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There is a very active and emotive debate in medical circles concerning he role of the Physician Associates (PAs) in the NHS. Council members of the Royal College of Physicians of London have called for an extraordinary general meeting (EGM) about their place in medicine. The debate is hot, sometimes personal. The term ‘fake doctors’ comes up, while others take a more balanced view, based on many years of good working relationships with PAs. The effect of this debate on existing PAs is significant – they must feel unloved, and this is recognised by the RCP (under whose umbrella PAs currently exist), who are ‘concerned for the physical and mental wellbeing of all our members’. This situation has crept up on us – on me anyway, as I have found myself having no strong opinion. However, delving into the reports and concerns soon focusses the mind. And as a member of the RCP, I should have an opinion. This is important. Here then, is an ethics focussed take.
PAs have been working alongside medical teams in hospitals and general practice for many years now, but a recent NHS workforce plan made it clear that they would increase in number over time and begin to represent a significant proportion of the medical workforce. In a July 2023 parliamentary debate, it was pointed out Barbara Keeley MP that ‘The plan aims to more than triple the number of physician associates in the NHS workforce in the next 12 years. By 2037, they will total 10,000, with around 1,300 trained annually from this year, and 1,500 trained each year in 10 years’ time’. She raised these concerns because one of her constituents, Emily Chesterton, died following the missed diagnosis of a deep vein thrombosis and pulmonary embolism. The coroner found that Emily’s death was preventable, concluding that,
Emily Chesterton died from a pulmonary embolism, a natural cause of death. She attended her general practitioner surgery on the mornings of 31 October and 7 November 2022 with calf pain and shortness of breath, and was seen by the same physician associate on both occasions. She should have been immediately referred to a hospital emergency unit. If she had been on either occasion, the likelihood is that she would have been treated for pulmonary embolism and would have survived.
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There are important questions to be explored, including how PAs are regulated. Currently the Physician Associate Managed Voluntary Register (PAMVR) exists, but the word ‘voluntary’ would appear to be problematic. The Faculty of PAs suggests that ‘In the interest of patient safety, the FPA strongly encourages all employers (NHS trusts, GP, PA agencies, and private healthcare providers) of PAs to check the PAMVR status of the PA at regular intervals during the year. The PAMVR should also be checked at the point of contractual agreement to ensure they are in good standing.’ Folding PA regulation into the GMC would appear to answer this concern – the GMC protects patients by assuring the competence and probity of doctors – but in joining the GMC, PAs would appear to gain equal status to doctors. Doctors are not keen on this!
In a later parliamentary debate (Feb 2024) Dr Dan Poulter MP made the point that a separate register for doctors and PAs should exist, ‘so that it is very clear that the different professions are regulated under separate registers. That is important for both accountability and transparency, and it is important that patients understand that.’ He went on to describe a personal case, in his capacity as a doctor, where a patient was sent home from A&E by a PA following a paracetamol overdose: ‘The physician associate incorrectly informed me that they did not require N-acetylcysteine treatment because their liver function test was normal, in spite of the fact that they were over the treatment line as a result of their paracetamol overdose.’
From an ethics perspective, the main issue appears to be consent. Do patients know that they are seeing a PA? Do they understand the difference between a PA and a doctor? Do they feel empowered to challenge their opinions or demand a more experienced one?
Will Quince MP, then Minister of State at Department of Health and Social Care, answered Barbara Keeley by describing the training requirement of PAs. It ‘involves at least 1,600 hours of clinical training, including 350 hours in general hospital medicine and a minimum of 90 hours in other settings, including mental health, surgery and paediatrics.’ These large numbers are less impressive when translated into years. PA training is 2 years, compared to the 5 years under-graduate and 2 years post-graduate experience that doctors require before being deemed independent (after this, hospital doctors are still ‘trainees’ for another decade or so). I think direct comparison between doctors and PAs is unhelpful. They are not trying, themselves, to be doctors, and do not pretend to have the same depth of medical education. This equivalence is only important if patients believe they are seeing a doctor, and their understanding is not corrected.
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Although PAs should be supervised (they are ‘dependent’, not independent), there is a risk that supervision will be in name only within a hugely stretched health service. Although they may have a named consultant who is responsible for their performance, the consultant is not likely to be seeing them regularly during the day. There may be firm instructions to discuss every medical decision that is made, but once a degree of trust has been established, once it is clear that the PA ‘knows their stuff’, they will be given more freedom.
This is likely to be safe most of the time. However, medicine catches you out. Doctors can make the right decision 90% of the time based on pattern recognition. Where the depth of education comes in useful, is when the patients present atypically, i.e. with symptoms or signs that do not fit the textbook description. This is when the doctor must dig deep into their knowledge, make connections between organs or pathologies that do not come directly to mind, and begin to entertain diagnoses that they may have only seen once or twice in their lives, or perhaps read about as an undergraduate. Sometimes, these unusual connections will lead to a diagnosis that leads to lifesaving treatment.
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A subtler point is knowing what you don’t know. It is quite easy, as a diagnostician, to convince yourself that a patient’s chest pain is caused by 1 of 5 common diagnoses. If the pattern doesn’t quite fit, it is tempting to interpret the clues in such a way that they conform to the preferred diagnosis. The relatively inexperienced medical practitioner will quickly arrive at a comfortable diagnosis and may not refer up to a senior. All seems well… until the patient deteriorates, and you realise that you had it all wrong. And what if they didn’t have one of the 5 diagnoses? Perhaps it was something much rarer, down at 18 on the list. To even know that this condition exists would require a deep immersion in medicine.
There is another important area to explore: a PA’s ability to cope with error. The closer you get to patients, the more direct your interaction, and in direct proportion to the number of patients you see, the greater the chance that you will make a mistake that results in patient harm. Fully trained doctors have observed what happens to patients, families and other doctors when things go wrong. Their training is more than the accumulation of knowledge; it is a deeper understanding of human frailty, nature’s sometimes inexplicable logic, and the long shadow thrown by disease and its treatment. If the NHS is to encourage PAs to occupy higher risk areas, it must ensure they are ready for everything. Websites designed to attract candidates into PA positions emphasise excitement and the autonomy; the other side of these attractions are responsibility and self-blame.
So, when it comes to the question of consent, we need to consider the individual patient who presents to hospital or the general practice with symptoms, and society as a whole. Patients must know that they are not seeing a doctor, and perhaps they need to know more than this. That this is an initial assessment; that any decisions made will be reviewed by a doctor; that the patient has the right to request a senior opinion; that should things not improve, they will definitely see a doctor next time. And as a society, do we consent to our health service being increasingly run at the front door by non-doctors? It seems to me that this has been happening for many years, and in many places it works. But for it to work well, and for all to be happy, issues of fairness, access to education and training, remuneration and governance need to be agreed. This will require time, a resource in short supply for a health service that is already struggling to deal with those who try to access it.
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This 2023 BMJ article, by the editor, provides a food overview and links to several good opinion pieces.
Available on Amazon – £5.99 paperback, 78p Kindle
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