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?

What.is the actual role of Physcian associate?
I took my Son to Dr's last week and we saw one ,he's severely autistic and Been eating a lot of beetroot and his urine was red i wssent at all concerned by this as i know it can be a side affect but his special schools wanted it checked out as he's non verbal etc and can't say if he's any pain
Anyway we saw one who took the history and then said needed to speak to the GP who them asked me the same questions and said he had no concerns,
Which made me think seeing the physcians associate first was a bit pointless ?

@NLG17 I don't. But a full proper check of blood pressure, chest, etc with a PA on the day, was better than a wait to see the GP.

I agree completely with this. Medicine needs to have a heavy duty of responsibility and take a long time to get through. The opioid crisis in America and the testing of children via gender affirming care shows how vulnerable the system is to predatory practices.

She needs to be exception reporting daily if those hours aren't exaggerated for effect... our legal max hours is 72h per week

GPs get PAs fully funded for free which is why they're in growing number there, in combination with so many GPs max exodus from the job as they're treated awfully and crazily overworked

It's definitely a worrying progression. I've been totally incorrectly examined by a PA ... to feel for blood clots through jeans and knee high leather boots, I didn't even raise it at the time as felt so god awful and knew I didn't have a dvt but still

Depends on your age. Mammograms are more accurate in older breasts, ultrasounds in younger breasts (my referral was about age 25 and the only investigation is ultrasound due to breast composition

Are you talking about England or the whole of the UK?

Contracts vary significantly in different parts of the country. And conditions vary in different deaneries. For example London F1s apparently don’t have to work nights. Though medical school graduates are able to show a preference for where they may want to work, they can be allocated anywhere, and have to accept the pay and conditions that prevail.

I think the BMA supervision guidance is helpful (which is why it was a bit of a bomb going off when it was issued) - PAs shouldn't be working with undifferentiated patients in primary care, and shouldn't be seeing children at all. They shouldn't be holding bleeps that allow them to make unsupported clinical decisions in hospitals either. There referral rates are high compared to GPs, but not as high as they should be.

I can easily imagine a PA being helpful with eg a healthy living clinic for people living with chronic health conditions- if you have tricky heart conditions or asthma or past strokes, you might need something more specialist than Weight Watchers, and some one like a PA who can flag up clinical concerns would add value.

Ironically it makes far more sense to use PAs in specialist surgery, which as far as I know is what they do in the USA (there's an American PA in my partner's family). Doing specific very technical procedures to a small group of selected patients wuth heavy team oversight, surgeons around, nurses looking after the patient - I can see that working. But if UK surgery looks very different and is thinly staffed compared to the US (which it might be), that's more worrying.

Steve Barclay seems to have slid through and got away with supporting this expansion and then slid out of being Health Secretary again without any comeback. There were probably others who did too - Hancock?

Sorry for your experience, it does sound awful.

I now work in paediatrics but I recall working in adult medicine as an F1/F2.

The team on a given day would consist of 1 consultant, 1 or 2 registrars, 1 or 2 SHOs (FY2-just below registrar level) and 2 FY1s. And we were often understaffed. So we might have 5 doctors in total, and 2 of those 5 really with the lowest level of experience possible (FY1s). The consultant and frequently the registrars needed to leave in the afternoon to undertake their procedures list or their clinics.

During busy periods the team had to manage up to 60-70 inpatients and furthermore the registrar might have to see new patients as they arrived or give specialist advice for a patient under another team. We all also might become very busy indeed if there were 1 or 2 very unwell patients to manage.

The consultant couldn't physically see or even maintain an awareness of all of the patients every day, even if the round was split with the registrar this did not leave enough time so some of the patients each day would have to be seen by / known only to an SHO. So generally the consultant would just see the new patients and any patients of particular concern

We could not have a handover of each and every patient every day (only the unwell / concerning or new ones) so for the majority of patients information is transmitted only from the notes not firsthand. And staff change not quite every day but there isn't the same team every single day because of night shifts, days off and cross cover of staff absences in other teams.

It was like an endurance race every day to get through them all. As an FY1 you usually write in the notes to help the senior SHO/registrar or consultant get around faster. You have to try to write as fast as they speak.

The day is at best 8 hours long, possibly only 4 of those hours with a senior present - minus any breaks or emergencies - and if there are 60 patients taking 5 minutes each that already adds up to 5 hours of ward round. But is 5 minutes a day enough to fully address the complexities of a 80 year old with about 10 complex intersecting chronic health conditions as well as whatever has brought them in?

You are absolutely right about the care the patients deserve but it very difficult to give personalised care facing these kinds of numbers day in day out. It dehumanises the patients almost by necessity.

From my junior perspective the chief priority was to do the paperwork necessary to get the patients out of the door to make room for the never ending flow of new patients.

Much more needs to be done to keep patients safely out of hospital, and to give them safe destinations to be discharged to. Until adult social care is prioritised and adequately funded, patients in hospital will not be able to get good care no matter how well things are organised, not when they outnumber senior experienced doctors 20 or 30 to 1.

Imo PA's have a role as cheap labour to perform repetitive highly differentiated tasks (eg specific procedures) or administrative tasks (eg discharge summaries). The problem is they may then procedurally deskill doctors, they aren't actually cheap, and it seems that they are being used to medically assess undifferentiated patients (v dangerous imo).

This is only the doctors' perspective I can't speak to nurses.

Damn, yes forgot to add to my post that although PAs doing specialist surgery tasks is undoubtedly safer than them being in primary care, that then undermines the training of junior doctors who rotate so often that every procedure they miss out in being trained on significantly undermines their ability to develop.

I can't help feeling that PAs counterintuitively might make more sense in a system with more spare capacity than the NHS. The Doctor's Assistant band 4 post that does legwork, admin, chasing and support makes far more sense for most of the departments I have ever worked in.

England is on the new contract, rest of uk on the old. If you Google max working hours doctor 2016 or 2002 it summaries limits on hours.

Exception report if exceeding on new contact. Request hours monitoring diary card if on the old contract

No nights in f1 is v common, I didn't do them in f1 in Lincolnshire (granted nearly 10y ago now), they often have twilight midnight finishes instead

What is your problem with pharmacists?
You do realise that they stop doctors killing in injuring you when doctors make mistakes when prescribing?
I agree that using PAs is very concerning.