Physician Associates: insights into a new role in the NHS

Introduction

There are many new emerging roles in the National Health Service (NHS) with Physician Associates (PAs) being one of them. To the majority of the general public and other healthcare professionals, the role is still an enigma and there are plenty of myths floating around in the ether. In this blog post, I hope to explain the role PAs play in healthcare delivery and debunk some of the myths.

My journey

One of the many amazing things about the role of a PA is the wide variety of backgrounds and life experiences we bring to the table. These backgrounds include nursing, physiotherapy, radiography, teaching and lots more.

My journey started in 2011 at the University of Liverpool, where I studied a BSc in Life Sciences Applicable to Medicine. I then went on to complete a PGCE in secondary science (specifically chemistry), after qualification as a teacher I taught in a secondary school for a few years and then did a year of locum work in primary schools teaching all year groups from reception to year 6. After a successful few years teaching, I decided to leave and pursue my dream career (as cliché as its sounds). My dream was always to work in healthcare in some form, but life got in the way and I fell quite happily into teaching. I was told about the PA role by a family member and after some research, I was sold. A two-year PGDip or Masters (which after already completing 4 years at university was ideal), plenty of patient contact and job flexibility sounded ideal.

Background

Surprisingly the PA role is not as new as you may think. In the UK, PAs have been around since 2003 when they were formally introduced. There are PAs working all over the world from the United States of America (USA) where the role formally began in the 1960s to Saudi Arabia, South Africa and many other countries. The role is a lot more established in the USA which currently has around 123,000 PAs. Interestingly the capabilities, governance and training of PAs are markedly different globally. For example, due to the current lack of registration in the UK, PAs cannot prescribe medication or order investigations which involve ionising radiation (e.g. X-rays), however, in the USA, PAs can prescribe all medications including controlled substances (except in the state of Kentucky).

So why was the role even developed? Let’s rewind to the 1960s in the USA where it all began. The role was initially introduced as a response to a shortage and maldistribution of physicians. To remedy this issue Eugene A. Stead Jr., MD, of the Duke University Medical Centre (USA) put together the first cohort of PAs in 1965. He selected four navy hospital corpsmen who had received considerable medical training during their military service. Eugene based their whole training programme on his knowledge of the fast track training of doctors during World War Two.¹

What is a Physician Associate?

Physician Associates are healthcare professionals who have been trained using a medical model. PAs work within a defined scope of practice and within limits of competence (as PAs are currently not a regulated profession). PAs work alongside other members of the multidisciplinary team including Doctors, Nurses, Physiotherapists (and many others) as an integral part of the team. We are dependent practitioners who work under the supervision of a medical supervisor who is typically a consultant.

What training is required to become a Physician Associate?

There are two ways to study to be a Physician Associate, you can either do an undergraduate degree or study as a postgraduate for a Masters or PGDip (postgraduate diploma) in Physician Associate studies. If you are a postgraduate, you have to have a prior degree in either a healthcare science or life science. On the course, you study for either 2 years as a postgraduate or 4 years as an undergraduate. During this time, you learn about the ins and outs of medicine, with very few holidays to decompress. Part of the training involves university teaching on anatomy, physiology, pharmacology, medical conditions, communication skills and clinical skills. Training also involves clinical placements in a variety of different specialties under supervision, in which you are expected to develop practical clinical skills and apply your knowledge. All universities may do this slightly differently but, in my case, the first year of placements were in general medicine, general practice and acute assessment units. My second year involved training in specialities such as paediatrics, obstetrics and gynaecology, mental health, surgery and an elective placement in oncology. 

What do Physician Associates actually do?

So, on a basic level, we are trained to manage, diagnose and treat patients in either a primary or secondary care settings.

Examples of some of the general jobs we do:

• Taking histories and examining patients
• Forming differential diagnoses and management plans
• Performing procedures such as venepuncture, cannulation, arterial blood gas sampling, catheterisation and suturing
• Requesting investigations such as MRIs, ultrasounds, echocardiograms, colonoscopies and endoscopies (this differs between hospital trusts due to local restrictions)
• Interpretation of investigations (even the ones we cannot order like X-rays)
• Health promotion and disease prevention

As a PA progresses their scope of practice widens, this may include learning advanced procedures, taking part in outpatient clinics, research and teaching. There are PAs out there who have been trained in advanced skills such as lumbar puncture, ascitic drains, first-assisting in theatre, joint injections and endoscopies. Some PAs also lead outpatient clinics when experienced enough. Regulation should allow the scope of PA practice to widen further over time.

Regulation

Physician Associates are currently a non-regulated profession. We have a voluntary register which is managed by the Faculty of Physician Associates (FPA) as part of the Royal College of Physicians. The FPA and PAs have been collectively lobbying for years to make the regulation for the profession mandatory and finally, in July 2019 the GMC announced they would take on the task of regulating us. Since then the GMC have been working tirelessly on designing policy and processes which will be required, however, regulation cannot take place until the government change certain legislation which will take some time. The goal is to have us regulated by September 2021, if everything goes to plan.

Due to the fact that there is no current legal obligation to be on the voluntary register, there are understandably things we are unable to do. This includes first and foremost prescribing and ordering ionising radiation.

Achieving regulation will be a big step forward for the profession and will change the role in many positive ways. Aside from the future ability to prescribe and order ionising radiation, regulation will further legitimise the role, protect the PA title, help to standardise university courses and provide more clinical and non-clinical opportunities.

What Physician Associates can and can’t do?

The most commonly asked question Physician Associates get asked is ‘can you prescribe XYZ for patient X?’. It is something people just assume you can do because you are working alongside other medical staff. As a result, I thought it was relevant to note down some of the things we actually can and cannot do for those of you who work with PAs currently or will do in the future.

Physician Associates can:

• Clerk and assess patients (i.e. take a history, perform a clinical examination, form a differential diagnosis)
• Perform clinical procedures such as venepuncture, cannulation, arterial blood gas sampling and catheterisation
• First-assist in theatres
• Request investigations that do not involve ionising radiation (the types of investigations varies by hospital trust)
• Perform more advanced procedures if appropriately trained including joint aspiration, lumbar puncture, ascitic taps, nerve blocks, fracture reduction, endoscopies, colonoscopies and cystoscopies

Physician Associates can’t:

• Prescribe medication and blood products
• Request investigations which involve ionising radiation
• Sign death certificates

Conclusion

As a practicing Physician Associate, I’m keen to broaden the understanding of the role so that other healthcare staff are aware of how we can add value to the delivery of patient care. I can’t speak for my Physician Associate colleagues but being a pioneer for the role is such a rewarding and exciting part of being a PA at the moment. Please welcome any Physician Associates joining your department with open arms, we are here to help you improve the delivery of patient care.

References

1. History of The PA Profession. 2020. Available from: [LINK].