Ria Agarwal is a physician associate in primary care, and lead physician associate for South Yorkshire and Bassetlaw Faculty for Advanced Clinical Practice. She is on Twitter: @riaagarwal19
Physician associates (PAs) are a rapidly expanding role in primary care, especially given the recent financial incentives to remediate some of the worsening workforce pressures, such as the Additional Roles Reimbursement Scheme (ARRS funding, colloquially referred to as ‘arse funding’ by a parody GP Twitter account, which perhaps is unfortunately suggestive of how it is perceived by some).
The Faculty of Physician Associates estimate almost one-third of the 3142 qualified PAs on the Managed Voluntary Register are working in primary care.1,2 Despite these rising numbers, General Medical Council (GMC) regulation has unfortunately been further postponed, with a proposed start date of the second half of 2024.3 Alongside the potential misuse of PAs highlighted in the recent BBC Panorama documentary,2 there is a need to ensure that they are being utilised safely and appropriately, with a view to retaining those who enter primary care.
“… the physician associates who defend their profession [are] often left feeling devalued or defunct by their ‘colleagues’.”
Resources are available for employers on the Faculty of Physician Associates and GMC webpages,1,4 but the intricacies of how each PA works in their practice is likely to be built on the specific needs of the practice(s), the experience of the PA, and a shared vision between both parties of what the role ‘should’ entail.
Previous literature5 describes problems in professional identity formation across two PA student cohorts, including a lack of PA role models to map their identity on, as well as ignorance or resistance to the role from others; an issue reasonably unique to PAs, and often being thrashed out on a Twitter feed near you.
As a PA student in 2011 facing resistance on my student placements, I too questioned, why bother with PAs? Why not more doctors and nurses? As time went on the answer became clearer to me, but the question itself has now become contagious, and a PA’s ‘value for money’ appears to be a widely debated topic on social media.
An impasse is frequently reached, with the PAs who defend their profession often left feeling devalued or defunct by their ‘colleagues’. With the eager justification of what we offer professionally to others alongside social media battles and regulation delays, it is easy to get swept up in defending our professional worth as opposed to feeling comfortable enough to question what we don’t or shouldn’t do.
There is no defined list of do’s and dont’s, therefore it is imperative that we understand our own professional identities so these can be accurately represented to our patients, employers, and colleagues; ensuring that as clinical scope proudly increases, appropriate boundaries remain in place.
“Over the years I am learning what is acceptable not to know, and that it is acceptable to say ‘No’.”
So, what are we? A qualified PA has completed a 2-year PA postgraduate diploma or Master’s level programme that is mapped to a standardised curriculum including 1600 placement hours, designed to give a generalist foundation to be built on by ‘on the job’ learning. For this to work well it relies heavily on close supervision;6 especially in the first few years of qualification, given the non-protocol driven nature of assessing undifferentiated patients. We complete 50 CPD hours annually to keep our registration on the Managed Voluntary Register, and sit a written national exam every 6 years.
Why are we here? We know that in relation to the traditional roles there weren’t enough clinical feet on the floor many years ago, and the situation is worsening. A PA may offer some additional advantages; a non-rotational workforce who can offer continuity within their scope of practice and speciality, who may have life experience attributes, or a previous occupation that can feed into their PA career. Some PAs may be science graduates with little clinical experience prior to their PA studies; but are new entrants into health care as opposed to robbing current clinical feet. Unlike many other roles their scope is not black and white, and is malleable to the PA’s interests and employer’s needs.
What do I do in primary care? Since the COVID-19 pandemic I consult under a hybrid approach of face-to-face consultations pre-booked by myself, another clinician, the patient, or telephone consulting. I request investigations (with permission if this involves ionising radiation) and organise my own referrals; although when I first qualified this was all discussed thoroughly with my supervisor first, as were any prescriptions. With experience, I file bloods and letters, and assess patients who are more complex than when I first started. Post-qualification training has taught me that the medical model doesn’t wholly work for some of the regular patients I see, such as those with chronic pain or mental health, so I may deviate to alternative models to maximise the effectiveness of my consultation. I fiercely seek out additional training in my spare time because I know that the patient in front of me next week is not necessarily a condition I studied in my PA curriculum.
What don’t I do? Primary care for any clinician often entails holding risk; ‘I don’t know what this is but I feel okay about it’ versus ‘I don’t know what this is and maybe that’s because I’m not a doctor’. I qualified thinking the latter on every occasion, but as clinical scope increases the former tends to appear because the doctor supervising you doesn’t know either. Over the years I am learning what is acceptable not to know, and that it is acceptable to say ‘No’.
“I fiercely seek out additional training in my spare time because I know that the patient in front of me next week is not necessarily a condition I studied in my physician associate curriculum.”
Every consultation in primary care is behind closed doors, and it is up to me to recognise the limitations in my own knowledge and when to seek assistance for my ‘unknown unknowns’. Insight, experience, and feedback from colleagues thoroughly help. Thinking about the practical don’ts, I don’t routinely perform home visits, as where I work these patients are more likely to be really complex or palliative. Some of my PA colleagues elsewhere do visits, and other PA colleagues don’t file bloods or letters. Either way, defined and mutually agreed boundaries are likely to be helpful to protect our professional identity and ensure our safety as much as anyone else’s.
Retention? Think about the PA as an employee rather than a reimbursed asset. This means not shifting the PA around multiple practices in a network; this is unlikely to be fair or safe for a clinician who may have entered primary care to offer continuity, and is unlikely to encourage them to stay. Basic needs (think Maslow’s hierarchy) otherwise include support to attend training to fulfil learning needs; appraisal to establish career progression and terms and conditions, such as salary review; sick leave and/or maternity leave to avoid losing them to secondary care; and provide ongoing supervision (often seen as a negative but should reduce over time).
Finally, in the words of Zoolander, ‘who am I?’ I am someone who is passionate about primary care, who qualified from a medical model PA course with a particular set of generalist skills that continue to grow, who is mindful and reflective of my perceived professional identity, and who welcomes urgent regulation of PAs to enable me to work to my fullest potential, but consults in the interim to the best of my ability.
I encourage all PAs to not only consider Zoolander’s almighty question, but to also question the ‘could’s’ and the ‘should’s’ in their own practice. And if they need a giggle after a miserable day, the film Zoolander is likely to be very helpful!
Disclaimer: This viewpoint reflects my own experience only, every PA needs to carve their own journey and professional identity.
References
1. Faculty of Physician Associates. Physician associates: the case for regulation. 2022. https://www.fparcp.co.uk/file/media/62e2afcbd5133_FPA_RegulatePAsNowFINAL_JUL_22.pdf (accessed 16 Sep 2022).
2. Faculty of Physician Associates. The Faculty of Physician Associates (FPA) responds to the BBC Panorama investigation into general practice staffing and deployment of Physician Associates (PAs). 2022. https://www.fparcp.co.uk/about-fpa/news/the-faculty-of-physician-associates-fpa-responds-to-the-bbc-panorama-investigation-into-general-practice-staffing-and-deployment-of-physician-associates-pas (accessed 15 Sep 2022).
3. General Medical Council. An update on the UK government’s timetable for regulation of PAs and AAs. 2022. https://www.gmc-uk.org/news/news-archive/an-update-on-the-timetable-for-regulation-of-pas-and-aas (accessed 15 Sep 2022).
4. General Medical Council. PA and AA regulation. https://www.gmc-uk.org/pa-and-aa-regulation-hub (accessed 15 Sep 2022).
5. Brown MEL, Laughey W, Tiffin PA, Finn GM. Forging a new identity: a qualitative study exploring the experiences of UK-based physician associate students. BMJ Open 2020; 10(1): e033450.
6. Agarwal R, Hoskin J. Clinical supervision of physician associates (PAs) in primary care: who, what and how is it done? Future Healthc J 2021; 8(1): 57–61.
Featured photo by The Nix Company on Unsplash.
