The PA conundrum

If physician associates are going to be part of the health service, they should serve the system, and the system should serve them

Fifteen years ago, when I first heard about physician associates (PAs), I thought we’d still be talking about them now. However, I assumed we’d be lauding them as one of the success stories of my lifetime. Back then, I was an exhausted emergency department registrar. One of my colleagues had just returned from the US. As we stared at each other in the middle of the night on the shop floor, he regaled me with talk of these fabled “assistants”. I almost cried with jealousy when he spoke of seeing his patients, and then asking the PA to arrange bloods and ECGs and medications. The PA would have been part of the triage process, and would have taken a history, and perhaps initiated some basic interventions prior to the doctor arriving too. I’d feel like Santa Claus if I were announcing the roll-out of this kind of service to our NCHD colleagues now.

So where did it all go wrong? PAs aren’t commonplace in Ireland yet, and we may not repeat the mistakes of the NHS. But history suggests that lessons from across the water are seldom learnt here. UK doctors are no less exhausted than anyone else. There is no world where one of their young doctors on a busy ward wouldn’t bite your hand off for someone to help do ECGs, make up some antibiotics, pop in a few cannulas or take bloods. But that’s not what’s happened. Anyone following the PA discourse in the UK will see that it’s been messed up by managers and politicians trying to save money and by some consultants trying to avoid pesky trainees.

Now, I’m no stranger to the multidisciplinary team. Despite the cries of “elitism” that lazily get thrown around every time this conversation happens, doctors in almost all countries have trained healthcare workers into advanced roles across pretty much all specialties. This isn’t about status. It’s about patient safety and equity. Young doctors in the UK tell tales of being unable to get anywhere near radiology, GP, surgery, and paediatric training jobs. This is despite attending medical school, completing membership exams, publishing research papers, doing audits, and enduring soul-destroying shifts. One can see, in those circumstances, why it’s difficult to stomach a comparatively much-less qualified PA taking up a nine-to-five role in the specialty that you as an NCHD have no hope of entering.

I think people understand the argument for PAs. NCHDs rotate a lot. That’s hard on departments, who may find themselves training registrars and SHOs from scratch every six-to-12 months. I don’t think many people would begrudge a PA being assigned to a highly specialised surgical team to help with the need for some degree of continuity. They’re a great help to senior doctors, but need to be balanced with a cohort who can help our NCHDs too.  

That’s what’s frustrating about this whole process in the UK. Their introduction could, and should, have been the greatest gift you could give to the NCHD community. If this had been managed well, they would have been the NCHD’s best friend. But they have consistently been used to replace doctors, or to push doctors out of practising key procedural skills. According to our UK colleagues, and their union, the net result is more NCHDs doing more non-medical tasks on the wards, while non-medical colleagues are attending theatre and clinics. We’re all human and we all understand how humans work. Nobody is naïve enough to think that every single PA will spend every single hour of their working life doing your cannulas for you. A job description that says “you will do the rubbish bits of our NCHDs’ job” is not going to recruit or to retain PAs.

Ultimately, this is about balance and the realisation of potential. PAs should serve the system and the system should serve them. It seems to me that if we could get NCHDs, senior doctors, and PAs together, and work out what each group needs from the process, we could design a healthcare worker role that would be supremely useful at a systems level, as well as being individually fulfilling. We should use the UK’s failure as our opportunity to begin again. But this time more intelligently, more collaboratively, and more critically.