Physician assistants: friends or foes to doctors?BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e4599 (Published 18 July 2012) Cite this as: BMJ 2012;345:e4599
- Joanne Ostler, year 5 specialty trainee in psychiatry1,
- Christopher Vassilas, consultant in old age psychiatry1,
- Jim Parle, professor of primary care, physician assistant course director, chairman of the UK and Ireland Universities Board for PA Education2
- 1Ashcroft Unit, The Moorings, Birmingham, UK
- 2School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham
Joanne Ostler and colleagues evaluate the contribution of physician assistants in one mental health trust
Doctors in all specialties will increasingly have to work with a variety of professionals within their multidisciplinary teams. In this article we describe the experience of working with one such group, physician assistants, in the Birmingham and Solihull Mental Health Foundation NHS Trust.
Physician assistants—who are they?
Physician assistants are health professionals with a postgraduate qualification who can work in a variety of healthcare settings under the supervision of a trained doctor. They originated in the United States in the 1960s as a way of providing primary care to areas of the country that did not have adequate resources. Subsequently the profession has grown: around 80 000 physician assistants now work in the United States, and there are over 150 US training programmes.1 Physician assistants in the US work in a wide variety of medical settings, including family practice, surgery, and psychiatry, and with adults and children.2 Physician assistant training programmes have also been set up in a number of other countries—for example, Canada, Australia, and the Netherlands.345
Physician assistants were first employed in the United Kingdom in 2003, working in primary care in the West Midlands.6 In the UK they now work mainly in hospitals in a wide range of specialties, predominantly general medicine and the emergency department but also in surgery and in smaller specialties such as paediatrics and oncology.7 We have found no descriptions of physician assistants working in psychiatry in the UK.
Several UK universities—Aberdeen, Birmingham, Hertfordshire, London (St George’s), and Wolverhampton—run courses to train physician assistants. These universities offer two year postgraduate diploma courses, primarily for graduates with a life sciences or health sciences degree. The courses are based closely on a nationally agreed competence and curriculum framework and are similar in content to an MB ChB course. Typically, UK physician assistant students spend 50% of their time in theory and 50% in practical work, with clinical attachments usually in general practice, medicine, paediatrics, obstetrics and gynaecology, and clinical psychiatry.8 All graduates take a national examination resulting in a postgraduate diploma in physician assistant studies and entry to the physician assistant managed voluntary register.9 The UK Association of Physician Assistants and the universities concerned have also committed to running a recertification knowledge test at six yearly intervals.
In 2010 the Birmingham and Solihull Mental Health NHS Foundation Trust piloted the employment of physician assistants in psychiatry for a number of reasons: firstly, limits on training numbers had made it more difficult to provide medical staffing for new clinical services, as trainees can’t be placed in a new service unless they are moved from elsewhere; secondly, recruitment of trainees into psychiatry remains difficult; and thirdly, concerns had been raised that the training commitments of junior doctors mean that they cannot always provide continuity of care. Between August 2010 and July 2011 the trust appointed five physician assistants to positions within the liaison, perinatal, forensic, and homeless services. Because of their limited knowledge of psychiatry they were all enrolled on the local weekly academic programme, the membership of the Royal College of Psychiatrists examination (MRCPsych) course that is run for year 1 core trainees.
Physician assistant role in psychiatry
At Birmingham and Solihull Mental Health NHS Foundation Trust physician assistants:
Undertake a comprehensive psychiatric history and examination
Order and interpret diagnostic tests
Make a clinical diagnosis and develop a management plan
Educate the service user
Work within the multidisciplinary team, with supervision from a consultant.
The scheme was evaluated qualitatively through a retrospective questionnaire. This incorporated open questions on the role of physician assistants in psychiatry, the advantages of employing physician assistants, and any issues that had arisen. These were distributed to the physician assistants, their respective consultants, a non-medical team member, and any attached junior doctor.
What did they say?
Before physician assistants were employed, the clinicians’ initial concerns were that:
The team would have a limited understanding of the role of the physician assistant
Physician assistants would not have enough psychiatric knowledge
Physician assistants would be unable to prescribe.
All those approached replied to the questionnaire: five responses were from physician assistants, six from consultants, five from non-medical team members, and four from junior doctors (ranging from foundation year 1 to core training year 3).
“Trained in the medical model with the ability to understand the ideas of systematic assessments.”
All the consultants highlighted this theme, along with the physician assistants’ keenness to learn and ability to seek advice. Three of the six consultants commented on improvement in continuity of care for service users. However, four consultants were concerned about physician assistants’ current inability to prescribe and their limited psychiatric experience (although this second concern could also be said to apply to junior doctors), and two were unsure whether a physician assistant could replace a core trainee or middle grade doctor.
“Physician assistants allow us more time to focus on a patient’s psychiatric problems.”
Neither the foundation year 1 doctor nor the core trainees indicated that working with physician assistants conflicted with their training or ability to do their work. Three of the four acknowledged that physician assistants, with their up to date general medical knowledge and ability to focus on physical health, were a useful support. Two said that a physician assistant was easily available to the team and improved continuity during induction. However, the junior doctors seemed unsure how much they could ask of the physician assistants because of their initial limited psychiatric knowledge.
Non-medical team members
“Easily accessible” with “good general medical knowledge.”
This group had more initial reservations, with all five saying that they had been unsure of the role of a physician assistant within their service. Despite this, most recognised continuity of care and accessibility as important strengths, with one respondent indicating that this had been mentioned positively by a service user. Three of the five commented positively on the physician assistants’ general medical knowledge, which they found particularly useful if a doctor was not accessible.
Physician assistants themselves
“We’re generalists . . . [and so we] can free up consultant and trainee [time] for more complex areas of needs.”
Four of the five physician assistants thought that their general medical knowledge was an important advantage, along with their flexibility. One said that the role was a good resource to non-medical staff and supported junior doctors. However, all indicated limitations concerning lack of training in psychiatry within the university course (this is typically three clinical weeks). One respondent who’d recently moved to a new post where the team had had no previous contact with physician assistants thought that she was not being given the same clinical exposure as in her previous post.
Tackling the lack of specialist psychiatric knowledge among newly qualified physician assistants was an important part of this pilot. Proposals have been made in the UK for physician assistants to have prescribing rights, as in the US; if these were enacted it would make physician assistants much more useful to the teams they work in and hence valuable to patients and to the service. The junior doctors did not see them as a threat but as having a complementary role; an important factor in facilitating this may be that they have been trained in the medical model.
Findings of other studies
Our findings are consistent with the results of pilot and feasibility studies in Scotland and Australia.1011 The Scottish study evaluated physician assistants working in a number of settings, including primary care (during working hours and out of hours), emergency medicine, intermediate care, and orthopaedics (box 1). The Queensland study evaluated the impact of employing US trained physician assistants in primary care, a general medical centre, a cardiology centre, and in emergency medicine (box 2).
Box 1: Scottish pilot study10
Physician assistants’ practice was found to be safe.
Patients who were interviewed were satisfied with physician assistants.
The opinions of team members interviewed in this study agreed with evidence from the US indicating that physician assistants complement the skills and attitudes in teams and should not be regarded as a potential direct “substitute” for a nurse or a doctor.
A strong and trusting relationship is required between physician assistants and their supervising doctor.
A limiting factor of the role of physician assistants in some settings was the lack of prescribing rights.
Box 2: Queensland study11
Physician assistants were thought to have made a valuable contribution to patient care at all the sites where they were employed.
Patients were satisfied with the care they received from physician assistants.
Doctors and nurses saw the role of physician assistants as beneficial to the healthcare system, but junior doctors and nurses in particular wanted reassurance that commitment to the existing workforce would continue.
Our experience has been that physician assistants work successfully within our psychiatric services despite the teams’ initial concerns. These reservations seemed to dissipate with time as the teams got used to working with this new type of clinician. A similar effect was reported in other pilot studies.1011
The trust has been pleased with the pilot study and believes that physician assistants have a role within our multidisciplinary teams. Recruitment has now taken place for a further three posts within the trust.