Intended for healthcare professionals

Opinion Primary Colour

Helen Salisbury: Training in the medical model

BMJ 2023; 383 doi: (Published 28 November 2023) Cite this as: BMJ 2023;383:p2793
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter @HelenRSalisbury

There’s been much discussion in the press and on social media about the role of physician associates and anaesthetic associates.123 Who exactly are they, and how are they trained? The Department of Health and Social Care says that they’re “trained in the medical model”—but what does this actually mean?4 Among many possible meanings, an early paper on physician associates from 2005 defines it as “the flexible application of knowledge and skills to needs of the individual patient rather than working to predetermined protocols.”5

The medical model I know is the one I experienced and have also taught. It involves learning a lot of basic science (anatomy, biochemistry, physiology, pharmacology, pathology, and more) and then understanding how these subjects relate to symptoms in patients and how we can investigate and treat illness. Many courses now weave these strands together, aiming for vertical integration of the curriculum and spiral learning, where you return to the same area but with more depth and complexity in successive years of study. As medical knowledge expands there are debates about what a doctor really needs to know—for example, the amount of anatomy taught to undergraduates has been reducing over several decades.6 And of course every academic believes that, if more of their particular subject was taught, the students would become better doctors.

When refining and revising the curriculum, the question at the forefront of our minds must be: what knowledge and skills do doctors need in order to practise safely? We need to ask the same question when it comes to training physician and anaesthetic associates. If we believe that becoming a GP really does take five years of medical school and another five of postgraduate training, why do some physician associates in general practice receive less supervision after two years of training than a GP registrar after nine? Our GP trainees have debriefs with a supervising doctor at the end of every surgery, but for many associates this clearly isn’t happening beyond their first year in practice, at which stage NHS England recommends monthly supervision.7 In theory, physician associates, as dependent practitioners, always have access to a qualified GP to answer any clinical queries; in reality, there are multiple reports on social media of associates working semi-autonomously with minimal input from busy GPs.

Experience is often used as a proxy for competence, the idea being that these new members of the healthcare workforce “learn on the job.” However, we must be alert to the dangers of experience without training. If no one’s looking over your shoulder or discussing your cases—not only those you struggled with but also the ones you thought you handled well—you may never know what mistakes you may have made or how your diagnosis, advice, or treatment could have been improved.

Experience boosts confidence, but without supervision and feedback it doesn’t improve competence. In the interests of patient safety the BMA has called for a pause in recruitment of these medical associate roles until their scope, regulation, and supervision requirements are more clearly defined.8