Article Figures & Data
Figures
- Fig 1.
Data collection and analysis model. PA=physician associate.
- Fig 2.
Facilitators to the integration of the first physician associates (PAs) into a secondary care service in the NHS.
Tables
Specialty Location PA gender Doctor rank/gender Group versus solo PA Medical SE England Female Consultant/male Solo SE England Female Consultant/male Solo NW England Male Consultant/male Solo SE England Female Registrar/male Group SE England Female Consultant/male Group Surgical SE England Female Registrar/male Solo SW England Male Registrar/male Solo SE England Female Registrar/female Group PA = physician associate.
Facilitator Data PA has some say in the development of the role Whereas some PAs had little say over how their role would be developed, others had substantial input: Surg PA 17 – ‘At the end of the first day we sat with our consultant and explained to him what our interest in [specialty] would be and the role was tailored to that for us.’ A medicine PA worked with a doctor who had previously worked with PAs and sought the PA's input into their new team structure. The PA was asked whether they had any resistance to their efforts to mould the role. They responded: Med PA 96 – ‘No, and I think that's partly because the consultant who was in charge of the inpatient team at that time is the one consultant who'd worked with a PA before, at [another hospital]. Yes, she vaguely knew what PAs were about and so she had said, ‘What would you rather do?’’ PAs have a clear understanding of the PA role and can communicate that to others PAs recognised quickly that it was up to them to be able to explain the scope of their role well to members of the healthcare team: Surg PA 28 – ‘I think the doctors, a lot of them didn't know what to expect. I think I've shown them, [over time], what I am able to learn and take on...I've been very vocal about how I want to progress. I think the doctors are very much in support of that and so I think they're happy to teach me and train me.’ PA sees opportunities to grow in their role One PA who went from simply attending ward rounds with the team to eventually running her own outpatient rapid-access clinic for specialty consultations illustrated this concept: Med PA 85 – ‘Compared to now, I was a lot more dependent on the doctors then. I was only a year out of university, so each morning I would do the rounds with them, kind of being more of a scribe [on the inpatient service] and just a presence rather than seeing patients on my own. I think that reflected my level. I wasn't seeing any outpatients. I started in [month], and initially we would review the inpatients in the morning, and, in the afternoon you do the jobs, and organising investigations, and paperwork and things. It was fairly shortly after that [consultant] start talking about setting up a rapid access clinic.’ PA takes initiative to develop skills that help the team PAs felt that, if they took the initiative to learn more skills, that would be rewarded by increase of scope of practice and trust and appreciation from their team. Surg PA 17 – ‘For example [invasive procedure G], on the PA course we weren't really trained how to do that. When we got into the role we said, ‘It's [Specialty], in a day we could have four [invasive procedure G]. For one doctor that's a lot. If you teach me how to do this, that's you doing two and that's me doing two.’’ ‘People were eager to teach us. ‘Okay, cool. I've seen her debride a wound. I've seen her suture a wound. I've seen her do other things, so clearly they have the capability of learning how to do this.’ People were even eager to teach us, so that they could rely on us more.’ PAs become skilled enough to teach others Two PAs really enjoyed teaching junior doctors and felt that it gave them credibility with the team.
Med PA 74 – ‘I'm known as the person who does the lumbar punctures, and I've started training the junior doctors when they come round, and they know that I've been there for a couple of years, and I'm looked at as somebody more trusted.’Surgeon A – ‘The other thing I had realised later on ... is that they became the trainers of the SHOs. So with the new SHOs joining in, the department would pair them up with the PAs because they then had a full knowledge of the SHO duties... and that was incredibly useful.’ med = medical; PA = physician associate; surg = surgical.
- Table 3.
A champion who helps effectively define and develop the role facilitates integration of physician associates
Facilitator Data PAs have a champion who is willing and able to provide support and advocacy Consultants felt that it was their duty to model acceptance and advocacy for their PAs to their junior doctors.
Physician G – ‘I hope that we modelled that acceptance by the fact that the consultants all treated [PA] with respect, as an important member of the team. We all thought it was a great appointment and she was going to be great and the idea was great. I'm hoping that we modelled that to the junior medical staff because they saw us treating [PA] as a respected, important member of the team, that they would do the same.’Med PA 96 – ‘I think, now that we've all worked with more of the consultants for quite a period of time, they're able to introduce us better. I think the fact that they are happy and used to working with us has a bit of a knock-on effect in front of the others.’ Potential for PA to provide continuity on the service makes champions willing to invest in them Consultants find that the constant churn of junior doctors is a poor fit for wards that care for patients with long-term chronic disease and that PAs are a better fit because they do not rotate away.
Physician H – ‘We are developing inpatient specialist diabetes [care]. Typically, the junior doctors rotate within the blink of an eye. Whereas diabetes is a long-term condition and [we get] benefits from [medical practitioners] who spend a bit longer. They get a more in-depth understanding. So we were quite keen to have the physician associate. I imagine that if she didn't like our particular specialty, she does have some choice of moving. So, by definition, if they stay, it's because they have chosen to.’med = medical; PA = physician associate.
- Table 4.
Principled behaviour on the part of physician associates allows the role to develop safely and effectively
Facilitator Data PAs know their limits and put patient safety first PAs discussed how they built trust by having a low threshold for consulting doctors early in their time in the post. Med PA 85 – ‘I am not sure if it's my personality, but I am quite cautious. In running things by [the doctors] and being extra specially safe and wary about any patient I am not happy with. I think over time people acknowledge that and then recognise you've got a pretty good clinical safety record. Being ultra-cautious from the beginning of your career results in [the doctors] trusting. That's eventually rewarded by, if you do have a worry about patients and you flag up your concerns, then they will absolutely take it seriously. [My PA programme] banged [patient safety] into us for the whole course. It is so important as a PA to know your scope and know your limits.’ Positive personal characteristics help the team accept the PA Both PAs and doctors recognised how positive personal traits, such as humility, friendliness, being hard working and having strong communication skills, helped them integrate into the team: Physician D – ‘These are maybe soft skills, but [the PAs have good] communication. They come out and say ‘I understand why we did this. I don't understand why we did that’. So it shows you ‘Okay – they are thinking about what's happening rather than just filling in forms or making requests, etc.’’ Physician G – ‘She's unassuming yet very capable. She doesn't put anyone's backs up. She just gets on with stuff... She's made a big impact on the team, on how well people get [along] together. I think she contributes more there than we'd anticipated.’ Med PA 74 – ‘Be keen and enthusiastic. Be humble in your role, and ask questions, show that you're interested on ward rounds. Go to one of your seniors if you have any problems, or any questions, and gain that trust from them. Be keen on doing procedures. Be keen on having difficult conversations with patients, and patients' relatives. Be confident, but not over-confident.’ A trusting relationship between PAs and doctors enables them to work together effectively A surgeon outlined the factors that had led them to trust their PAs.
Surgeon A – ‘Let's say I am at home, and I want to know something about the patient. Nine times out of ten, I would call one of [the PAs] rather than call the SHOs. Perhaps, partially because the SHOs rotate and are new to the job, but also partly because I know that if I ask [the PAs] it will be done, and I do not have to check whether it has been done and documented. I know for a fact. The personal relationship that you have them that is part of this trust; not only their competence, but just that you know their character. They are going to tell you the truth.’med = medical; PA = physician associate.
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