Physician associates missing diagnoses

[Rover1992]

Doctors are highly trained - and they too make mistakes. If they’re making mistakes after all the years of training, how can we expect physician associates not to? They have TWO YEARS of training. This expansion of them is terrifying

https://www.dailymail.co.uk/health/article-12738457/amp/Breast-cancer-tragedy-shows-vital-health-chiefs-clamp-physician-associates-just-TWO-YEARS-training-MoS-handed-dossier-400-reports-concerned-doctors.html

Agreed.

I saw a PA last year. I wasn't initially told he was a PA, I asked to see a doctor and was not told he was not. He was cagey about his actual status throughout to be honest. I would not have minded his being a PA had he dealt with me properly, but he failed to acknowledge my level of pain and recommended an OTC remedy which didn't work, so I ended up in A&E. They said I needed an US. He referred me, but for an US of the wrong part of my body, which I did not find out until I got there and then when he got the report saying that what they had looked at was fine but they could not rule out bowel cancer, he simply filed it!

Luckily, I did not turn out to have bowel cancer, but it was no thanks to him!

I don't think PAs should be diagnosing or prescribing. Carrying out certain procedures for which they have been trained is different.

If the Daily Mail story is accurate (which would be a first) an 8-months pregnant woman attended her GP surgery for a breast lump. She was advised it was nothing to worry about. Very sadly, shortly after giving birth she was diagnosed with cancer which had spread to multiple organs.

An investigation concluded that the PA followed correct procedure in not doing an immediate 2 week wait referral but failed to set up a follow up in two weeks to see if symptoms had changed. So this was not an incorrect diagnosis as such, but a failure to follow procedure.

It seems extremely unlikely given the timing that a faster diagnosis would have saved this young woman's life, which is a tragedy. It's also unclear that if she had been seen by a GP the outcome would have been any different.

I'm sure many of us have stories of health care professionals who haven't followed correct procedure. My GP forgot to do a two week wait referral for my DH a few years ago. All HCPs need adequate training, oversight and regulation.

That’s the point, people should be seeing doctors. Imagine the ‘what’s ifs’ of the family. Similar in the case of Emily Chesterton, which is also tragic.

We wouldn't need all these physician associates to plug gaps if they funded proper medical training the same way they fund other health courses.

I reckon a lot of people doing these physician associate courses would probably make great GPs with the right training but they are choosing these courses because most people have to follow the funding and you can get a funded apprenticeship to train as a PA or do it as an "allied health" subject on a postgrad course with a postgraduate student loan.

The PA course is attractive because it's shorter than a nursing degree (FFS) with more responsibility if they go to work in an average GP practice or A+E where they're supposed to be supervised but really who has the time to do that properly?

I'd love to retrain as a doctor, have wanted to since I graduated, and know I would be good at it if I did. But there's no access to any sort of student loan to pay for the 5 year undergraduate medical degree course fees, I don't have a related enough degree to walk into the postgrad one (which isn't well funded AFAIK either) and I don't have £45,000 sitting around plus living expenses. You can get a student loan to pay for a second degree in any allied health courses, nursing, paramedics, but not medicine, dentistry or pharmacy. Despite the fact we need a lot more doctors and dentists than art therapists right now.

Until they sort out proper funding for training to be a doctor and widen access so those of us who are from non-traditional backgrounds with the same aptitude have a reasonable chance of getting a place on a course and completing it (i.e. not having to leave for financial reasons), they're going to keep throwing out these stupid sticking plasters and complaining they have a shortage of doctors of their own making. And these sort of mistakes are the result.

PAs do not prescribe just worth noting. What they do is suggest a medication and the GP prescribes. This is routinely done in my surgery.

The GP is accountable for patients

they don’t prescribe but often recommend the treatment plan which the GP then prescribes. The PA discusses patients and should be discussing everyone - but actually info out recently that 1 in 20 patients are being discussed. GP holds ultimate responsibility - I don’t know why anyone would put themselves in a position to supervise these positions.

are the appropriately trained to deal with all complications of procedures? Probably not

I understand that whether PAs should be able to prescribe us currently under consideration.

^is

I saw a PA last year who missed a red flag symptom. He introduced himself as "a Physician". Fortunately I saw a GP a week later who was fuming and referred me on a 2ww. Since then I have followed this story.

This guy on Twitter posts a lot about PAs and the risks to patients.
It is against the law for someone to say they are a doctor or physician if they are not.
There is a huge backlash among doctors and trainee doctors about PAs.
The training for a PA is two years after a degree. Many were students who applied and failed to get into medical school.
They start on about £40k compared with a junior doctor on £30k.
They are not allowed to prescribe but in some hospitals appear to be given huge responsibility - running clinics, seeing patients.

As a GP, I agree. I now work in a practice where we do not and will not have PAs as the majority of partners are opposed to them. During my hospital training time it wound me intensely to have PAs expecting me to prescribe based on their briefly presented 1-2 minute summary of the patient, sometimes with very little information and the shortest of time spent assessing the patient, and I never felt safe doing it. Compare that to a medical student asking me for the same thing and it was expected that a full history and exam would be presented with me often then going with the student to patient to clarify things and perhaps examine the relevant bit myself too, a process which might take 15 mins. Then I felt secure I could trust the students and my own judgement that the course of action was the correct one. Yet when I attempted to do the same with a PA I was rebuffed and made to feel like I was undermining them!
I will see one myself as a patient but then I know what's right and what's not as I am a doctor so am not worried about my safety. I tell my non medical family to refuse to see them.

From the other side, I recently spoke to a current biosciences undergraduate who has been passionately mis-sold the PA degree. She was adamant she will be a doctor at the end of this training and will be free to tell patients she is one too.
I informed she was completely mis-informed and needs to read the course information much more closely as well as googling recent high profile cases like those mentioned. I hope she has changed her mind!

@HiCandles that's interesting. As a patient with multiple health conditions, how would I be viewed if I said I didn't want to see a PA? I am perfectly happy to see the ANPs at the surgery who are excellent but if it's an urgent appointment you don't get a choice.
I see my GP are recruiting another PA and the advert says "experience preferred". and the role will involve responding to and treating patients with undifferentiated diagnosis.

I’m a doctor. I often have worked with PAs who were being paid more per hour than me. I did their prescribing for them, took responsibility, had years more training and student debt. I’d done countless shifts at night and weekends gaining experience of looking after sick patients rather just routine day to day ward work. As part of my training I’ve been forced to move to new hospitals frequently (we all know how awful starting a new job is). The govt seem to want to give them all the perks of being a doctor but none of the sacrifice.

I used to be scared about the detrimental effect they’re having on my training. Now I’m scared about being a patient and seeing them or them looking after my family.

My cancer was also misdiagnosed by a PA. The GP refused to see me and would only book me in with a PA. Both actions meant a delay in diagnosis and treatment.

Well you need to write to your MPs.

It's coming from the top.

All the money is going into getting more of these allied health professionals and your own qualified doctors are looking to making a future abroad.

There isn't enough doctors mostly because of the conditions they have to work in. So the government is plugging gaps by expanding training for these other health professionals.

I think its already gone too far.

If you can pay private you can book a GP appointment. Everyone else will have to see a PA or some kind of specialist nurse practitioner.

It shouldn't raise any eyebrows. Plenty of patients have a note on their record to say 'does not want to see Dr X' or 'prefers to see Dr Y unless an emergency' or 'will not see the pharmacist'. It's so commonplace that nobody gives it a second thought - but it does mean that you may need to be prepared to wait longer for your clinician of choice to become free. To be honest while it's clearly primarily about patient choice, it's also about avoiding the inevitable time consuming complaint that making a patient see someone they don't want to is going to generate, and it's about having a smooth mutually happy consultation. It's in everyone's interest to facilitate patients seeing who they want to, where possible!
In your case it could be wise to ask to have it noted that you see the same GP each time who knows your history if it's complex - some practices are great at recognising how much easier this makes life for both patient and doctor, others sadly not so much.

I am certainly concerned about the rise in other professions taking on medical roles without adequate training and supervision. I know that there are lots of fabulous Nurse Practitioners, ACPs etc (my son's asthma nurse is brilliant )and also that doctors also make mistake, but my personal experience with HCPs other than doctors making diagnoses and treatment decisions has been poor and I can't help that colouring my opinion. In the last 5 years there have been 3 occasions when either I or a family member have been sent home with incorrect diagnoses from our GP practice after seeing someone other than a doctor. On two of the occasions emergency surgery was needed within the next 24 hours, by the third time I just knew the person was wrong, went home and dialed 999. My family member was admitted straight from A&E to ICU and I am in absolutely no doubt would be dead by now had I listened to that HCP.
I also think there is a knock on effect on nursing. So many of the experienced nurses seem to be moving into these kind if roles that care on the wards in our local hospital seem to be mainly delivered by health care assistants. And again, I have met lots of lovely, dedicated people in that role as I have unfortunately been in and out of hospital a lot in the last few years but they are not qualified nurses and shouldn't be asked to take on responsibility for things above their pay grade. I had another narrow escape in hospital when a post op complication was missed. The HCA had recorded all my abnormal observations beautifully but (not unreasonably) couldn't interpret what she was seeing and nobody checked for a considerable period of time. I was going into kidney failure before anyone realised.
It seems to me that we have a lot of nurses and other HCPs doing jobs that doctors should be doing, a lot of health care assistants doing jobs that registered nurses should be doing and nobody doing a lot of what the HCAs used to do. In my last NHS stay I didn't have a shower or full wash of any kind for 5 days. I wasn't allowed unsupervised in the shower as it was deemed unsafe but there was nobody with time to help. Other patients who were more mobile helped me change my pyjamas and cut up my food for me so I could eat.
I appreciate we don't have enough doctors and that there is no easy answer. I don't know what the solution is, but if my experience and that of a number of family members is anything to go by the current plans just aren't working and a different approach is needed.
I have lost all faith in our local NHS to be honest and had my last surgery in a private hospital which was like a different world. Obviously not everyone can afford that though and the slippage of standards is very worrying.

everyone needs to be spreading the word about what PAs are, what qualifications they have and should not be afraid to ask for a doctor. They are NOT doctor replacements. I’m not talking about ANPs etc.. This is about PAs.

We don’t have enough doctors and nurses so the government are going to put sticky plasters over the situation which will be to the detriment of our loved ones. Scary scary situation

Exactly. Everyone needs to be spreading the word and there needs to be uproar. Why would doctors stay here when PAs are making more than them in the first few years post qualification - and it’s those doctors that have to do their prescriptions and order scans. The government are facilitating a two tier healthcare system

They will at some point if you read the legislative consultation and plans

And when they reply.

Sorry there are no doctors.

It's see this person or an ANP?

What then?

There aren't any more doctors. I don't think you're understanding this.

It's not that you got fobbed off. And would have been able to see the 'GP'.

There probably aren't any GP appointments at all.

Maybe there were 5 and they got booked up.

Then you could decide to try ringing again a different day,and again the 5 appointments are booked up. And the only option wpuld be to see the PA. Would you just not bother getting seen?

oh I’m understanding it alright. If you’re willing to take the risk then by all means go for it