload in general practice. Other countries don't do this. The reason this is being forced on GP practices is so that the government will have figures to wave at the election saying that X% of people now get an appointment at their GP practice within X hours/days.

I think each GP should work between 2 surgery rooms with a band 4 or 5 Doctor's Assistant in each - the GP sees the patient, makes the decisions, the DA gets on with the emails, referrals and chasing while the GP sees the next patient.

Not all breast cancers can be felt.

The gp often doesn't do the chasing - they've got secretaries that do this. They also often use a dictaphone or similar fir referrals/emails etc

Not a PA but I was referred to a so called 'orthopaedic specialist' who is based at my GP practice for my knee.
They gave me exercises to do that weren't as good as the physiotherapists, and very little else.

They didn't even refer me to get more specialist help, I had to ask for that after a few weeks with no improvement and suggest that I might need an xray or mri to see what was going on.

Essentially they were there to fob me off.

I've never heard of a PA, I'm in Wales, I don't think we have them here? What qualification is it? Is it a banded role, like nursing (qualified nurse starts at band 5).

When I make an appointment at my surgery for myself or any of my children, I know whether we need to see a GP or the advanced nurse practitioner. The receptionist will always try and put you with the ANP, no matter what you tell them, but I always ask who the appointment is with, and if they say the ANP, I just say please can you change that to the GP, and they do.

From experience though, the ANPs at our surgery are awful, and don't seem to be very knowledgeable at all.

Thanks for your thoughts all - a somewhat mixed bag of experiences but generally it does seem the system needs some major refinement.

I’m not sure how time intensive the supervision of PAs aspect is for GPs, but all in all the current system doesn’t seem to save much time at all- and in fact sometimes duplicates it.

@Shoppingfiend i know - which is why I would have liked the referral for a scan. I suspect the GP will say tomorrow (as the PA has suggested she will) that I don’t need one, as she seems to think it’s all explicable by my menstrual cycle (even though I’ve had the pain for about a month) 🤔 Tbh if I’m fobbed off tomorrow I’ll probably just arrange an appointment with a private breast clinic…

I have never heard this before. That's appalling. I take it it's a cost-cutting attempt. It's disgraceful. We're told continually (and experience it) that we are short of Drs in hospitals and GPs- but what you are saying is there are many student Drs who want to do these jobs but the jobs do not exist because the NHS is not funding them- so instead of advertising for 2000 GP trainees, they have decided to train Physician Assistants and Nurse Practitioners (for example)?

I’ve never heard of them or encountered one. What’s the idea behind it?

Whenever I read or hear about other surgeries I just can’t believe how lucky we are with ours. Always seen a GP same day for urgent and within the week for non urgent. Granted we don’t use it loads.

It’s likely the PA debriefed with the supervising GP and said they couldn’t feel a lump. The GP, being fully responsible for the PAs actions, decided they needed to check themselves as they didn’t fancy a law suit.
One of the problems with PAs is that they aren’t regulated, unlike all other associated care professionals.

PAs are a complete waste of time and are being used as a temporary fix by the tories to massage the GP appointment crisis . Meanwhile actual doctors can't get GP training posts .

Yes, that’s exactly what is happening.
these are not ‘student doctors’ though, which sounds like they are still in university studying medicine. These are fully qualified doctors who have their MB BS degree and have completed 2 foundation years minimally. And yes, thousands have been turned away from GP and hospital specialty training. Because the government chooses not to fund them.

I am really shocked- both by what you say and by my ignorance of this. Is this a Tory thing or was it an issue pre-2010?

OP I don’t think you’ll get a referral for a US for a breast lump. You might get referred to the breast clinic, and that’s where they might do the scan. AFAIK referrals for breast US tend to be rejected otherwise.

I have two DNs in medical school atm. I love them to bits and they’re super clever girls, but nowhere near being able to diagnose etc after 2 years. And yes, I know PAs do 2 years after a first degree, but that’s not a medical degree and it’s not enough.

GP surgeries employ them because they are funded differently and not paid by the GP surgeries. £ free work and some will be ok or very good.

@LuluBlakey1 that’s horrendous. Your poor aunt.

I’m wondering why you don’t need a mammogram, rather than an ultrasound?
also, sometimes nobody can feel the lump for early breast cancer.
But also, most breast cancers do not present with pain.

@JussathoB i wondered the same, but apparently an US can give a better/ different view. I have, for want of a better word, quite ‘lumpy’/ fibrous breast tissue so haven’t established if there’s an ‘actual’ lump. Hoping as you say the pain is a ‘good sign’. Potentially a cyst or something …

Ah ok, yes I’ve heard some women ( often also younger eg under 45) don’t suit mammograms well because they have denser breast tissue

I took a referral from a PA today . They had not asked vital questions that a doctor would have known to ask.

Incompetent reviews are a waste of time. 10 years ago , we would have demanded that a competent person see the patient before they waste time and resources travelling to hospital . Now you just accept whatever care was provided. It’s rubbish . PA s need to be assistants not substitutes.

Yes US give better imaging in younger women than mammograms. Also certain types of lumps like cysts will be well imaged on US.

A physician associate missing breast cancer in a patient will potentially cost the NHS a lot more than the £36 you say is the cost of a gp appointment. Delays in referrals cost money but also a poorer outcome for the patient, though hopefully not in your case OP. It’s not as if we have great outcomes in this country to start off with.

I’d want to be either examined by a GP or a specially trained nurse, not someone who has had a mere two years training and not very much experience.