What a ‘physician associate’ does – and when to demand a doctor instead
After being forced to wait days or weeks for an appointment at your GP surgery, it would be fair to assume that your consultation is going to be with a doctor. In reality, it may well be with a physician associate.
This medic may examine you, make a diagnosis and refer you to a consultant, or simply tell you to go home and manage symptoms yourself.
However, they haven’t been to medical school and have had a measly two years of training, compared to the five completed by GPs after securing their medicine degree.
The number of physician associates working in the NHS is set to triple over the next decade, as officials look to plug gaps in general practice and hospitals.
“Physician associates can contribute to a sustainable workforce but there are several problems that need to be addressed,” says Dr Billy Palmer, senior fellow at health thinktank The Nuffield Trust. They need to be supervised by a GP or consultant, which will be tricky as doctors are “already under strain”, he says.
Additionally, public awareness of who these staff are and what they can do is “too low and needs to be improved”, Dr Palmer adds. Even their title adds to the confusion. Some falsely describe themselves on social media as doctors, GPs and medical consultants, leading to calls for a rebrand to “physician assistant”.
There has been mounting concern among doctors and patients alike about their role following a spate of deaths and safety incidents. Emily Chesterton died after her blood clot was dismissed as a sprain by a physician associate, who she believed was a doctor, prompting calls for their responsibilities to be stripped back and for patients to be permitted to ask to see a doctor instead. “The handling of this emerging role is creating disproportionate problems for the NHS and staff,” Dr Palmer warns.
What is a physician associate?
Physician associates have been working in the NHS since 2002. These medics have completed a biomedical or science undergraduate degree and a two-year postgraduate training course. They can then work within the NHS, including in general practice, hospitals and A&E, under the supervision of more qualified staff.
In contrast, GPs complete four to six years of medical school and five years of postgraduate medical training. They must also pass two exams – a clinical knowledge test and a simulated surgery to show they can manage patients safely – before they are allowed to work independently as a fully-qualified GP.
Like GPs, physician associates can take medical histories, carry out physical examinations and develop and deliver treatment and management plans. They cannot currently prescribe medication or refer patients for X-rays or CT scans.
However, the Department of Health and Social Care is looking to regulate the profession by the end of the year, which would give the General Medical Council oversight of their education, training and standards. Once regulated, the remit of the role could be expanded to include prescribing powers.
The idea is that physician associates can increase capacity within the NHS and reduce doctors’ workloads. As of June 2023, there were 3,215 working in the NHS, including 1,707 in general practice. The Government plans to dramatically increase their numbers to 10,000 by 2037.
When should you insist on seeing your GP?
If you’ve developed any new ailment that needs to be diagnosed, you should tell your practice that you want to see a GP instead of a physician associate, according to Dr Heather Ryan, managing director of Formby GP in Merseyside.
“As a GP myself, I don’t feel that physician associates should be seeing undifferentiated presentations – i.e. being the first point of contact with a patient and making an initial diagnosis and plan,” she says.
“Seeing undifferentiated presentations is one of the hardest jobs in medicine. It takes a lot of skill and experience to manage uncertainty, assess risk, make a diagnosis and develop a safe management plan which doesn’t result in either under- or over-treatment.”
The more junior medics are better suited to managing the care of patients who have already been diagnosed, such as those with high blood pressure or chronic obstructive pulmonary disease, she says. “Physician associates may be able to safely do that sort of work, as long as they have regular high-quality supervision and support,” Dr Ryan adds.
However, she notes that practice nurses are trained in chronic disease reviews and are regulated professionals, unlike physician associates.
“As a doctor myself, if I were unwell with a new problem and needed a diagnosis, I would want to see a doctor, not a physician associate,” she says.
“I think many members of the public feel the same way. I am the co-founder of a private GP practice. Some of our patients tell me that they have chosen to pay for an appointment because they know they will see a doctor, as opposed to seeing a physician associate for free on the NHS.”
The British Medical Association (BMA) recommends asking if you are talking to a doctor or physician associate if you are uncertain during an appointment and states that patients have a right to demand to see their doctor.
However, Dr Ryan notes that it’s up to practices to decide how they deliver care.
“If a patient would prefer to see a GP, I would suggest that they ask the surgery. Many GP surgeries will be happy to accommodate a preference to see a specific member of staff, especially if the patient is willing to wait for an appointment rather than needing to be seen the same day,” she adds.
Recent guidance from the BMA has set out how the role of physician associates should be cut back, which would leave them unable to treat children, be a patient’s first point of contact at a GP clinic or make referrals, unless they have been signed off by a doctor.
What are the risks of seeing a physician associate instead of a doctor?
Concern around misdiagnosis by physician associates has been mounting following a series of high-profile deaths and harm to patients.
Emily Chesterton, 30, a musical theatre actor, developed calf pain in October 2022 and had two appointments with a physician associate at her local surgery in north London, who she believed was a GP.
The medic diagnosed her with a sprain at the first appointment and told to take paracetamol and rest. At a second consultation with the same physician associate one week later, by which point Ms Chesterton was suffering from breathlessness and her leg was swollen and hot, she was prescribed anti-anxiety medication.
Ms Chesterton had actually developed a blood clot and died just two weeks later from a pulmonary embolism – when a clot blocks a blood vessel in the lungs. A coroner concluded that the physician associate should have immediately referred her to a hospital emergency unit, where she would have likely been accurately diagnosed and treated.
The practice admitted that patients should not see a physician associate twice for the same condition and that the medic did not have the right to prescribe her anxiety medication.
Colleen Howe, 34, died from breast cancer after a physician associate misdiagnosed her tumour as a blocked milk duct in August 2021 and told her to take paracetamol and book another appointment if the lump worsened.
As a result, it was not until October that year that her cancer was diagnosed, by which point it had spread and was incurable. She died last April.
In another case, Norman Jopling, 79, was forced to re-learn how to walk and talk after a physician associate dismissed his severe headaches, which turned out to be a brain bleed.
The BMA has called for the role to be renamed as physician assistants and for patients to consent to being seen by one of these medics rather than a doctor. Its recent survey of more than 18,000 doctors found that nearly nine in 10 had reported physician associates working in ways that could risk patient safety.
An NHS spokesperson says: “The NHS has been clear that physician associates must always work under the supervision of a doctor and within the scope of their practice. Further guidance has been issued to local health services today making clear that physician associates should not be used as replacements for doctors on a rota.”
So, when is it fine to see a physician associate? For patients needing ongoing treatment, it’s often preferable to see one rather than wait ages for an appointment with a GP. Also a physician associate can still provide a formal diagnosis and refer patients for treatment – and may reach the same conclusion as a doctor would. However, if worried about new symptoms, benefitting from the superior knowledge and experience of a more senior medic will likely put your mind at ease.
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