Physician Associates: What is the role and why did doctors call for an immediate ban on their recruitment to the NHS?
Jan 25
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Dr Jennifer O'Neill, PhD
In November, the British Medical Association (BMA) – the body that represents doctors in the United Kingdom – called for an immediate pause on the NHS recruitment of physician associates. The call was the result of growing concern following cases of patient harm.
What is a physician associate?
Physician associates are semi-autonomous healthcare professionals who do not have medical degrees but are trained to provide specified forms of patient care.
The UK Faculty of Physician Associates (FPA) describes the role as “varied, dynamic and versatile” with responsibilities that include patient history-taking, diagnosis, physical examination and performing therapeutic procedures. The FPA note that the role continues to evolve to include “more autonomous working”..
How are physician associates trained
The profession originated in the United States in the mid-1960s to ‘improve and expand access to healthcare’ with early training based on the fast-track approach to training doctors adopted in the Second World War.
US physician associates must obtain an accredited undergraduate degree, an accredited 3 year master’s, followed by completion of a national certifying exam and state licencing exam. Recertification is required every 10 years.
UK training, which is not accredited, involves completion of a 2 year postgraduate degree or diploma offering a “generalist medical education”. Graduates are then required to complete a UK Physician Associate National Exam (PANE) which permits entry onto a voluntary register.
How does this compare to doctors’ training?
Medicine is a regulated profession in the UK. The medical regulator - the General Medical Council (GMC) - oversees all medical training. A medical degree must be obtained from an approved institution - normally involving 4-6 years of study - followed by the two-year Foundation Training Programme, with doctors eligible for entry onto the Medical Register after the first year. To become a General Practitioner (GP) or Specialist Consultant doctors must spend several further years as ‘Doctors in Training’ on GMC approved programmes in order to attain their Certificate of Completion of Training (CCT).
To protect patient safety, all licensed doctors who practice medicine must revalidate every five years which involves continued professional development to keep up-to-date.
How are physician associates regulated?
Physician associates are currently unregulated in the UK. Plans to regulate the profession have been beset with delays. The Department of Health and Social Care announced that the GMC would become the regulatory body for physician associates and anaesthetic associates in 2019 however, details of the regulatory requirements are still under GMC review and registration is not expected until later this year at the earliest.
How many physician associates are there?
There are currently around 3000 physician associates in the UK.
The profession was introduced to the NHS 20 years ago as one of several ‘Medical Associate Practitioner’ (MAP) roles - including the anaesthetic associate, surgical care practitioner and critical care practitioner. Under the UK Government’s Long Term Workforce Plan the physician associate workforce will rise to 10,000 by 2036.
Why are doctors concerned?
The BMA moratorium was issued on grounds of public safety, with doctors seeking reassurances that the profession will be properly regulated and supervised going forward.
Whilst the BMA statement acknowledged that physician associates have an important role to play as part of wider healthcare teams, doctors are increasingly concerned by an overall lack of clarity surrounding the scope of the role. As semi-autonomous practitioners, physician associates often consult patients and doctors are concerned that patients are not aware when they are under the care of physician associates and not registered medical practitioners. Given their growing autonomy and lack of supervision, doctors are concerned over patient safety. Concerns have heightened in recent months following a series of cases in which patients have tragically come to harm.
Earlier this year, in a harrowing case, a young mother lost her life to an aggressive form of breast cancer that was initially misdiagnosed by a physician associate. Collen Howe believed she was seeing a GP when she visited her local practice in August 2021, but instead saw a physician associate. The 34-year-old, who was 8 months pregnant at the time, was wrongly reassured that a lump on her breast was a “blocked milk duct”. Colleen was later diagnosed with an aggressive form of breast cancer which, by that time had already spread and become incurable.
In another case of misdiagnosis, Ben Peters was sent home from Manchester Royal Infirmary in November 2022 after a physician associate wrongly diagnosed his symptoms of chest pain and shortness of breath as anxiety. The 25-year-old, who had only recently completed his final exams to become a solicitor, was found dead by his father the following morning having died from a catastrophic haemorrhage within his heart.
In the same month, Emily Chesterton was also misdiagnosed with anxiety by a physician associate. The 30 year-old had made two appointments at her local GP practice in the space of a week but was unaware that she had seen a physician associate at both consultations. In messages sent at the time, Emily described seeing “the doctor”. Emily’s ongoing symptoms of calf-pain, swelling and shortness of breath were also misdiagnosed as anxiety. Emily died suddenly and unexpectedly from a blood clot. A coroner at the inquest into her death concluded that Emily’s life could have been saved had she been correctly diagnosed and immediately referred to A&E where she could have received treatment for a pulmonary embolism.
In 2023, Labour MP Barbara Keeley highlighted Emily’s case in the House of Commons and raised concerns that physician associates may not always be working under supervision, particularly where GPs are already over-stretched. Speaking on behalf of Emily’s mother, the MP called for physician associates to be renamed ‘doctors apprentices’ as their current title sounds “even grander than a General Practitioner” and may lead to patient confusion. Such concerns are shared by doctors who have also called for the profession to be renamed. At the BMA Annual Representative Meeting this summer, GP Peter Holden told colleagues that patients who had subsequently discovered they had been treated by physician associates, and not registered medical practioners “felt cheated, deceived and misled”.
Professor Banfield, BMA Council Chair, voiced doctors’ concerned over “increasing instances” of medical associate practitioners “encroaching on the role of doctors”. He asserted “they are not doctors, do not have a medical degree and do not have the extensive training and depth of knowledge that doctors do.” It is not the first time doctors have raised such concerns. In 2019, junior doctors voted to oppose plans to treat all medical associate practitioners with equivalence to junior doctors for staffing purposes. They also voted against plans to make practitioners elligible to sit postgraduate medical exams which could see them become senior healthcare decision-makers in teams. The BMA also believe that plans for physician associates and anaesthetic associates to be regulated by their regulatory body, the GMC, will only serve to further blur the lines and sew greater confusion amongst the public.
Whilst the BMA statement acknowledged that physician associates have an important role to play as part of wider healthcare teams, doctors are increasingly concerned by an overall lack of clarity surrounding the scope of the role. As semi-autonomous practitioners, physician associates often consult patients and doctors are concerned that patients are not aware when they are under the care of physician associates and not registered medical practitioners. Given their growing autonomy and lack of supervision, doctors are concerned over patient safety. Concerns have heightened in recent months following a series of cases in which patients have tragically come to harm.
Earlier this year, in a harrowing case, a young mother lost her life to an aggressive form of breast cancer that was initially misdiagnosed by a physician associate. Collen Howe believed she was seeing a GP when she visited her local practice in August 2021, but instead saw a physician associate. The 34-year-old, who was 8 months pregnant at the time, was wrongly reassured that a lump on her breast was a “blocked milk duct”. Colleen was later diagnosed with an aggressive form of breast cancer which, by that time had already spread and become incurable.
In another case of misdiagnosis, Ben Peters was sent home from Manchester Royal Infirmary in November 2022 after a physician associate wrongly diagnosed his symptoms of chest pain and shortness of breath as anxiety. The 25-year-old, who had only recently completed his final exams to become a solicitor, was found dead by his father the following morning having died from a catastrophic haemorrhage within his heart.
In the same month, Emily Chesterton was also misdiagnosed with anxiety by a physician associate. The 30 year-old had made two appointments at her local GP practice in the space of a week but was unaware that she had seen a physician associate at both consultations. In messages sent at the time, Emily described seeing “the doctor”. Emily’s ongoing symptoms of calf-pain, swelling and shortness of breath were also misdiagnosed as anxiety. Emily died suddenly and unexpectedly from a blood clot. A coroner at the inquest into her death concluded that Emily’s life could have been saved had she been correctly diagnosed and immediately referred to A&E where she could have received treatment for a pulmonary embolism.
In 2023, Labour MP Barbara Keeley highlighted Emily’s case in the House of Commons and raised concerns that physician associates may not always be working under supervision, particularly where GPs are already over-stretched. Speaking on behalf of Emily’s mother, the MP called for physician associates to be renamed ‘doctors apprentices’ as their current title sounds “even grander than a General Practitioner” and may lead to patient confusion. Such concerns are shared by doctors who have also called for the profession to be renamed. At the BMA Annual Representative Meeting this summer, GP Peter Holden told colleagues that patients who had subsequently discovered they had been treated by physician associates, and not registered medical practioners “felt cheated, deceived and misled”.
Professor Banfield, BMA Council Chair, voiced doctors’ concerned over “increasing instances” of medical associate practitioners “encroaching on the role of doctors”. He asserted “they are not doctors, do not have a medical degree and do not have the extensive training and depth of knowledge that doctors do.” It is not the first time doctors have raised such concerns. In 2019, junior doctors voted to oppose plans to treat all medical associate practitioners with equivalence to junior doctors for staffing purposes. They also voted against plans to make practitioners elligible to sit postgraduate medical exams which could see them become senior healthcare decision-makers in teams. The BMA also believe that plans for physician associates and anaesthetic associates to be regulated by their regulatory body, the GMC, will only serve to further blur the lines and sew greater confusion amongst the public.
In calling for a separate, designated regulator to be established, Professor Banfield explained “[t]he General Medical Council is the exclusive regulator of doctors in the UK. Adding staff who are not doctors and do not have a medical degree to the GMC register brings into question the competence and qualification of the whole medical profession”.
In response, the FPA released a statement recognising concerns and the need to “work together to create a better understanding of the physician associate role” and to ensure their appropriate utilisation in practice. The FPA previously outlined plans to develop information materials to help better inform patients of the physician associate role.
In response, the FPA released a statement recognising concerns and the need to “work together to create a better understanding of the physician associate role” and to ensure their appropriate utilisation in practice. The FPA previously outlined plans to develop information materials to help better inform patients of the physician associate role.
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