The evolving medical team: physician associates and junior doctors

The new president of the Faculty of Physician Associates (FPA) Kate Straughton and the BMA junior doctors committee deputy chair Dr Matthew Tuck answer some questions about the ongoing debate about medical associate professions in the NHS workforce.

One of the motions at this year’s British Medical Association (BMA) junior doctors conference focused on the growing role of ‘medical associate professions’ (MAPs). The grouping of MAPS includes physician associates (PAs), surgical care practitioners, advanced critical care practitioners and anaesthesia associates.

The seven-part motion split the opinion of the medical community, as it called for the BMA to oppose MAPs being placed on the medical rota, oppose MAPs being permitted to sit any postgraduate medical examination, and oppose MAPs being used to fill medical locum vacancies and rota gaps.

Kate Straughton, the new president of the Faculty of Physician Associates (FPA) and Dr Matthew Tuck, the BMA junior doctors committee deputy chair, answer some questions about the ongoing debate.

What was your reaction when you heard about the motion at BMA junior doctors conference?

Kate: I guess it was frustration — we’ve come so far, but still have a long way to go. The NHS is under such pressure, and clinicians across the country are overstretched every day. So, we’ve got to ask ourselves: is it right to pit two different professions against each other? It’s challenging to listen to doctors talk about the expectations on them, how incredibly hard they have to work, and the impact on their lives, but also hear they don’t want to work with a profession that can help reduce some of their workload.

I understand that trainee doctors may have questions about the role PAs can play. This is totally natural and something we can and should address. I hope we can reshape the debate around how the professions can work side by side to complement one another.

It’s clear that junior doctors have a lot to say about physician associates and other MAPs. Could you sum up the top three things that you took away from the debate at the recent conference?

Matt: All too often, doctors in training find themselves in positions where change occurs around them without their voice being sought. Especially when teams and working practices evolve and diversify.

Our recent experiences with employers (in England and across the four nations) have given us reason to be doubtful about top-down reorganisations. I think the debate at conference was so passionate and so extensive because it was the first time that many doctors had been asked what they thought about the changing makeup of their workforce.

The debate showed a desire among attendees to protect the training time of doctors, something that’s under constant threat from many angles, but at the same time acknowledging the opportunities that multidisciplinary working can provide in modern healthcare teams.

Secondly, there was a clear message that PAs and MAPs shouldn’t be used to correct the mistakes of poor workforce planning and medical recruitment. PAs and doctors in training are not interchangeable. Neither profession should be defined as a line on a rota, but rather as individuals with differing skill sets to be used for the benefit of the patients we care for.

Finally, there was an acknowledgment of a lack of support and guidance for doctors in training in how to best work alongside PA colleagues in situations both where the doctor is the more experienced team member, but also where the PA is more experienced. It is this lack of guidance and information that drives caution, fear and division.

I believe all of these problems have collaborative solutions that come about when doctors and PAs push in the same direction.

Can you share your experiences of working with trainee doctors? How can PAs and trainees work together? When has it worked well, and are there times it hasn’t?

Kate: I first began practising as a PA in 2010, working in acute medicine at the Queen Elizabeth Hospital, Birmingham. At that time there were only a handful of PAs working across the country. It was likely that I was the first PA most of my patients and fellow clinicians had worked with, so it was normal for me to spend time explaining my role to people.

I commonly saw, and still see, trainee doctors that were nervous about working with a PA. They weren’t sure what I could do, how I fitted into the hierarchy, and whether I would be a help or a hindrance.

My experiences were nearly always positive. People learned what we could do, and embraced the role we could play as part of the wider clinical team. I was a source of support for new trainees in the department, particularly as I got more experienced.

I later moved to a rural district general hospital where I often acted as a point of continuity between teams as they navigated their on-call rotas. I got to know the patients who attended more frequently and could advise on some aspects of their care. I could help the trainees find their way through the trust’s systems and processes, as well as being able to offer clinical support — working as part of the clerking team, or carrying on with ward work while the trainees got to attend their teaching.

There are times when it hasn’t worked so well. I have worked with trainee doctors who are clearly frustrated by my lack of ability to prescribe, and who feel I just cherrypick jobs. As I can clerk but have to ask a doctor to prescribe or request the X-rays for me. I also get frustrated by this!

During my time as a PA we’ve gone from a very small group to now numbering nearly 1,400. Statutory regulation provides a real opportunity for trainees and PAs to take stock of the relationships they have. I hope it sparks positive discussions with people able to ask questions about the roles of PAs and how the role is developing to ensure that PAs can be fully embedded and working to the full extent of the role. 

Some trainee doctors feel that the introduction of PAs impacts on training opportunities for trainees. How can trainees and PAs work together to ensure both roles get ample training opportunities?

Matt: There’s clearly enough work to go around. I think all healthcare professionals in training struggle to access supervision and supervised learning experiences. ‘Training’ certainly includes assessing and treating patients, but it isn’t limited to this. Supervision at work, particularly for ‘craft’ specialties is essential.

At a time when the demand for supervision time from consultants is at an all-time high, we have many doctors dropping their educational commitments due to work pressures, pension impacts or burnout. The solution is not to continue to spread our seniors even more thinly.

The start of this solution is fostering a culture that is currently lacking — one of a proper MDT conversation. Doctors don’t know what PAs need, and PAs don’t know what doctors need, never mind the needs of the other members of the team that we could be addressing through MDT peer training. The lack of this dialogue is fundamentally a lack of departmental leadership and we need to be asking those in leadership positions to be facilitating this.

Many of the factors that negatively impact doctors’ training will also impact PA's training: cancelled lists, closed wards and winter pressures to name but a few. Surely on these areas we can come together to challenge our training providers to do better?

What would you say to a trainee doctor who was sceptical of the benefits PAs can bring?

Kate: Find a PA and spend the day working alongside them! Or at least have an open and honest conversation with a PA about what they can and can’t do, and base your opinion on that, rather than on rumour. The PA profession is growing, but there are still huge numbers of trainees that have not worked with a PA, and this is where a lot of concerns come from.

PAs have a vital role to play, both in providing high-quality clinical care for our patients, but also as an extra source of support for trainee doctors and wider teams. Not everyone will agree with the profession, but I would like to understand the issues so that we can continue to develop together.

Where PAs have been successfully introduced, there is often clear support from clinical leadership, which is vital. It is important that consultants play a key role in building teams where the skills of PAs and trainees complement each other.

Consultants need to understand that PAs need development and learning opportunities, like any other profession, and that PAs and trainee doctors can both continue to learn, grow and thrive together in the clinical environment. The development and support of one role does not need to disadvantage the other. There is research that shows that having a PA on the team is not detrimental to the training of doctors.

Once statutory regulation is in place, what do you think prescribing rights might look like for PAs?

Matt: Prescribing rights, and the protections and training underpinning them, is likely to be a matter for government consultation. For PAs to be effective team members they must have the legislative infrastructure to safely carry out their duties, including prescribing.

Clearly we can’t continue to have situations where both PAs and doctors are put under pressure. To either prescribe for others without the time or space to make their own clinical assessment, or where either is asked to prescribe beyond their usual scope of practice.

Many hospitals restrict who can prescribe toxic substances, such as chemotherapy, to those who have experience above and beyond a medical degree, and I would imagine the same to be true for PAs.