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:

 This is an assistant role to doctors helping with simple practical procedures, administrative tasks, and working with patients in a supportive and specified role.
 This does not extend to seeing undifferentiated patients in any situation.
 In a hospital setting, this means that they should not work in an emergency setting unless a supervisor reviews each patient in person
 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
 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.
 Pas/AAs/SCPs must not make independent management decisions for patients nor be responsible for initial assessments of patients and diagnosis.
 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.
 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.
+ProceduresPhysician 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)AssessmentsPhysician 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 radiationCommunication with Patients and ColleaguesPhysician 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 protectionDaily WorkPhysician 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 independentlyClinical GovernancePhysician 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 UnitPhysician 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 RadiologyPhysician 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 PracticePhysician 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 personMedicinePhysician 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’OphthalmologyPhysician 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’PaediatricsPhysician 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’PsychiatryPhysician 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’SurgeryPhysician 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 HealthPhysician 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.
References

Category:Healthcare occupations