What is a Physician Associate?
A Physician Associate (PA) is a dependent healthcare professional who is trained to the medical model and works under the supervision of a Consultant or GP.
The Department of Health defines a PA as:
‘A new healthcare professional who, while not a doctor, works to the medical model with the attitudes, skills and knowledge base to deliver holistic care and treatment within the general medical and/or general practice team under defined levels of supervision’ (DOH, 2006).
PAs take medical histories, conduct comprehensive physical exams, request and interpret tests, diagnose and treat illnesses and injuries, and counsel on preventive healthcare. PAs are trained to be generalists and must pass a national assessment at the end of their training and also pass a generalist re-certification exam every 6 years.
Qualified PAs are employed by the Trust or Surgery at which they work. The result is a flexible healthcare professional who adapts to their supervising physician’s needs and who is able to provide consistency and continuity to patients and the healthcare team.
The concept of PAs was first proposed in America in 1961 by Charles Hudson. He recommended to the American Medical Association that there was a need to develop a new role for people with non-medical and non-nursing backgrounds. The first cohort launched when Duke University Medical Centre in North Carolina assembled its first class in 1965. This was largely composed of US Navy Hospital corpsmen who had offered first line care during the Vietnam War but had no formal medical education. There are now over 110,000 qualified PAs in the US.
In the UK in 2006 the Department of Health, along with a number of the Royal Colleges, developed the Core Curriculum Framework (CCF) for PAs and a matrix of conditions that PAs should be competent in assessing, identifying and treating. The CCF also specified the minimum number of hours that training courses should offer and outlined clinical placement requirements.
In 2022 the General Medical Council announced the new pre-qualification education framework which sets out the knowledge, skills and behaviours that new PAs and AAs must have when they start work
PA and AA pre-qualification education framework – GMC (gmc-uk.org)
A day in the life of a Physician Associate in A&E
I am a recent graduate from St George’s University of London who has just started working in a busy A+E department. Typical shift patterns include 08:00-17:00, 12:00-21:00 and 16:00-00:00 Monday – Sunday. The department consists of minor injuries, majors, paediatrics and resuscitation. I generally work in majors and paediatrics and will occasionally help out in minors and resus if needed.
There is no ‘typical’ day in A+E as they vary a great deal. In general, however, the day is something like this…….
8am – 1pm
It’s 8am and I make my way to the Doctor’s Office for handover from the night team. There are currently 16 patients in the department, some of whom have not been seen by a medical professional yet. I usually see the next patient waiting to be seen unless there is someone who is more acutely unwell who the Consultant would like me to see first. I can see anything from an acute abdomen to an MI or a febrile child. I clerk, examine and formulate a management plan which I discuss with a Consultant or Registrar early on in my assessment to ensure optimal patient care.
Today, the next patient on the list is an elderly lady with ‘shortness of breath’. The nurse has kindly taken this patient’s bloods and done an ECG. I clerk, examine, take an arterial blood gas and discuss the case with a senior doctor. As PAs, we are currently unable to order x-rays so the doctor has ordered a chest x-ray on my behalf. This patient is too unwell to be sent home so I have referred her to the medical team for admission.
I see the next patient on the list who is a 67 year old gentlemen with ‘chest pain’. After analysing the patient’s ECG it is clear he is having an MI so I inform my Consultant and we put out a ‘chest pain call’ and he is taken over by the Cardiology team to undergo an angioplasty.
I then go on to see a young gentlemen with a fractured jaw in minors whom I refer onto MaxFax for surgery. Next, I see a COPD patient who needs some steroids and nebulisers to help with his shortness of breath and is sent home with antibiotics.
1pm – 1:30pm
Lunchtime!
1:30pm – 5pm
There has been in a sudden influx of patients in majors, in addition to 7 priority calls in the space of 40 mins, one of which is a paediatric emergency. Due to Resus being so busy I have been asked by the Consultant to see an elderly patient with an upper GI bleed presenting with malaena who has become quite unwell. Together with one of the senior emergency medicine Registrars we stabilise this patient so he is able to undergo an endoscopy to find and treat the source of the bleed.
I then see a child with a high fever. After some time in A+E the child’s fever improves, I diagnose tonsillitis and send her home with antibiotics. I then see a patient with acute abdominal pain and vomiting whom I refer on to the surgeons as I am concerned he has an obstruction.
Towards the end of the shift I type up my discharge summaries for all the patients I have seen today and head home.
A+E is a challenging yet rewarding environment to work in. We use our clinical skills and knowledge to the best of our ability to treat acutely unwell patients and to stabilise them enough either to go home or to be referred to the appropriate specialty.
Nimisha Patel is an A&E PA at Surrey and Sussex Healthcare NHS Trust
A day in the life of a Physician Associate in Orthogeriatrics
My day starts quite early as I need to be at the Trauma Meeting with the Orthopaedic Surgeons at 8.00 am to discuss the patients with neck of femur fractures who have been admitted overnight. After this meeting l see the newly admitted patients with my Consultant in order to complete a pre-operative assessment and to introduce ourselves. The rest of the morning is spent doing a ward round with the patients who were already under our care. This ward round is done either with the Consultant or on my own. If I have any concerns or questions during the ward round then my Consultant or Registrar are available to me. My team consists of three Junior Doctors, one Registrar and two Consultants.
In the afternoon I complete ward jobs such as putting in cannulas, chasing blood results, making referrals, organising investigations and updating the patients and their relatives. I attend family meetings to discuss the rehabilitation potential of individual patients to decide the level of treatment or rehabilitation they require. I also attend and run a monthly Bone MDT (multidisciplinary team) and a weekly Orthopaedic MDT with my Consultant.
Outside of the ward I help to write podcasts on dementia and delirium as well as organising the use of new comfort blankets for our dementia patients.
Once a week I spend an afternoon calling our previous patients to answer any concerns they may have.
Pamela Trangmar is a PA in Orthogeriatrics at Surrey and Sussex Healthcare NHS Trust
A day in the life of a PA in General Surgery
I am part of the upper GI surgical team, so I have a varied week with time on the wards, time in theatre and time in the Surgical Assessment Unit (SAU).
Each day starts with the surgical handover at 8.00 am when patients who have been seen the previous day and night are discussed. Following handover we join the consultant to see patients who have been admitted overnight along with the inpatients.
The ward round is usually finished by 10.30 am. Following this I work alongside the FY1 and then go to SAU to assist the on-call doctor in training. There are a variety of jobs to do for each patient and these are prioritised with the help of the senior members of the team.
The work I do is varied and involves taking bloods (including from PICC/ CVC lines); cannulating patients; discussing scans with the radiologist; examinations following the ward round; writing and discussing referrals to other specialties, and reviewing deteriorating patients.
At around 12.00 pm I go to SAU where the doctor in training is taking referrals from A&E and GPs. He/she will tell me who needs to be clerked, which involves taking a history, examining the patient to develop a differential diagnosis, and planning for further investigations and immediate treatment. I discuss this with the doctor in training and/or the registrar who will review the patient.
On any day a variety of patients are seen. Today I see a lady who has been admitted through A&E with abdominal pain following a colonoscopy. When I see her she is visibly uncomfortable and on examination she is generally very tender with signs of local peritonitis over the area where she had a biopsy. I am concerned she may have a perforated bowel and discuss this with the SHO and registrar who review her immediately. The registrar advises requesting a CT scan and to wait for her bloods to come back. The SHO kindly requests the scan and I discuss the case with a consultant radiologist to ensure it happens quickly.
While I wait for the scan to take place, the registrar asks me to see another patient; a 9 year old child who was admitted via her GP with suspected appendicitis. The child is in the paediatric A&E department with her mother. She tells me the pain in the middle of her tummy has lasted 6 days. The child does not have a temperature and has been eating and drinking, but on examination she has a soft, non-tender abdomen and is able to jump up and down. I do not think she has appendicitis. The registrar pops her head in and agrees on review that the child is unlikely to have appendicitis. But as it is her second visit to hospital with this pain and she has not yet had any blood taken, the registrar suggests this and her mother agrees. In the paediatric A&E they cannulate to take blood and I finish the procedure.
It is nearly the end of my day. The registrar and SHO are going through the on-call list of patients and any results that are available. The CT scan is back and the images suggest that the lady has a bowel perforation, but her blood test results are not back yet. She is clinically stable so she will be reviewed by the on-call consultant when her results are available as she may need to have surgery. I will find out what happened to her tomorrow on the ward round.
