Intended for healthcare professionals


Physician assistants can lighten doctors’ workload but are a challenge to professional boundaries

BMJ 2016; 354 doi: (Published 31 August 2016) Cite this as: BMJ 2016;354:i3490
  1. Matthew Limb, freelance journalist
  1. BMJ Careers
  1. limb{at}


Expanding the work of non-medical staff can give doctors more time for training, says Matthew Limb, but it also prompts concerns about the boundaries of different roles

The Royal College of Surgeons of England looked at perceptions of training and the potential offered by new team models.12 It surveyed nearly 1000 doctors in training and 22 specialty association leaders, interviewed NHS staff at eight “case study” sites in England and Wales, and analysed workplace diaries.

Complement not substitute

The report found that doctors in training can be anxious about the idea of non-medical practitioners, like physician associates, playing a bigger role in surgical teams. “To a degree it’s the fear of the unknown,” says Ian Eardley, vice president of the college. “Because these staff are relatively new, some juniors worry they might be a threat, they might take away training opportunities. For a surgical trainee, that’s about operating,” he says.

But a positive picture of the benefits to patient care and training brought by extended teams involving advanced nurse practitioners, surgical care practitioners, physician associates, and surgical first assistants emerged overall. The college found that, in hospitals that have adopted new team models, resistance had “mostly dissipated.”

Johnny Mathews, an orthopaedic trainee who co-wrote the report, says, “The extended surgical team can realise its potential when designed to complement rather than substitute junior doctors.”

Eardley, a consultant urologist, says that, because junior doctors often rotate between departments, the constant presence of physician associates or other non-medical colleagues can help with handovers and provide patients with a familiar face. “It helps the new junior who is coming to a ward when you’ve got somebody who can show them round, who knows the patients, and can do some of the tasks like catheterisation or drips or bloods or paperwork,” he says.

The college’s report found that higher surgical trainees believed that the constant presence of surgical care practitioners gave consultants the confidence to step out of the room, leaving senior trainees to operate independently. “In this respect these roles help the gradual withdrawal of supervision for more senior doctors in training, to proximal consultant supervision,” the report said.

Crossing the line

The college is concerned about the “confusing” plethora of job titles for non-medical practitioners. Eardley says that the list of names and job titles “is as long as your arm” and believes it should be streamlined.

The report flags up concern over the “fluid” scope of practice arrangements for non-medical roles, significant variation in what they do in different hospitals, and the nature of postgraduate qualifications. The college says that there need to be clear lines of accountability, strong governance to protect patients, effective workforce planning, and adequate support for staff development.1

The college found that a number of medical directors and senior surgeons at the case study sites were open to non-medical staff “taking on almost any role, including doing simple procedures independently, provided they had the right training.”

But resistance within a couple of the sites “suggested that this was a line that some felt should not be crossed.” Many of the medical staff interviewed drew the line at non-medical practitioners performing surgical procedures—such as carpal tunnel decompression or hernias—independently.

Physician associates cannot prescribe independently, because they are not subject to professional regulation, and they can’t order x rays or computed tomography scans. The report says that this limits what physician associates can do out of hours—and given that delivery of out-of-hours care is one of the drivers of the introduction of this group, it is a “major concern.”

Eardley says that this is a “significant barrier to them being a useful part of the work team.” Hospitals are looking at a number of ways to address the prescribing restriction for this group, the college says.

The college recommends that standards should be developed to guide the evolution of non-medical roles within surgical specialties. The report found that where the benefits of non-medical staff in extended teams were seen, roles had been well coordinated.

Mathews says, “To achieve this it is essential that these roles are properly planned according to local need, and are implemented in the presence of strong consultant leaders who support a culture that prioritises training as well as service.”