While still awaiting official recognition and regulation, the number of physician associates in Irish healthcare has gradually increased. Advocates say they offer flexible support and continuity of care within medical and surgical teams. Catherine Reilly reports
The evidence on doctor burnout “should scare us and concern us”, the Director of the RCSI physician associate (PA) programme, Prof Lisa Mustone Alexander, told University Hospital Limerick’s grand rounds on 11 February. She stated that PAs were not the only solution to physician burnout and workforce deficits, but they should be part of the response.
PAs are trained under the medical model to take histories, perform physical exams, order and carry out investigations, make diagnoses, and devise management plans. They diagnose, treat, and manage patients with the guidance of their supervising consultant/GP.
In January, 17 students commenced RCSI’s two-year MSc PA programme, the seventh cohort since the course’s establishment in 2016, when there was an intake of seven. It is the only PA programme in the State (Ulster University also offers a MSc PA programme).
Prof Alexander told the Medical Independent (MI) there are currently more employment opportunities in Ireland than graduates.
Status
PAs are well-established in US healthcare and growing in the NHS. The UK’s General Medical Council has published a number of guidance documents for PAs, including interim professional standards, in preparation for overseeing their regulation from summer 2023 at the earliest. The situation in Ireland is not nearly so advanced.
The Department of Health has not yet officially recognised the grade and PAs have no statutory regulator. As such, they have no authority to prescribe medications or ionising radiation. There are 51 PAs working in Irish healthcare, mostly in secondary care. MI understands that the NCHD pay scale is used in a number of public hospitals. In 2020 Our Lady’s Hospital, Navan (OLHN) took on its first PA and now has six in permanent posts (see panel p5). Dr Malik Anwar, Consultant Gastroenterologist and General Physician at OLHN, has a PA on his team and has also worked with other PAs at the hospital.
“They are very much able to multitask… they can help you in your clinic, in endoscopy, inpatients, in the medical assessment unit, so wherever you may be.”
Another key benefit was continuity of care, Dr Anwar told MI. “They are part of the team on a longer basis as compared with the SHOs who might be with you for three months.”
Expanding on the role’s differences and similarities to other healthcare professions, he added: “In my view, what I see is that the clinical nurse specialists are in a particular area in the hospital looking after a specific type of patient. But with PAs, when they are in the service or in the team, they can be useful any– where with any clinical scenario. Their role at the moment is much more diverse. I feel it is much more like a non-consultant hospital doctor in many ways and if they are allocated to a particular service for a long duration then they become very familiar with the conditions that we routinely deal with.”
Dr Anwar continued: “In the pandemic we had PAs allocated to the Covid ward and we found they were very, very helpful.… When you go there to do the ward round, they would be able to go through all the patients one by one. I found them really very useful.”
There were some “limitations” to the role, which mainly related to lack of regulation.
Dr Anwar also noted there was a pathway for nurses to become nurse endoscopists and he saw no reason PAs could not “perform these kind of competency skills with appropriate training”.
NCHDs and nurses had been “receptive” to the PAs and initiatives to further inform the patient population would be helpful.
DoH position
A Department of Health spokesperson noted that, in 2015, RCSI commenced a two-year pilot in Beaumont Hospital with the recruitment of four PAs in surgical units under the supervision of surgeons.
As the pilot was confined to surgical units and only two PAs were involved for the second year, “it was not possible for the Department to make an informed evidence-based national level determination regarding the establishment of the grade at that time,” the spokesperson informed MI.
No business case or request to establish the PA grade had subsequently been received from the HSE, they said.
On what further processes need to be fulfilled for the Department to consider granting recognition, the spokesperson said it would need to consider “the benefits of the introduction of a further wider pilot project which would better inform future deliberations”.
They continued: “Ideally a successful pilot programme would have been completed” and “an independent evaluation carried out on the pilot programme which would robustly interrogate the costs and benefits of the role”.
“The HSE would need to submit an evidence-based business case setting out the costs and benefits of creating this new grade…. A full workforce plan would need to be developed to support this role taking account of stakeholder and IR issues.”
The Department was supportive of “any initiative” which ensures sufficient professionals in areas where healthcare need is anticipated.
Prof Alexander met with Department representatives in February and is hopeful of progress.
“There are a lot of NCHD posts that are non-training posts and I think there has been a lot written about that. We had a meeting [recently] with a surgeon who was relatively frustrated because they had thought somebody was coming for this rota; they ended up not coming. So there are these gaps in the system, and it is just negatively impacting care delivery.” She suggested some of these non-training posts can be converted into PA roles.
Prof Alexander added that “PAs are not putting themselves out as an autonomous provider. We work on a team, with collaboration of the consultants and the registrars…. There are safety measures that are embedded in that system, and when a consultant develops a relationship with a PA then the level of trust in their abilities and scope progresses over time.”
Recognition would be a vital step towards regulation. Prof Alexander has said the Medical Council would be the most suitable regulator for PAs in Ireland.
In the absence of statutory regulation, the Irish Society of Physician Associates (ISPA) operates a managed voluntary register.
PA graduates must take a national certifying exam, as well as a recertification exam every six years. Continuing professional development requirements have also been outlined.
Ms Aoife Sartini-Bhreathnach, surgical PA, breast team, Mater Misericordiae University Hospital, Dublin
Since 2019, Ms Aoife Sartini- Bhreathnach has worked as a surgical physician associate (PA) with the breast team in the Mater Misericordiae University Hospital in Dublin.
Ms Sartini-Bhreathnach, a graduate of RCSI’s MSc in PA studies, has a primary degree in biomedical sciences. She worked for a number of years in clinical research and wished to become involved in patient care and further her education.
The “fast-paced” nature of the RCSI programme appealed to her and she “loved” the course. She acknowledged it was “intense” and “probably the hardest two years of my life”.
At the Mater, there is variety in her day-to-day role. Broadly speaking, her work comprises a mixture of clinic and theatre-based duties and she is also involved in research.
Her tasks at clinics would be the same as those undertaken by an SHO or registrar. She would review patients, go through their history, undertake breast examinations, ensure medication tolerance and compliance, make sure mammograms have been arranged, and any other radiology updates as required, etc. She would see new patients alongside the consultant, but may solely review returning patients while raising any queries with her consultant.
“If I felt at any time that I was unsure or had any queries, the consultant is always there and there is always someone I can talk to or discuss a decision or a management plan with.”
In theatre she would generally act as first surgical assistant during breast surgeries. “That would be the highlight of my week, whenever I get into surgery. I would be working for two consultants mostly – Prof Malcolm Kell and Ms Siún Walsh.”
“I prep before theatre even starts, so I make sure I know all the patients coming into theatre, I see them pre-operatively down on the ward, if they require any bloods or ECGs and so on, I make sure that is arranged.”
Ms Sartini-Bhreathnach reviews pre-op assessments and discusses the list with the anaesthetist, as well as setting up pre-op imaging in theatre, etc. She also stays in contact with the consultant surgeon about any delays to the list.
If there is a SHO or registrar in theatre, the role of first assistant would be shared. She reports a positive relationship with NCHDs and believes PAs can enhance, rather than hinder, their training. She said no issues have arisen in terms of adverse impact on NCHD training. The consultants would also be “very aware” of ensuring access to procedures for trainees and, in this regard, she may act as first assistant to SpRs.
“The consultant is there reviewing the SpR and I would potentially first assist the SpR. It works in a way that there is another person there that can help them be their first assist while they are training.”
She said nursing colleagues have also been “really supportive” since she began in the role.
The PA role promotes continuity of care, she believes. Due to the nature of NCHD posts, there are regular changes in personnel, and following changeover in July, there is a completely new medical team. She said she can provide guidance to new colleagues on the consultant’s methods of working and how the team and clinics are run, etc. In addition there is familiarity with returning patients who, as cancer survivors, may be anxious about follow-up appointments.
Generally, patients tend not to have heard of PAs. “They don’t know much about the role and I explain it. There are times they say ‘oh, okay doctor’ and you say, ‘I am not a doctor, I am a physician associate, I can tell you more about it.’ To be honest most of the time they say, ‘look, I just want to be looked after, I really don’t mind.’”
Another PA joined the breast team in 2020 and works predominantly with consultant Mr Mitchel Barry.
Ms Sartini-Bhreathnach said the current restrictions on writing prescriptions and ordering ionising radiation procedures do not hugely affect her work. However, she believes regulation would greatly help the profession’s progression. “We want this career to progress and do the utmost in everything we have been trained to do.”
Ms Sartini-Bhreathnach is a member of the Irish Society of Physician Associates.
Geography
Meanwhile, a geographic maldistribution of PAs has emerged, with most based in greater Dublin.
RCSI is exploring the possibility of offering the PA programme in a remote hybrid format so that students would not have to relocate to Dublin. This would involve training in local communities, online lectures, and attendance at campus for skills training and anatomy labs, etc.
The role’s wider development is also hindered by lack of access to indemnification in general practice (in public hospitals PAs are covered under the Clinical Indemnity Scheme). “There are some practices that have incorporated PAs into their indemnification scheme, but it is a barrier because it is very nuanced,” stated Prof Alexander. The regulation issue has been raised, she acknowledged.
A Medisec spokesperson said it regarded the absence of regulation as a barrier to PAs becoming part of the healthcare team in general practice and was engaging with stakeholders. Dr Rob Hendry, Medical Director at Medical Protection Society (MPS), said it would welcome the regulation of PAs “as this would allow them to better fulfil their potential, create more clarity around their roles and responsibilities while also helping to assure quality and safety”. MPS was exploring “how we can provide access to indemnity” for PAs.
Access
Fees for the RCSI programme are €12,000 per year and Prof Alexander has identified a need for more financial supports to facilitate greater access. Some private hospitals have sponsored students, but most are self-payers. Applicants must have a health science or science-related degree and this requirement is applied very strictly as the course is “incredibly accelerated”, according to Prof Alexander.
“When you start a new profession, it is risky enough trying to sell the concept to a wider audience, but you want the final product to be something everyone is very comfortable with,” she underlined.
Many entrants have come from other healthcare roles including nursing, physiotherapy, and paramedicine. Is this ultimately addressing workforce deficits?
This is a “familiar” question, said Prof Alexander, who added “we don’t aggressively ‘poach’ from other professions”. She said there will always be people who want to increase their scope of practice or find satisfaction in a different role.
A HSE spokesperson told MI: “The grade of physician associate has not been introduced into the Irish public health service. The potential role of any proposed new grade… would be a matter for consideration by the Department of Health in the context of Sláintecare reforms.”
*The RCSI is holding a PA studies careers event on 25 March at the College and online. Visit the following link for registration details: www.rcsi.com/dublin/news-and-events/events/event/2022/physician-associate-studies-open-event
Ms Shaneika Farrell, medical PA, acute general medicine and respiratory team, Our Lady’s Hospital, Navan, Co Meath
Ms Shaneika Farrell joined Our Lady’s Hospital Navan, Co Meath, in March 2020 as the significance of the Covid-19 pandemic unfolded. The hospital now has six physician associates (PAs), who were the first PAs to sign a permanent contract with the HSE, Ms Farrell informed this newspaper.
Ms Farrell, who holds a primary degree in human physiology, is a graduate of RCSI’s MSc in PA studies. She said she “really enjoyed” the programme, which facilitated “a lot of experience and exposure through the use of the simulation suites and patients, which mirror the hospital environment and also through the clinical placements”.
Initially the PAs at Navan were highly involved in assessment, management, and treatment of patients with Covid-19. They were also engaged in the roll-out of the hospital’s staff vaccination programme.
Ms Farrell works in acute general medicine and with the respiratory team. Her consultant is Dr Mazen Al-Alawi, Consultant Respiratory and General Physician and Clinical Lead at the hospital. He has been “very supportive” of implementation and development of the PA role locally, she noted.
The medical continuity offered by PAs is a fundamental benefit for the whole healthcare team and for patient care, according to Ms Farrell.
“The PA is the constant thread in the team tapestry. We have a continuous presence at the ward level and so are familiarised with inpatients and their management whilst in hospital….” If ward staff have a query about patient management, they also have a familiar point of contact.
The NCHD training pathway requires regular rotations, whereas the PA is a permanent team member and generally will stay within the service over longer periods of time.
“Knowledge and understanding of our patients’ management as an inpatient means that when they are reviewed as an outpatient in clinic, they do not have to explain it to someone new. In chronic disease management, being aware of the patient’s history and baseline makes it easier to optimise their medications and input into their ongoing management. In respiratory, this would be patients with conditions, such as chronic obstructive pulmonary disorder, asthma, and interstitial lung disease. Patients are appreciative of that continuity and familiarity.”
Ms Farrell is also involved in the Meath Integrated Respiratory Service, a consultant-led service that integrates care between community and hospital settings. She is a liaison for community-based colleagues if patients require sooner review or if they need adjustments to their medication or oxygen prescription after discussion with the consultant. Ms Farrell is also strongly active in patient education.
Typically, Ms Farrell is involved in ward-based care and can take responsibility for a patient caseload under the supervision of a consultant or senior registrar. She also undertakes a wide range of clinical administration tasks, attends multidisciplinary team meetings, and acts as a liaison with families. At hospital level, she organises the monthly morbidity and mortality meetings and is involved in NCHD induction during changeover.
Ms Farrell also noted that a PA’s duties are dependent on their specialty.
“As we are trained within the medical model, PAs have many clinical skills that overlap with other team members. We can review patients, do a physical exam and are trained in clinical skills, such as phlebotomy, cannulation, ABGs, ECGs, we can also carry out other procedures like NG insertion or catheterisation that may be required for the patient. Although PAs do not prescribe medication at this time, PAs have detailed knowledge of the medications prescribed to patients. PAs are required to undertake the study of pharmacology and therapeutics within their clinical training and apply this knowledge in the clinical setting.”
Asked about the response of NCHDs and nurses to the role, she said “everyone has been welcoming and supportive” and recognise the “benefits to patient care”.
On trainees specifically, she said the feedback is that the PA role can benefit their training. “Having that extra person on the clinical team facilitates them to be able to go and do continuous professional development and also allows them to deal with more complex patients.…”
With regulation of PAs imminent in the UK, she is hopeful Ireland will follow suit. She said PAs require supervision, governance, policies, and guidance to work to their potential.
Ms Farrell has developed a scope of practice governance document at Navan and this is helping to ensure PAs can work to their full scope of practice.
While PAs cannot prescribe ionising radiation, they should be able to order other diagnostic tests. There has been a restriction with the online system at the hospital in facilitating PAs to order investigations, but this is being resolved. There will also be a full audit of the impact of this change, explained Ms Farrell.
“That is one stepping stone to utilising us to our full ability.”
Ms Farrell is a member of the Irish Society of Physician Associates.
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