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Growing the Physician Associate in the UK
In the United Kingdom, PA stands for physician associate.
"This is a moniker with a more exacting ring," according to Jeannie Watkins, then clinical placement lead in the Physician Associate Master’s Program at St. George’s University, London, and Director at Large for Regulation and Legislation for the Faculty of Physician Associates at the Royal College of Physicians.
“We have been pushing for regulation of the profession for 10 years . . a long time,” she said, explaining the name change in her interview." And in 2013, our government said, ‘Your title doesn’t do you any favors." “Associate,” Watkins reasoned, takes away the handmaiden connotation of “assistant.” “You’re working in conjunction with rather than insubordination to someone,” she said. “And I know in the U.S. they have been trying for a long time to change that, but I understand that it’s legislated by the state—that’s a lot of state law that needs to be changed.” An issue, she admitted, up for debate.
One of Six Original PAs
“I’ve done everything you could practically do in a program, from teaching students to writing questions to examining to blueprinting to raising the profile to external communications,” she said. “We’ve gone from 11 students to 70, and that’s taken eight years. We’re now moving into our 10th cohort … which is amazing.”
Transforming Five Hundred Years of Royal College History
For Watkins, as well as for PA Program Director Karen Roberts, having a new faculty in the 500 years of Royal College history is also amazing.
“What the PA is doing is bringing new people into health care. So we’re taking biomedical graduate students in the main, and I think we graduate something between 16 and 18,000 of those per year in the U.K.,” Watkins said.
“And we’re taking those people who are smart, who have the academic capability of learning medicine in two years, and it isn’t all of medicine we’re trying to deliver either, it’s the common and important things.”
An Intensive Two-Year PA Program
I was allowed the opportunity to interview a group of five students in the intensive two-year program, hailing from all corners of the country and with diverse backgrounds in biomedical science, oncology, neuroscience, and psychology.
“Everybody’s got a bit of information to help, to add,” said Jess, then a first-year student who appreciated being able to learn from her peers. She received much of her own work experience in Brazil, where she still has family. “It’s a lot more relaxed there,” she said. “I just met a nurse, and I told her, ‘Oh, I would love to get some experience in a hospital.’ And she was like, ‘OK, I’ll call a doctor.’ She called a doctor and was like, ‘Oh, I have a friend that wants to go to the hospital.’ And he was like, ‘Yeah, yeah, just tell her to come in.’”
However, while she was thrilled to be shown around every specialty, Jess was dismayed that health care there was a luxury, with wealthier patients receiving preferential treatment.
Arjun had a similar experience volunteering in rural Kenya.
“When you see the facilities that they have,” he said, “the resources that they are limited to, it really makes you appreciate just what we have here.”
While a fully developed nation like the U.K. is held to a much higher standard, all of the students admired the National Health Service, including Sara, whose admiration is more personal as she has witnessed the positive impact her father has made as a sedationist and her mother as a radiologist.
"I've kind of known I've always wanted to do something with medicine. My dad's a doctor my mom's a radiotherapist so I kind of knew something was on the cards but I didn't really know what and then this (PA) just kind of ticks all the boxes for me it's kind of the perfect integrative thing where I can kind of just do a bit of everything I want to do. I just love the kind of feeling that you're actually doing something positive."
Healthcare as a Public Service
Seeing health care as a public service and the NHS’s problems as a welcome challenge, they had taken the classic PA charge to extend quality care. In a system where doctors rotate in and out of hospital departments, especially junior doctors looking for experience, the main focus of the PA is to provide continuity, “where you have this consistent generalist who is working across medicine at a reasonably high level,” said Watkins. “That’s fluidity. That’s streamlining. That’s patients not getting lost . . . it’s continuity of care for them, and junior doctors, as well, because [the PA] knows the system, they know the processes. It’s your first day on the job and you’re going, ‘Where is this? Who do I need to speak to? How do I do this?’ This person is that constant.”
"The PA is a Constant"
U.K. PAs already working in wards and assisting in surgical theaters at St. George’s University Hospital echoed Watkins.
“I always think that the benefits that they get from us or from PAs into different specialty teams is the institutional knowledge that we bring to those teams,” said Chaz, in urology. “There is so much rotation around junior doctors that when they first start, they probably don’t know how to refer a patient, they don’t know how to book a patient, they don’t know where things are—so us being around frees up that time of being inducted into the ward, being inducted into the team. So I think that helps.”
Laura, working in plastic surgery, agreed, “It makes a huge difference in terms efficiency.” “I like to think that patients appreciate seeing the same face,” Adrien, once in neurology and now neurosurgery, chimed in. “Because the doctors do on-calls and things, so if someone’s been on call the night before, then they’re not going to be in today, or they may not be in today because they’re going to do on-call tomorrow. So I would’ve seen the same set of patients every day this week. And I’m going to be the continuity in my firm for this week.” He added that he would be helping at least two doctors who would be in and out, which he admitted can be rewarding but also a source of frustration at times.
“One of the challenges is August,” said Adrien. “Everyone changes in August. You get a whole brand new team of registrars coming in. It can be frustrating sometimes if you have an entirely new team come in and you have to start again from the beginning.” This might mean re-winning the confidence of those not acquainted with the PA and renegotiating one’s role. “Initially I would say a challenge was that awareness of what people can and can’t do and where you can kind of fit in,” said Laura, who had been working in the same specialty for six years. “Initially we started completely on the wards and it was a kind of process of building trust and negotiating to see patients in clinic and to assist in theater.” She added that has changed as more-permanent staff have become familiar with PAs and with the development of PA-specific roles within specialties, such as has benefited Dom, a newer PA in breast surgery. “They had watched other specialties have PAs,” he explained, “and then developed a role specifically for a PA coming in, varied with a good level of responsibility already built in. So I didn’t have to fight for that in my current role.”
Dr. Davendra Sharma, the urology department lead at the time, was enthused by the introduction, and subsequent commitment of PAs over the preceding five years.
“We were training a PA up to doing urodynamics, which is a minimally invasive procedure,” he said. “I was quite impressed with the speed with which that individual took up the practice and progressed. It shows just how much we can get from the PA cohort.”
But with national regulation yet to be passed by Parliament, PAs cannot prescribe or order X-rays, and some PAs yearn for more challenges.
Chaz, who was helping draft a urology curriculum, said PAs don’t have “a scene of responsibility, where they feel they’ve gotten to the top of their level and they don’t have anywhere else to go . . .” “. . . and then they change specialties,” Laura concluded. “And that can happen quite quickly,” Chaz continued, “so you need to keep PAs a bit more enthusiastic about their role and keep them entertained.” Laura smiled. “To rephrase that,” she said more tactfully, “for any career, what satisfies people, in clinical careers, is the patient interaction and that kind of amazing relationship that you manage to develop with meeting different people and taking histories . . . but it’s personal development and a level of autonomy, a level of being able to improve oneself and reach actualization.” When I asked what their futures held, most indicated they would continue in their specialties, except for Laura, who also had a master’s of science in tropical diseases. She replied, “There is no ceiling,” and since the interview, has returned to medical school while continuing to work part-time.
Just before speaking with me, Watkins was tweeting to congratulate Jeremy Hunt on his return to Secretary of State for Health and Social Care, a minister who seemed supportive of PA regulation now sidelined by the Brexit spectacle. I asked if there was any opposition to normalization of the profession.
“Not really,” she said. I think our numbers, we started small. And it’s like small acorns, and when you plant small acorns, you get great trees. And eventually it kind of seeps out and builds up. And in doing it that way, I think we’ve done the profession right. You know, now we’ve got a massive increase in numbers coming through…. You then become visible with increase. That’s when people start thinking, What about us? What about this? What about that? So not massive opposition, not yet. People have concerns…. But we’re not here to take anyone’s jobs or anyone’s training opportunities. We’re here to redistribute the workload of this health service that’s just on its knees, its beyond on its knees, you know. And PAs, that’s what we’re about, providing good medical care to patients. The Health Service as I said, is in my words, broken in England, in the U.K. PAs are there very much to increase access, patient access to care. So if you think about it, you got very small numbers—you got doctors who are leaving, you got nurses who are leaving, you know, people who don’t want to be in health care anymore because they’re demoralized; they can’t provide quality care because there just aren’t enough people.
"Cut Price Doctor" Will See You Now
When I brought up the dark-sided headline that had appeared in that morning’s Daily Mail:
“Cut-price doctor will see you now: 3,000 assistants with just two years training to work at GPs and hospitals,” she called it journalist sensationalism to sell papers. “It’s not the first time we’ve had that article,” she said, a storyline that not only plays on patient fears but often pits doctors, rightly seeking better conditions, against PAs, who are meant to help not replace them.
The Grenfell Tower fire, just a fifteen-minute walk from where I was staying, was all that was on TV news and the front pages of papers that day, and probably had attracted any and all media attention. However, my writer’s mind could not help drawing parallels between the health and regulation aspects of both the fire and PA stories. If the U.K. government could not ensure health and safety by providing and enforcing elementary building codes—Grenfell Tower mind-bogglingly did not have water sprinklers, or alarms in every unit, in addition to having very flammable cladding that already had exacerbated similar building fires around the world—how could lawmakers ever find the willpower to support the NHS in regulating PAs, a profession successfully implemented in the United States over the past 50 years and which has similar incarnations in Britain’s former colonies, namely Kenya going back to the 1920s?
These foibles are less tragedies than farces of dramas that have been played out long ago. Watkins also bemoaned Brexit, the then just-developing drama that has since turned into a Shakespeare comedy of its own, with the expected loss of European Union funds and professionals.
“If people from Europe cannot stay in the U.K.,” she said, “we are dead in the water across our public services.” Granted, the E.U. is less than a wholly transparent, democratic entity, just as the PA may not be a wholly perfected profession, but both are projects worthy of championing, to overcome their faults for their higher ideals.
The Continued Growth of The UK PA
Watkins informed me by email that there is nothing further on regulation at the moment, but that the government has pledged to regulate the profession. “We need the four governments of the U.K. to agree on who the regulator will be,” she said. “We are waiting for them to decide. Once this happens, regulation can move forward.”
The fourth installment of this blog series, “The Test,” is on the trials and tribulations of the very first Israeli PAs.
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