Physician associates and doctor apprenticeships can be part of the future of medicineBMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2797 (Published 27 November 2023) Cite this as: BMJ 2023;383:p2797
- Aneez Esmail, , professor (emeritus) of general practice, University of Manchester,
- Sam Everington, GP, barrister, Tower Hamlets
Physician associates and apprenticeships are seen by many in the medical profession as controversial, and some doctors have expressed concerns that their medical training is being devalued and their roles are being undermined by less qualified staff.1
We should be open to new avenues into medicine, including physician associates and apprenticeships, and support the incorporation of these roles into the medical workforce. Physician associates complete a two year masters programme in medical sciences and are trained healthcare professionals who diagnose, treat, and care for patients. Medical apprenticeships involve supervised hands-on training to become doctors and can improve access to medical school, modernise medical training, and provide support and nurturing to students throughout their training.
The number of places at medical school is set to expand at an unprecedented rate.2 The development of apprenticeships will challenge medical schools, many of which need to modernise their training and curriculums because they still place excessive emphasis on basic sciences and haven’t embraced issues such as data literacy, better understanding of research methods, working as part of multidisciplinary teams to deliver healthcare, and critical appraisal to improve decision making.
Medical school training is unique in many ways. It combines academic training with elements that could also be appropriate in many apprenticeship programmes. For example, the preceptorships that many medical students do in their final year include attending clinics and learning under supervision of a senior doctor.
Medical school is geared to prepare the future medical workforce for the NHS and should reflect the broader demography of society in terms of ethnicity and socioeconomic status. With current workforce challenges, we need to maximise recruitment and retention—especially in areas of the country that are difficult to recruit into because of remoteness of location and social deprivation, which are barriers to clinical work. The two key determinants of recruitment and retention of staff in the NHS are where staff are brought up and where they train. Medical apprentices recruited locally are more likely to stay and work in their local NHS services, thus avoiding brain drain and keeping skills in local areas.3
If we are to support apprentices in the medical workforce we need to tackle concerns that apprenticeship training will create a two-tier system.4 Medical apprenticeships involve the same training as the traditional route to becoming a doctor and could provide an equal opportunity for all young people in the UK to get a place at medical school.
For apprentices, the final exam will be the same as for medical students, but apprentices will have the opportunity to be supported and mentored as part of an interdisciplinary medical team for five years, undergoing training and learning practical skills while receiving a regular income. This is important for students who do not have external financial support. The way forward is to evaluate pilot studies for apprenticeship training and to determine whether they are feasible and equivalent to traditional medical training.
Unlike medical apprenticeships which aim to train doctors, physician associates complete a postgraduate qualification allowing them to diagnose, manage, and treat patients (excluding prescribing or requesting tests with ionising radiation), working with doctors as part of a multidisciplinary team. Physician associates can be a vital support when doctors are in short supply. In 2016, GP commissioners recognised the shortage of GPs and invested in new local training programmes for physician associates, particularly focused on primary care.5 In the absence of central funding to train more GPs, there was nothing else on the table to resolve the shortage. If we want to tackle the crisis in GP numbers, we should establish a pathway for physician associates to go on to train as doctors and for newly qualified doctors to go straight into five years’ training as GPs.
The medical profession pushes back against physician associates because of anecdotal examples of clinical mistakes and a coroner’s report that linked a patient’s death to one physician associate.6 There is also confusion among professionals and patients about role title and limits of the role and no system of regulation. These are legitimate points for development and this new role needs to evolve, like any other clinical role. It hasn’t helped that some GPs and private companies have employed physician associates as substitutes for GPs to save money on salaries and to reduce their responsibilities in training, mentoring, and integrating them into the wider primary care teams.7
Mistakes happen when physician associates are working outside their area of competence and are left unsupervised because of a shortage of senior clinicians. This can also apply to junior doctors when they are unsupervised. Physician associates can enhance the care provided as a part of a wider primary care team including nurses and allied health professionals. They improve access for patients to healthcare and continuity for many patients when integrated into a wider healthcare team. No evidence suggests that physician associates make more mistakes.8
Junior doctors may argue that physician associates are paid more. Our response is that junior doctors need a pay increase themselves but must consider that there is little pay progression for physician associates as opposed to junior doctors, who will receive pay uplifts when they have completed their training. After four years’ training a junior doctor will be earning more than a physician associate.910
Logically, physician associates would be regulated by the General Medical Council. Their training is clearly geared towards working with doctors as physician assistants rather than as independent practitioners, and the GMC is well positioned to provide clarity around the scope of the role of physician associates and doctors.
Provenance: commissioned, not externally peer reviewed.
Competing interests: None declared.