tin_robot wrote:

Diluted Dante wrote:

Doesn't really fit here, but this is the place I suspect Tin is most likely to see. Physician Associates. I don't understand them. They seem to be, essentially, fake doctors. I don't get why they exist, or why I would be happy to see one.

Paul the sparky wrote:

Never heard of a physician associate like. Sounds like a sparky's mate, can help out with the heavy lifting, sweeping up etc but can't do any of the technical stuff a spark can

Right then.  Grab a cup of tea and sit down, as I'm liable to waffle here.  I'll start with that they are, then why they exist, then why you might be happy to see one, before getting onto the long list of problems I have with them.

So what are they?  In short pretty much what Paul said.  Physician's Associates (PAs) can take histories, do simple examinations and procedures, offer management plans, and give out advice. However they have to work under the supervision of a doctor, and (currently) have no independent professional registration.

These "noctors", as some in the profession have christened them, are really controversial amongst medics for a bunch of reasons.

So why do we have them?  In short, because we don't have enough doctors.  It takes 5 years to put someone through medical school, and a minimum of 10 before you can call yourself a specialist of any sort. (That's for GPs - assuming they pass every exam and everything goes to plan. For other specialties it can take 15-20 years and many never make it remaining "junior" doctors for their entire career.). 

PAs can be trained in 2 years - so they can be quickly recruited to fill the gap, and have been.  They are pretty common on hospital wards, and increasingly so in GP.  In General Practice for the last couple of ears we've been able to recruit them as "Additional Roles" - basically all practices were given funding with which they could recruit specified roles that *weren't* doctors or nurses.  Which is why you may have found your GP surgery suddenly has loads of physios, pharmacists, care co-ordinators etc, but not that many actual doctor appointments. (I think most of us would much rather have spent that funding on GPs, I certainly would have, but the argument was that there simply weren't the numbers needed to do so.).  There was recently a big fuss on GP social media as a GP surgery made all its salaried GPs redundant and swapped them out for APs instead.  (A brave move considering it's not clear how long the Additional Roles funding will continue. It was part of our current contract which ends in April, and we're yet to be told what, if any, contract we'll have after that.  Which is enormous, but a side issue - just don't be surprised if all the GPs go on strike...)

So, they exist because there aren't enough doctors.

I'd argue there are some other benefits too, to be fair.  That long recruitment process for doctors is inherently exclusionary.  Most people from working class, or even middle class backgrounds, look at funding themselves through 5 years of Uni, and the average emerging debt of about £80,000, and decide it's not for them. (I'm lucky, it was still free when I did it.). The academic barrier to entry is also insanely high, but in reality you don't need to be a genius to be a doctor. As a result the current selection process results in many doctors who have little idea of how the majority of people really live, and are intellectually astute, but sometimes lacking in emotional intelligence.

A lot of PAs are caring, smart people who couldn't clear that barrier of entry but desperately wanted to do that job.  They often have an abundance of the most important qualities - empathy and the ability to communicate. I suspect there are many PAs who have better bedside manner than some of the doctors they work with.

So that might be a reason why you'd prefer to see a PA.  They also generally get given much longer to see a patient (certainly in GP), and by definition see the people with the easier problems. As such people often really like seeing the PA because they'll spend more time with them, and go through things in more detail. 
(In GP a PA may see someone with a cough, or a rash or other clearly defined problem such as a review session - they'll have 20 minutes or so to do it in, and not have the weight of clinical responsibility for the decision.  The GP will have 10 minutes for someone with complex multi-morbidities, all of the responsibility, and the PA knowing ion their for asking what to do abut a rash..) 

So, in short, you might want to see a PA if you have a well defined, but relatively straight forward problem. You'll get more time, may well feel better listened to or understood. Seeing a PA probably beats seeing no-one, which is obviously the risk given we've got very few doctors (and half of them are on strike).

So what are the issues with them?  Well, I've alluded to a lot already.  They're not doctors, and they don't have anywhere close to the level of training that doctors do. To be fair, that's not as big an issue as you might imagine. The first two years of Med School are traditionally spent covering a lot basic science that most of us never really need to call on again.  (Though the schools would argue that foundation is essential to allowing us to be able to make decisions on our feet, and in separating "bad" medicine from "good".  And they have a point - though I can also safely say that knowledge of the bloody Krebs Cycle doesn't help me one bit.)

Anecdotally there's quite a bit of evidence that PAs aren't always very good at making it clear they're not doctors. I'm never sure whether this is really a problem with them, or whether patients simply tune out "Physician's Associate" and assume that they're seeing a doctor - but it causes a lot of consternation.

In hospitals it's become a particular issue - not just because patients don't always know who they're seeing, but because PAs are occupying the spaces traditionally taken by very junior doctors in training - which results in blocking of training places, and thus those doctors going elsewhere, and leaving the NHS.  They've filled the gap, but they've blocked the progression down that 10-20 year pathway, meaning they will potentially be a bigger gap in really well trained doctors further down the line.

This also means a lot more stress for the doctors that remain as they shoulder the weight of the work the PAs do, but which they carry professional responsibility - and liability - for.  It's making it a not very appealing job.  I have a friend who works in a practice that has gone down the "lots of PAs, hardly any doctors" route.  He used to love his job, but now hates it , as he spends his day in a room dealing with queries from other people rather than seeing patients face to face - the reason he signed up in the first place. He feels deskilled, demoralised and undervalued - and plans to quit as soon as he can afford to.

This may well change - PAs are seeking to become a recognised independent profession in their own right - something the GMC is involved in.  This is, in itself, something doctors are up in arms about, but personally I think it makes sense for the role to be regulated, and if they're filling the role carried out by doctors, then they should be regulated in a similar fashion - but many doctors disagree and feel it legitimises a role that has no place claiming such legitimacy.

The final problem for me is that PAs represent, I think, a failure to understand what doctors are, what they do and why they matter.  There is a belief held by many in NHSE and Whitehall that medicine is a transactional thing.  Patient has Condition A, and requires Treatment B - and all that is required is the gathering of sufficient data to resolve this.  It's an appealing version of the job - especially if you need to reduce it to numbers for management purposes. It's this vision that leads them to imagine that AI will be able to replace doctors entirely in the not too distant future. In that version of medicine, all you need is someone to take the history and examine the patient before feeding the data in to a device and waiting for the diagnosis, and you're done.

Some of medicine is, indeed, like that.  And I'll be honest, I love seeing patients where that's what needs to happen.  It's a piece of piss, I can catch up my surgery a bit, and relax my brain a little.  It's why my on call sessions at work have shorter patient appointments than my regular surgeries - because they are more likely to be that kind of consult. The sort that, yes, a PA can do no problem.  But it's generally not the majority of people I see, and the challenge is rarely that transactional.  It's more like "Patient has condition A, B, C & D, their treatments are mutually exclusive, they don't understand some of it, and are in any case, actually worried about Condition F which they read about a few weeks ago, and are describing the symptoms exactly as the magazine said to do. As an aside they want you to know they believe condition B isn't condition B at all, because they started with symptoms after they stroked the  neighbour's dog just after it had caught a bird, which they are convinced is the true cause.  None of which is actually why they are here really.  They're really here because they think their husband's having an affair and they need to speak to someone, but they also can't because then it might be real, so they're not going to tell you about it unless you notice there's something more and choose the exact right words to bring it out. Oh, and they need a blood pressure review."

Navigating that takes a certain amount of experience - and if you use the transactional model, what that patient gets is a treatment for Condition F (which they don't have), a BP check and a lingering sense that something isn't right. To be fair, there are definitely PAs capable of navigating that (and doctors who aren't) but crucially they can't do anything with it even if they do. Their role is designed to fit entirely into the transactional model - where lots of work gets done, people get what they came for, but rarely get what they need.

OK, I'm really waffling now.  I'll wrap up. PAs are generally good people, doing essentially a "Doctor Lite" job without much of the underlying training. Doctors are sniffy about them - partly for good reason and arty,m frankly, because they feel threatened by them. A final note I'll end on is that I'm not sure it's a job I would recommend, in that I think it may have a short shelf life. There's lots of talk now about having Doctor apprenticeships - where you work whilst at Med School and thus get paid to be there.  It's a whole operate controversy within the profession, but if it takes off a lot of the reasons for PAs existing fall away.  I train 4th year medical students and they're all quite capable of doing a PAs job. What's more, an apprenticeship is likely to attract the people from walks of life that the traditional training rate does not.  I think (hope?) there's a good chance that the Physicians Associate will become a brief anomaly, rather than a permanent fixture.  That said, who knows?  As I mentioned there are many in major positions within Government and NHS England who still very much regard PAs and other "noctors" as the solution, both now and in the long term (helped by AI) - not least because they don't understand the slightest thing about medicine. (And doctors are expensive)

Ahem.  Sorry. You did ask...

Minnesänger wrote:

Wonder if a PA could have written that more concisely.

hylian_elf wrote:

Was really happy Thursday morning that my chesty cough seemed to have cleared up and breathing was better and I was feeling well. Mostly. Just a sniffy cold left. 

Since yesterday afternoon, have had a splitting headache which is making me feel really miserable. And tired. And cold. 

How long is this shit gonna last?!

Gremill wrote:

This gout is just not shifting. Usually after a few days of naproxen it goes, but not this time. Can't be on my feet more than a few minutes, can't sleep properly - bloody miserable is what it is.

MyNameIsKrisG wrote:

Tiredness.  I feel like I've not woken up properly for days.  Vitamin D perhaps?

Please be light again soon please be light again soon please be light again soon.

Dark Soldier wrote:

Second week of that virus that is going round. Hit me for round two or three today, keep thinking I've shifted it then it twats me again

hylian_elf wrote:

 Hope you feel better soon. My cough sort of returned yesterday but aches had gone.  It seems to fluctaute between symptoms!