Physician assistant

A **physician assistant** or physician associate (UK) is a healthcare worker who is not a qualified physician but practices medicine under supervision.  The title used and what exactly they can do is different in different countries.

They started in the USA in the 1960s, but there were similar jobs during World War II.  There are now similar jobs in many countries as there is a general shortage of physicians.  The training for these assistant posts is much shorter.

A **physician associate** is a health-care provider working in the NHS in England, Scotland, Wales and Northern Ireland.  They provide diagnosis and treatment of medical disorders.  They work under the direct supervision of a named GMC qualified General Practitioner or GMC Registered Consultant. USA during World War II and the Korean War there was a shortage of doctors. The US military began training people in more advanced skills. In 1967 the first class of advanced clinicians from Duke University Physician Assistant program on October 6, 1967 graduated. When their training was finished  they were able to provide medical and some surgical treatments within the USA military.  This included ordering tests and prescribing medicines under the supervision of a qualified doctor. After a decade or two the role was expanded to civilian practice. PAs practising in medical clinics, surgical centres and civilian hospitals started in California. This slowly expanded across the USA including USA overseas humanitarian and military establishments. PAs in the USA now mostly practice without supervision from a doctor.

In 2003 the NHS in England took an interest in the role in order to help deal with the lack of qualified doctors and surgeons and add to the nurse practitioner role. In 2003 the first physician assistants began practicing in the NHS:  They were USA qualified. At first they were called physician assistants like the US.  The UK government was advised that calling them that in the UK would likely lead to a legal inability to practice. A change to **physician associate** and placing them under the Royal College of Physicians for legal purposes let them provide medical care. They had to be supervised by a a doctor or a surgeon. They are not yet able to order diagnostic tests like x-rays or prescribe medications. They do most things a junior doctor or nurse practitioner does such as examinations, taking a history and taking blood samples. They need to obtain signatures for x-ray, MRI lab tests, performing an arterial blood-gas and giving drugs.  Physician associates may get the right to order tests, initiate treatments and prescribe any medicines their supervising doctor can prescribe. This is something some senior nurses and nurse practitioners can do already. The supervision that NHS PA's will likely need will probably be in line like that in the USA. Their supervising doctor does not need to be in the same building but can be available via phone or email. The key is that the PA must be able to obtain advice and an opinion quickly. This would mean that for most of the day PAs would work without direct one-on-one supervision.

Acceptance by the general public has so far been quite well received. Most people dont  see the difference between PAs and nurse-practitioners or junior doctors. Once the role has been explained there have been very few problems. They are generally easier to see than doctors.

## Scope of Practice

There is no agreed upon scope of practice for Physician Associates in the United Kingdom as of 2024, despite them working in the United Kingdom for over a decade.

The British Medical Association published their recommendations for doctors supervising PAs in early 2024 in an effort to formulate a scope of practice aligned to the education received by PAs.  The six core principles of this guidance were:

1. This is an assistant role to doctors helping with simple practical procedures, administrative tasks, and working with patients in a supportive and specified role.
1. This does not extend to seeing undifferentiated patients in any situation.
    1. In a hospital setting, this means that they should not work in an emergency setting unless a supervisor reviews each patient in person
    1. In a GP setting, a GP should first triage all the patients and decide which ones a PA can see for some protocolised reviews in stable patient
1. When seeing differentiated patients (those already triaged by a doctor as appropriate, or already assessed, diagnosed, and on a treatment plan by a doctor), MAPs must be directly and closely supervised.
1. Pas/AAs/SCPs must not make independent management decisions for patients nor be responsible for initial assessments of patients and diagnosis.
1. MAPs must make it clear in all communication to patients and to other staff members that they are not doctors and be clear about their specific role.
1. Statements such as ‘I am one of the medical team’ must not be used unless also stating their own title.

The British Medical Association highlighted a number of activities that they felt PAs should not be undertaking.
|Procedures|
| --- |
|Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT: Perform, train in, or consent others for invasive or life-threatening procedures including: * Any procedure under a general anaesthetic (GA), under sedation, or regional anaesthesia (including spinal, nerve, Bier) * Giving a GA except in the case of an AA giving it under the direct and immediate supervision of an anaesthetic consultant * Endoscopy (any) * Surgical procedures under GA, spinal anaesthesia, or local anaesthesia (LA), including caesarean section. * Diagnostic and therapeutic abdominal paracentesis * Angiography, echocardiography, pacemaker insertion or valvular intervention * Pleural procedures * Interventional radiology procedures * Vaginal delivery of a baby, including * instrumental delivery of a baby * Lumbar punctures * ABGs with lidocaine (therefore, excluding most ABGs)|
|**Assessments**|
|Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT: * Undertake outpatient work in clinics unless this is within a predictable, protocol-led role within the department (e.g. surgical pre-op assessment) where no diagnosis or medical decision making is expected and there is a clear pathway for escalation of unwell or unstable patients * Assess, diagnose, or manage undifferentiated patients (this includes areas such as ED, the acute medical take, and general practice) * Make independent decisions regarding initial management or ongoing care of patients * Have input into DNACPR decisions/ ceiling of care/or escalation decisions (other than as a supportive role) nor sign DNACPR/RESPECT forms * Perform medication reviews * Be consulted for, or provide, specialty specific advice unless documenting on behalf of a consultant/senior registrar in that specialty (it must be clearly stated/ documented as such) * Triage or vet referrals received to the specialty/department/practice in which they are employed * Issue a formal radiology report * Undertake Mental Health Act assessments, diagnose or manage any mental health condition for which inpatient care is required * Accept devolved responsibility for the physical health of patients under the inpatient care of a psychiatrist * Use any ‘workarounds’ to get access to credentials for prescribing or requesting ionising radiation|
|**Communication with Patients and Colleagues**|
|Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT: * Clinical documentation must not include prefixes such as ‘Dr’ or ‘Mr/Miss/ Ms’ that could imply status as a medical practitioner (or surgeon) * Direct/instruct a doctor or other professional to prescribe a medication or to alter an existing prescription * Direct/instruct a doctor or other professional to request an investigation or procedure * Direct/instruct a doctor to perform any task based on the PA’s sole assessment * Be involved in end-of-life discussions, except as a source of information or in a supportive role. The decision-making and related paperwork must be completed by doctors * Be involved in giving specialty advice (unless repeating a consultant/senior registrar’s advice and making it clear who the advice has come from) * Take consent for procedures that they themselves do not perform * Notify public health in cases of notifiable infectious diseases nor make any public health decisions regarding infectious disease unless specifically instructed to by a doctor or public health specialist working in health protection|
|**Daily Work**|
|Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT: * Cover, share, or participate in a rota designed for doctors at any level * Sign a death certificate or cremation form * Make any independent treatment decisions * Attend, prepare, or give any teaching or seminars to doctors as part of their specialty or foundation teaching. PAs or AAs are not eligible to attend doctor teaching of any specialty unless offered to the wider MDT * Be the sole person taking PICU/ICU step-down or transport handovers without a doctor present * Discharge patients independently|
|**Clinical Governance**|
|Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT: * Publish or be involved in publishing research about the effectiveness of the PA/AA/SCP role without declaring this as a conflict of interest * Operate in any supervisory or leadership role in which oversight is given over medical staff (e.g. clinical or medical director, clinical or educational supervisor, responsible officer) * Be involved in revalidation of medical staff except as a colleague giving feedback * Be involved in disciplinary or fitness to practice investigations at departmental, Trust, Board or MPTS level other than as a witness * Prepare reports for coronial inquests / procuratorial inquests or act as an expert witness in a civil or criminal trial (though it is permissible to act as a material witness like any other member of the public)|
|**Anaesthetics and Intensive Care Unit**|
|Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT: * Formulate anaesthetic management plans or lead the brief for the anaesthetic team * Assist in any paediatric anaesthesia (<18 years) * Assist in any emergency or trauma anaesthesia * Assist in anaesthetising any patients in remote environments (i.e. outside of main operating theatre suites) * Assist in anaesthetising any patients outside of normal working day hours (0800-1800) Monday to Friday * Administer any medicines by any route to patients * Induce anaesthesia * Undertake laryngoscopy or endotracheal intubation * Undertake any advanced airway procedure * Conduct emergence of a patient from anaesthesia without direct supervision by a consultant anaesthetist * Undertake Rapid Sequence Induction, or advanced airway procedures * Anaesthetise any patients with a known or predicted difficult airway (such as previous grade 3 or grade 4 Cormack-Lehane view) * Anaesthetise patients for any high-risk elective surgery, including any cardiac, thoracic, neuro-surgical, and obstetric surgery * Perform total intravenous anaesthesia * Undertake neuraxial or regional anaesthesia * Perform conscious sedation * Perform central venous or arterial cannulation * Percutaneous drainage or needle aspiration of contents of any body cavity * Undertake any anaesthetic work with less than a 1:1 supervision ratio, except where the supervising consultant is supervising a senior (post-FRCA) anaesthetic trainee or SAS doctor in an immediately adjacent operating theatre and 1:1 recommended for all but the most experienced (10 years plus) * Undertake any anaesthetic work with less than a 1:2 supervision ratio under any circumstances * Cover any vacancy on an anaesthetic or intensive care doctors’ rota * Hold a specialty bleep, take specialist referrals of any kind, nor be involved in vetting referrals * Discharge patients independently * Use the titles ‘consultant’, ‘registrar’, ‘specialist’, ‘resident’ or ‘senior house officer’|
|**Clinical Radiology**|
|Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT: Formally report imaging in any modality including: * Plain film * Computed tomography (CT) * Magnetic resonance imaging (MRI) * Nuclear medicine * Ultrasound Approve, vet, or protocol imaging in any modality including: * Plain film * CT * MRI * Nuclear medicine * Ultrasound Perform, train in, or consent for invasive of life-threatening procedures including: * Fluoroscopic procedures * CT-guided procedures * Ultrasound guided procedures * Any endovascular intervention Lead or coordinate MDT meetings Interpret imaging for MDT meetings. * Hold a radiology referral bleep or mobile device * Take specialist referrals of any kind or give specialist advice * Be on the radiologist rota at any level or be used interchangeably with radiologists in any way Auxiliary roles within an intervention theatre: * Diagnostic radiography * Radiation planning * Radiotherapy delivery * MDT coordination * Use the titles ‘consultant’, ‘registrar’, ‘specialist’, ‘resident’ or ‘senior house officer’|
|**General Practice**|
|Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT: * See undifferentiated patients* * Consult with any paediatric patient (<16 years) * Be sole practitioner on call or duty clinician * Be sole practitioner in the premises * Be responsible for clinical triage * Undertake direct supervision of GP registrars, FY2s or medical students * Undertake teaching of doctors * Undertake debriefs for GPRs/FYs/medical students * Undertake EoLC discussions and documentation (DNACPR or RESPECT forms) * Complete cremation forms * Undertake home visits involving undifferentiated patients * Perform minor surgery, IUS/IUD/Nexplanon insertion * Undertake 6/8-week baby checks * Steroid injections or any intra-articular injection * Do referrals to secondary care (scheduled) or advice & guidance, unless reviewed by a GP * See any patient that has not a) been clearly informed at the point of booking that the appointment is with a PA rather than a GP b) subsequently consented to the appointment with a PA * Use the titles ‘generalist practitioner’ or ‘registrar’ or other titles that imply equivalence to a doctor  *_Unless the patient is also reviewed by a GP, immediately and in person_|
|**Medicine**|
|Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT: * Lead a ward round * Provide specialty advice other than when documenting or communicating advice from a consultant or registrar in that specialty * Hold a med reg bleep or equivalent * Clerk, triage or accept referrals for acute medical take, unless relating to protocolised assessment on a defined pathway under direct supervision Perform, train in, or consent for: * Endoscopy * Cathlabs * Pacing * DCCV even protocolised Respiratory: * Change NIV settings * Undertake pleural procedures including pleurodesis, drain insertion, or pleural aspiration * Perform and interpret thoracic ultrasound imaging * Perform thoracoscopy Clinical oncology: Should not perform any of the following auxiliary roles within an intervention theatre: * Diagnostic radiography * Radiation planning * Radiotherapy delivery * MDT coordination * Be on the doctor rota at any level or used interchangeably with doctors in any way * Hold referral bleeps, be involved in vetting referrals, or be acting in a way where they need to give specialist advice * Discharge patients independently * Use the titles ‘consultant’, ‘registrar’, ‘specialist’, ‘resident’ or ‘senior house officer’|
|**Ophthalmology**|
|Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT: * Consent patients for surgery * Perform any intraocular or extraocular surgery under any circumstances (not including non-emergency intravitreal injections) * Consent patients for or perform any laser procedure * Triage, review or examine any undifferentiated patients in eye casualty * Review or examine any undifferentiated patients in outpatient clinics * Independently request investigations or ionising radiation imaging * Cover any trainee/registrar shifts during absence/sickness of doctors * Review patients independently on ward rounds * Discharge inpatients independently * Be on the doctor rota at any level or used interchangeably with doctors in any way * Hold referral bleeps, be involved in vetting referrals, or be acting in a way where they need to give specialist advice * Use the titles ‘consultant’, ‘registrar’, ‘specialist’, ‘resident’ or ‘senior house officer’|
|**Paediatrics**|
|Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT: * Hold a referral bleep for any specialty or be part of any referral triage or vetting role * Act as a registrar or senior doctor in any capacity * Take any PICU step-down or transport handovers as the sole receiver of the handover without a doctor present * Do the first post-operative review * Perform any UAC/UVC or long line insertion in an infant or any other central venous or arterial lines in any age * Carry the crash bleep on the NNU or children’s wards * Attend deliveries as the SHO or registrar or as anything other than an observer or assistant role * Be on a transport rota in the role of a doctor * Intubate infants with endotracheal tubes, nasal endotracheal tubes, or apply NPA * Give any routine immunizations * Decide that a child is fit to undergo chemotherapy * Undertake an LP for ICP or sepsis, or any neonatal indication * Make any changes to any medications or direct any doctor to do so * Undertake any part of safeguarding reviews or NAI assessments * Be involved in any palliative care decisions or end of life conversations with parents, unless there in a supportive role only to parents * Attend any outpatient clinics or participate in any outpatient work in clinics, unless assisting under the direct supervision of doctors e.g. taking bloods * Lead any ward rounds * Be on the doctor rota at any level or used interchangeably with doctors in any way * Hold the referral bleep in any capacity nor be responsible for giving any specialty advice at any level. * Discharge patients independently * Use the titles ‘consultant’, ‘registrar’, ‘specialist’, ‘resident’ or ‘senior house officer’|
|**Psychiatry**|
|Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT: * Undertake Mental Health Act assessments, diagnose or manage any mental health condition for which inpatient care is required * Accept devolved responsibility for the physical health of patients under the inpatient care of a psychiatrist * Be a substitute for doctors when a patient presents with physical symptoms * Consent for or initiate treatment * Make decisions that deprives a person of their liberties (MHA/MCA/DOLS/LPS) * Be involved in decision making or delivery of experimental (psychedelics, rTMS, etc.) or invasive treatments (ECT, or similar therapies) * Be on the doctor rota at any level or used interchangeably with doctors in any way * Hold referral bleeps, be involved in vetting referrals, or be acting in a way where they need to give specialist advice * Discharge patients independently * Use the titles ‘consultant’, ‘registrar’, ‘specialist’, ‘resident’ or ‘senior house officer’|
|**Surgery**|
|Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT: * Perform, train in, or consent for invasive or life-threatening procedures including: *# Endoscopy (any) *# Surgical procedures under GA, spinal  anaesthesia, or LA (local anaesthesia) *# Chest drain insertions *# Cystoscopy * Act as first assistant in the operating theatre * Have their own theatre list * Removing cholecystostomies * Removing or flushing neurosurgical drains including but not limited to external ventricular drains and post-operative drains following the evacuation of a subdural haematoma’ from/in any space within the central nervous system * Lead ward rounds * Review or clerk new acute patients in the ED, Surgical triage units, surgical admissions units etc. * Be on the doctor rota at any level or used interchangeably with doctors in any way * Hold referral bleeps, be involved in vetting referrals, or be acting in a way where they need to give specialist advice * Discharge patients independently * Use the titles ‘consultant’, ‘registrar’, ‘specialist’, ‘resident’ or ‘senior house officer’|
|**Women's Health**|
|Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT: * Undertake outpatient work in clinics unless in an assistant role (e.g. ANC, PMB clinic) * Assess women for labour, PPROM, SROM, APH, HTN/PET, or reduced foetal movements, or any acute presentation in pregnancy * Have any role in maternity triage * Be involved in surgical management of miscarriage, surgical termination of pregnancy, medical management of miscarriage, medical termination of pregnancy unless taking an assistant role under the direction of a doctor * Act as first assistant in the operating theatre  Perform, train in, assist with, or consent for invasive or life-threatening procedures including: * Caesarean section, Instrumental delivery, Perineal repair, Cervical cerclage, Hysteroscopy, Hysterectomy, Laparoscopy, Salpingo-oophorectomy, Prolapse repair, Colposcopy * Vaginal examination including speculum and bimanual examination (in inpatient and outpatient settings) * Ultrasonography of the pelvis, either transabdominal or transvaginal * Insertion or counselling in long-acting contraceptive methods, including IUS, IUD, implants, and injectables * Administration or counselling in methods of hormone replacement therapy (HRT) * Initial fitting of vaginal pessaries for organ prolapse * Be on the doctor rota at any level or used interchangeably with doctors in any way * Hold referral bleeps, be involved in vetting referrals, or be acting in a way where they need to give specialist advice * Discharge patients independently * Use the titles ‘consultant’, ‘registrar’, ‘specialist’, ‘resident’ or ‘senior house officer’|

## Criticism

There is criticism as to the level that Physician Associates work at. PAs train to the same model that doctors train to. Nurses train to a caring and nursing model to assist doctors. After nurses have been graduated for three years they can take a 4 month prescribers course at a university and upon passing it become full independent prescribers of any drug that a doctor can prescribe in the British National Formulary. 3 years and 4 months after graduating nursing school a nurse can legally prescribe any drug for any condition they feel they are fit to treat. They are legally independent. A doctor cannot tell them not to prescribe the drug; even if the drug the nurse is prescribing is wrong. A working PA who has graduated with a 3 or 4 year masters degree and has been trained to write prescriptions from year 1 can not do this. Whilst there is movement to grant PAs prescribing rights it is seen as moving too slowly. They would still not be independent prescribers unlike nurses. There is some concern that whilst the physician associate profession has been modelled directly from the USA model it is growing much slower than in the US. Although some have stated this might be due to the public not trusting the profession it seems that it is actually the medical and nursing professions who are acting as obstacles and the public have accepted the role as merely part of a modern NHS. In the USA in many states PAs now practice without needed to be supervised by a doctor at all and are coequal with doctors, nurse practitioners and physician assistants as the triad of clinical care paid for by Medicare.