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?

Yes, in general, it is a false economy. They don’t have the training, experience and authority to make decisions in the majority of cases. OP Your case illustrated the uncertainty, duplication of effort and waste of money. Regardless, end result will be a referral to the breast clinic…now or in a month. Might as well just self refer in the first place and miss the primary care step.

@Flossflower but the PA didn't prescribe you the antibiotics......because they can't legally prescribe anything! So same argument the gp had to be involved anyway

My gp surgery seems to have a good system.
There is a GP in one office and 2/3 PAs in consulting rooms. The PAs take the appointment and then pop into the GPs office and run through/get prescriptions signed.

Ive had scenarios where it’s all gone as the PA said, times when the GP has popped in to check something herself or when the plan has changed after they have spoken.

I recently had a 30 min face to face appointment with the PA, went through piles of stuff with her and came out with a fit note a prescription and an appointment for a load of bloods. She diarised calling me back when the results would be in which she then followed through with and I now also have a referral to endocrinology.

I saw a GP a week before for virtually the same reasons and was offered antidepressants and told to get out in fresh air a bit more. I was so rushed that I didn’t mention the ear pain (that needed antibiotics) and he completely dismissed my concerns about my thyroid based on 6 month old blood tests, which the new ones have now flagged as out of range.

@Amermaidandaman it would be interesting to know what the outcome of the 30 minutes with the PA, loads of blood tests, telephone call for follow up and Endo app is vs the previous quick appt with the GP and his advice for fresh air. The result may well be the same after you’ve seen the specialist. Also, imagine if the GP did have 30 minutes with each patient. Also, how is a 30 minute PA time less than a GP’s 10 minutes? It isn’t. PA salary 60K pa vs GP 80K full-time, or thereabouts.

We do have PAs in Scotland. I had one taking blood for blood cultures when I was recently an inpatient. She already had a degree in Biomedical Science and admitted becoming PA as a next best thing to studying Medicine. She didn't attach the dressing properly and left blood gushing from my arm. Wasn't impressed.

My main symptoms were dizziness and tiredness - plus a heap of work related stress that was causing me to feel depressed. She picked up on an ear infection even though the ear pain wasn’t that noticeable, treating that resolved the dizziness and lifted some of the doom I was feeling. I actually returned to work before my fit note ended.
The blood tests revealed iron and folate anaemia which I’m being treated for and my thyroid test indicated secondary hyperthyroidism which requires investigation from an endo.

A rushed, overworked and dismissive GP didn’t have the time to listen he just heard work stress and tried to fob me off. The PA did, and I’m already feeling better and hoping a few more weeks of tablets will help. I don’t think less qualified medical staff is the answer, but I think relieving some of the pressure on GPs has got to help, since they are already dangerously under resourced.

@Amermaidandaman I agree with you. The point I was making is that a 30 minute PA time (plus the signing off from her supervising GP) costs much more than 10 minutes GP time. Sadly, this Tory government is short sighted and pushing for expediency. PS glad you’re better.

I had a similar experience. After finally getting past the PA the GP referred my child urgently to paediatrics and we were seen that week. The PA caused this to be delayed by 6 weeks by just hearing the words "diarrhoea" and thinking acutely. If only we were given a GP appointment in the first place. I'm not sure how to even avoid such situations. I was very clear when I made the appointment my child needed a GP appointment, but we turned up and it wasn't.

It would help if we complain to practice manager every time something like this happens so they have evidence

Yes, complain to the practice manager. PAs are unregulated, there’s no one else to complain to.

I would always ask if unsure whether the medic I was seeing was a doctor or a PA.
This is really concerning.Why is the NHS hiring fake doctors.

@Oneblindmouse that’s a great article. My DNs were saying the aim is for a 5:1 ratio of doctors:PA in 10 years’ time. Terrifying.

Oh god. This is scary. So these people have less training than a nurse?! Having read about these I’m now worried as I had to take an elderly person to minor injuries earlier this week who was in a great deal of pain after a fall. I assume they had seen a nurse who thought they hadn’t broken anything but to me their pain level suggested that the injury is more serious than just bruising. They’ve been sent away with codine and told that the hospital will examine their X-rays and call them if they think they need to go in!

@LuluBlakey1

Nurse practitioners aren’t the same as a PA.
Nurse practitioners are either someone like me (I’m an emergency nurse practitioner) who has a degree in nursing and has gone on to complete further education including Prescribing for example and we work independently, obviously we can consult with Dr’s/colleagues etc but we are accountable for our decision making and we are regulated by the NMC.
and you have advanced nurse practitioners who have a full Masters.
and are usually specialists in an area and invaluable with a wealth of knowledge.

PA as far as I understand are not regulated and therefore are dependent and definitely can’t prescribe etc.
and their background can be something science related like Biomedical science

nurse practitioners aren’t a cheaper option to doctors, we’re highly skilled and trained in our own right 😊

@LuluBlakey1

also I’m very sorry to hear about your Aunt’s experience
there is no reason not to meet her basic care needs or ensure the wards are cleaned.
please contact PALs about this!

@Kitcatmouse

I've just seen the nurse practitioner and had such a bad experience. I'm prone to chest infections and have asthma, I had pneumonia this time last year, and for the past 2 weeks I've had an infection which I can't shake off. It's not quite on my chest, but more my larynx. Either way, I've got a terrible productive cough, and I'm bringing up loads of thick green mucous.

I'm feeling really unwell today so I got an appointment, saw it was the nurse practitioner and hoped for the best, but it was dreadful. She listened to my chest and said it was a flare up of my asthma (it's definitely not that, I saw the GP last week and am on pred already as a precaution), she suggested a course of steroids and I had to point out I'm already on that and my asthma has not been affected by this current infection.

She then tried saying it was croup... and said green mucous doesn't need antibiotics. I had to disagree and said I am prone to these infections and they only get worse not better with me. I've been hospitalised before.. I asked her how do I get rid of the green mucous? She did not have an answer. I said I'm worried it will spread to my chest.. she said it wouldn't but would not offer an explanation as to why.

She did give me antibiotics but as I was going out the door she said I had not listened to her. This upset me as I had listened to everything she said. I feel she didn't like it because I know my body and rejected her diagnosis.

PA ‘s were used as a quick fix to create more ‘GP’ appointments , only not with a GP. 50 million new appointments!
Supposedly there is a shortage of GP’s but there are literally thousands , yes thousands , of GP’s who are struggling as practices won’t employ them , because this government decided to fund other roles instead.
And there will be hundreds more qualifying soon , who are worried about their future.
I’m a doctor with 24 years experience, 12 of them as a GP. I can only find work one or two days a week now , though willing to work all 5.
When I need to see a GP for myself , 4 out of 5 times, I get to see a locum ANP or a PA .
Not sure what the agenda here is or who pushes it and why, but surely this isn’t right.

Collected a prescription that a PA ordered today(after getting signed by the dr)
same brand…. Wrong product and 1/10th of the usual amount on the repeat prescription for eczema ointment.
called the drs and the receptionist just sighed - I’m guessing it’s becoming a regular thing.

I get this all the time since the gp practice employed a pharmacist to review meds and deal with repeats. You have a telephone consult, they argue about everything, then do the Px with the wrong quantities and usually something I didn't need and missing something I do need. Then wait another few days for a gp, that I have never spoken to, to sign the Px.
The poor dispensing pharmacist at the chemist, who has know me for years, then has to call the surgery to try to help.
I can't see how this helps anyone.
I used to order my repeats online.
Still a few mistakes, but the time frame was shorter to rectify.

I presume you locum then, by your description? GP practices being stuck relying on locum doctors so much who are paid much much more for often less work than the regular GPs (in our PCN the locums don't deal with any correspondence/results at all for example) is also not a sustainable way to run general practices surely. I dont blame individual doctors for wanting to do that btw at all, it's a symptom of the broken system we have, but it's surely a good thing if practices can have some of their workload done by consistent, much much cheaper staff members like ANPs and PAs (who are actually basically free in GP land due to the ARRS which I'm sure you know), who do provide continuity for patients with things like referrals/test results/correspondence than using locum doctors who don't, and cost many more times to boot.

Young doctors often do not have a choice but to locus. There uis a huge shortage of places for speciality training. Only one in three applicants will get a place, made worse by PAs using up existing training resource.

Trouble is that PAs are also replacing locums.

DD is an F1. She is increasingly resigned to the fact that when she finishes F2 there probably won’t be a job for her and her options will be to move to Australia or do something else.

By then she will have invested eight years into studying medicine. She enjoys the work and seems to be good at it. The NHS will have betrayed her.

You don't get 30 mins or indeed sometimes any appt time with a GP because the govt has put limits on how many GPs can be employed.
The fund put in place to top up GP practices with essential staff excludes GPs.

On top of that the govt has also reduced and capped how many GP training places can exist.
So hundreds applying for each place just to train.
Thousands unable to be employed
At a time of GP shortage

Introduction of PAs has been happening for several years - it's a clear plan to replace Drs across the NHS without the public noticing. It's been so insidious that even hospitals like Great Ormond St using them in surgery. Bet parents haven't been told- our kids treated there and we certainly weren't.

If you assume PA training is akin to say senior nurse training you are wrong.
It's a 2 yr post grad very low level cse where 100% pass rates guaranteed when you only have to pass 30% of the paper ( see Reading uni or any other prospectus.) No science degree needed. A BTEC in sports science will do. No GCSE or A levels sciences needed.
Parents of those revising for GCSE biology will have kids who've done more anatomy and physiology.

Dr's are now taking their own regulatory body to court about this.

Some PAs may be lovely ppl but they can't do differential diagnosis as a GP can because they don't have 10 yrs training.
If you want the destruction of primary care then accept to see a GP
But don't then complain you can't see the Dr that PA replaced.Because they're now unemployed

It’s a route to an inferior health service I believe. It wouldn’t surprise me if it was partly politically motivated. The tories seem to resent doctors and not want to pay them a proper market rate in what is a global market for their skills.

How can someone with inferior training to a doctor deliver the same quality of service? I’d be interested to know which other countries do this and what the health outcomes evidence is.

My DM saw a PA a fortnight ago with 3hrs notice, with me in attendance.
I was very happy.
She was given a full MOT in a 30min appointment. She promised to chase a referral, and after the PA consulted with Dr and raised an appropriate prescription.

Overall I have been incredibly impressed with the care my DM has received via various parts of the NHS over the past 3 months, and very impressed by her GP surgery.

So, would respectfully ask,how do you know there weren't findings that should have alerted a PA that other investigations were required? No red flags.

Getting 30 mins to feel enough time to explain symptoms alongside basic obs does not equate to clinical safety.
A PA isn't trained to interpret findings, or read results, or refer for scans, or prescribe.

Because they don't learn medicine. They learn lists to rote.
A GP supervising relies on a PA case presenting to them.
Relying on someone to present on something they are literally clueless on is not going to capture what is needed unless incredibly simple presentation.

But the red flag for pts should be why aren't they regulated and haven't ever been?
Because regulation is there to provide professional boundaries & pt safety
Without that it's the wild west as PAs constant posting about pts on tictoc shows.

Coroners have issued warnings to GPs in our area after preventable deaths.
So whilst 30 mins with nice person seems good would trade for 10 mins GP regulated with 10 yrs experience & training any day
Even having to wait weeks with inthe meantime getting basic obs done by HCA prior to any appt
Or clinic nurse if long term condition
Anything but a PA