Are Physician Associates replacing Doctors?

Are Physician Associates replacing Doctors?

Caution:  This transcript is AI generated and is likely to contain errors.

[0:00] Music.

[0:06] Are physicians associates replacing us doctors? And what does this mean for us?

If you are a doctor, what should you be doing? How should you be reacting?

Or are you a PA like me, frustrated, misunderstood, judged, and starting to impact on your work day to day?

Welcome to the podcast that is for all frontline clinical staff working in primary care, and in fact, anywhere in the NHS.

I'm Munir Adam, your host, and new for season three, well we've got a couple of things to say one is that we have now consolidated our team so there's a range of multi-professionals from across the uk that are part of the team to represent the different professions across primary care that's one thing and we're also doing selected episodes on camera and so if you're listening to this on a podcast there's a video version going to be released on youtube soon now the doctor versus pa topic you know if we can describe it in that way I know it's quite divisive, perhaps to say in this way, or polarised.

It's hot. Everybody's talking about it. It's a problem. It's a major problem at the moment as we speak.

There's anger, there's frustration, and there are concerns about patient safety as well being expressed.

[1:17] So we can't ignore this topic. Now, there's fairness that's coming up as well.

You know, is it fair for all the professions in terms of the changes that have been happening?

I mean, you only have to turn to social media and you find people discussing this.

And the doctors' professional organizations, their bodies have published material in relation to this as well.

And actually, you know, it's in the mainline media as well, in the news.

Now, I did say that we represent all the professions, so that includes doctors as well.

And I think I am within my rights to actually say that I think to some extent, the anger that doctors are feeling, to some extent it is justified.

[1:51] But it should not be towards PAs. For PAs, it's a very difficult and uncomfortable time.

Again, like you said, there's a lot of changes and uncertainty and changes impacting on their day-to-day work as well.

So guys, I'm going to introduce myself. My name is Mariam. I'm a physician associate represented for the Primary Care UK podcast. I'm a PA ambassador.

I have been been qualified for nearly four years as a PA.

So they say PA is a fairly new profession but matter of fact it has been around for 20 years and what exactly do they want?

Well they want some sort of support from the doctors, encouragement but instead they're getting a lot of verbal abuse and even death threats on social media.

Now that is not quite fair and it's impacting on their mental health quite a lot.

We're going to explore all of these issues today's episode. We will have have a PA voice, Stephen Nash.

He's from the United Medical Associate Professionals.

And we also made contact with GMC and the BMA.

So there will be a series of questions we're going to go through and asking, and so many of you are asking right now, day-to-day jobs in properly in Twitter, social media.

And we also get the opportunity to hear what Steve have to say and and others and share our views today.

Starting importantly in relation to patient safety, is it being compromised?

[3:17] The differential pay between the physician associate and a doctor and junior doctor in particular.

[3:24] Also, professional identity is another major concern amongst all professional and how should one or another should introduce themselves to the patients and the public in particular.

And RPAs are being blamed by the doctors. is there any particular grudges, personal vendettas, or in relation to are the doctors venting out the frustration?

I think it's good to cover all of this, and it is about doctors versus PA, but this does impact on other professions as well. So how are we going to resolve these issues?

And actually, when we started doing this, we thought we could have it in one episode, but we just couldn't. I mean, there's just a lot of stuff out there to cover.

And so we've split it into two episodes, and this is first half.

[4:06] But yeah, there's confusion, there's anger, uncertainty, insecurity, there's even hatred there.

Well, you know, education is key, as we always believe in this podcast.

Like, for example, we did an episode, well, two episodes, in fact, that was also in two halves, on racial discrimination in primary care. That was in season one.

And even that, what we felt was our responsibility was to share the reality of what is happening to people, their experiences, but not from the perspective of blaming anybody, pointing fingers, but actually just so that we can become more aware and think about how we can do things better, right?

How we can help resolve the problem, whoever we are, wherever we may be.

So yes, education is key. And so this podcast is not a political podcast. We're not politicians.

We don't understand politics. I certainly don't. What about you, Mariam? Do you, are you, you've got a hidden political background that I'm not aware of? No, not at all. No.

So, you know, we're educationalists, but it's very politically hot topic, and it may come across as if we're trying to take a political standpoint.

And if we are, we apologize. That's not our intention.

It is about education. But strong words are going to be expressed, as they would in topics like this, because our aim is to try and convey the reality of what is actually going on.

This is Primary Care UK. Let's learn together.

[5:22] Music.

[5:36] So, Mariam, do you want to start by telling us, just talk a little bit about what is a physician associate and then maybe some of the facts that might be pertinent?

Because I know a few of them, but there's probably a lot I don't know either.

[5:48] No, definitely, Munir. So physician associates are healthcare professionals who work part of a multidisciplinary team with the supervision from a named senior doctor, which could be a GP or a consultant.

Is ultimately providing care to patients in primary, secondary and community care environments.

We're also part of the medical associate profession grouping in the health and care workforce and have been working in the UK since 2003.

So like I said previously, we have been around for 20 years.

So what exactly can we do and what can we not do?

There is a long list here, but I'll just touch on a few.

We take medical histories from patients. We do carry out physical examination.

Examination, we see patients with long-term chronic conditions, we also support with differential diagnosis and management plans and undifferentiated diagnosis.

Now I know there's a bit of a debate about that whether we should be doing that or not but actually it's a fact and it's something that we have been doing for quite a while.

We also perform diagnostic and therapeutic procedures and we deliver and develop appropriate treatment plans and management and again this is always under the supervision of a doctor, so we're not let alone to do an act on our own accord.

The things that we cannot do is to prescribe, and we cannot request any ionising radiation.

[7:09] Currently, we have 4,000 PAs across the UK, and the NHS Long-Term Workforce Plan is to expand over the next few years to 10,000, and I think that's what's triggered a lot of anger and frustration amongst the doctors at the moment.

So now where are we at? So 2006, we do have a document was introduced, a competitive framework by the Royal College of Physicians and the Royal College of General Practitioners and FPA were part of it.

It was a collaborative work on a document to review the competence and curriculum for the PAs and it clearly states on the document what we can see, what we cannot see.

[7:47] And then 2011, volunteer register was introduced by FPA and that was to support the employees to to ensure that PAs have passed the national exam.

So, for example, we have to have minimum 2.1 in our undergrad BS science degree.

So this could be a biomedical or a healthcare related degree.

And then we go on to do a two years master's in PGD and level seven equivalent to a physician associate studies at university.

Now, just because we have qualifications does not mean that we can just go straight and start working, practicing as PA. We must sit the national exam, which basically is 200 SBA questions and 14 OSCE stations.

It was introduced to standardise all the university learning.

And we get three attempts. If we fail the three attempts, we cannot qualify as a PA.

So now, 2017, the GMC introduced, HCPC were introduced to discuss who's appropriate body to regulate us. and the discussion was the fact that because we work very well with doctors, GMC was decided to take over.

And in 2024, law has passed where GMC will be the regulatory body and also that our titles will be protected as physician associates.

And hopefully 2024, regulation comes into force.

[9:08] Now, that all sounds good and well. Now, there have been some concerns expressed, haven't there, by various people about this.

It all sounds very positive, the way you're explaining it. what sort of issues are there,

[9:19] There's a lot of concerns by the doctors, BMA, RCEP.

First of all, it's GMC, it's appropriate body that should be regulating us.

Also, the need for more doctors has been ignored.

[9:34] Remaining as a supervised role, but appropriate resourcing of that.

And also, of course, is sadly the death of the Emily Chesterton.

I would like to pass my condolences to the family for what has happened.

It's really sad what has happened and it shouldn't happen again.

And no parent should go through that. But it also has raised valid patient safety concerns that do need to be addressed.

And also another concern, PAs are being paid more than junior doctors.

[10:05] OK, shall we start then with the first point? point it's it's only entirely appropriate to start with is patient safety being compromised right mariam i think that's got to always be the most important thing for for any professional health care professional and the way i look at it you know with the case you just mentioned actually with um the pulmonary embolus the patient was seen twice um and on both occasions the diagnosis was missed i mean look it's everywhere in the news we don't need to go through the case now that's not the aim here. But the point being made, right?

Look, my argument is this, and this is one that's shared by many, I believe.

You have to do extremely well at college just to get into medical school.

You know, you need three A's or better usually.

And then you have to spend five years working really hard.

[10:55] And sometimes six. Some people do an integrated BSE, for example.

And then after that, when you qualify, you've got the foundation year, quite intensive hard work experience to do as a junior on the wards and in primary care, etc.

And then after that, depending on what you do. So for example, if you decide to go into GP training, you'll spend three years doing that.

And that's well supervised, particularly in the GP posts, you have an educational supervisor.

And this is a a carefully selected and qualified person who is trained to supervise.

And so at the end of it, it's been about 10 years since you started that journey.

And you know something, I teach medical students and many of them have come after doing a BSE, a three-year degree, before they even started their medical career. So it would be even longer then.

Now, if we compare that to a physician associate who does a three-year undergraduate degree in something that might not even necessarily necessarily be that relevant to working as a PA, then does a two-year course, and that's pretty much it.

And then they can do most things except for just a few limitations, which, Mariam, you clearly explained.

And also, unlike with GP training, the doctor supervising the training of a PA, as things stand at the moment, doesn't even have to be a qualified educational supervisor, right?

And finally, when something does go wrong, the doctor gets blamed.

So all that said, Surely there is something about patient safety there, is there not?

[12:23] Well, let's hear what Steve has to say. I'm sure he'll agree with me.

[12:29] So is patient safety being compromised then? There's no peer-reviewed evidence that shows MAPs are unsafe.

We cannot use case studies to write off entire professions. There needs to be a call for perspective.

For example, there are over 12,000 medical negligent cases per year aimed at doctors.

It costs the NHS over £2 billion per annum.

So if we take the 70 cases of avoidable harm that the anti-MAPs think they found, bearing in mind they haven't seemed to report or confirm those through official channels and we divide that across both workforces doctors are 188k in the nhs pa's 4200 and then respectively you get 0.063 cases of harm per year per doctor and 0.016 cases of avoidable harm per PA.

And that stat on its own shows the motivation for this is not patient safety.

Otherwise, it would be a much broader conversation.

[13:30] And there's been 20 years practice from PAs in this country.

And there's been some decent studies carried out across that time.

One in 2020 compared FY1 and FY2 doctors case notes with that of PAs in the same ED.

And they were both seeing undifferentiated patients and they found in both that PAs worked to the same standard as their doctor counterpart and were more likely to investigate the patient's or the suspicion of the patient to confirm their suspicions and their differentials and I suppose you then have a question about our training.

We have a good substantiated scope post-qualification called the conditions matrix and this differentiates the familiarity the PAs will have with a given condition and post-qualification PAs go on to do the same courses that doctors do and the same CPD in-house that doctors do.

Why is that? Well, doctors dominated the CPD field.

Every course is geared at them. And we have been piggybacked into those courses.

So ALS, ATLS, endoscopy, minor surgeries, the list goes on.

[14:37] We pass all those courses too, and we're held to the same standard that doctors are held to on those courses.

So how can you tear down the training if the outcome is professional that sits alongside and passes those courses with you?

So I'm waiting patiently for independent peer-reviewed evidence to compare our safety statistics and then we can put it to bed once and for all.

However, that being said, where there is safety compromised is when the management of PAs is rushed or not taken seriously.

Every incident of harm that's taken place has had integral failures in the management of the role and there's a shared responsibility to get this right?

If the PA role was that unsafe, why are 50% of our workforce in GP land working well with their GP colleagues?

The argument, unfortunately, makes no sense.

[15:31] Okay, some interesting points made there by Steve. I think we agree on appropriate, you know, management and supervision, Mariam.

I think that's one point from what I'm hearing from Steve that we do agree on.

Yeah, well, I suppose, to some extent, I do agree that as long as PAs are appropriately supervised, then I guess to some extent that does justify the shorter training period. Okay.

And actually, this point about supervision is something that the Royal College of General Practitioners, the RCGP, has stressed importance about in fact, in a statement that they released just in March.

So this month, it's March now, as well as specifying some other important criteria as well. I found that document really helpful, well worth read.

And I know that the Royal College of Physicians has also produced something similar as well along the lines of the importance of supervision.

And actually, Mariam, I just want to be clear. I'm not scapegoating.

I'm not judging the case of the PE. To be honest, I know nothing about that case.

[16:31] Mistakes, even minor mistakes, when I do a mistake, when I make a mistake, the first thing I do is I learn from it, right?

I learn from it, and I try and work out what is it that I need to change? What did I do wrong?

And I accept the responsibility for that. that. But then, after that, I asked myself the next question, which is, why did I do that?

And you know something, Marianne, when I asked that question, invariably, system factors come into play.

So yeah, as much as you know, one might blame an individual clinician, whoever they may be, at the end of the day, the system is at fault to some extent in some way.

And I think that that That is going to be the case almost always.

It is, at the end of the day, in primary care, GP partnerships responsibility to ensure adequate supervision and appropriate management and make sure systems are in place.

So I think that's worth just mentioning as well.

[17:29] But listening to yourself and Steve, I mean, like Steve says, it is shared responsibility.

Accountability is really important. important and like you said money the ability to as any health care professional you should be able to have self-awareness and be able to reflect on every event such as this and learn from it as a case example and in health care we should always be open in discussion and learn how we can improve because not everything's always in within our control um there's always some uh like you said there are some system and factors and sometimes errors do occur.

Now practice is not always liable the individual is also liable they do take accountability as a physician associate if I make an error I will be held into disciplinary meeting I will get sat down I'll be able to put my written feedback and discuss the case with my senior GP these incidents they get documented It's based on CQC regulation.

We have so many authorities in the NHS England to regulate all of that.

And I think time should be given to PAs. Debris should not be rushed.

And ultimately to make sure that we ensure patient safety by making sure measures are put in place.

[18:44] Now, there are a few things like preceptorship scheme by the NHS England.

It outlines very clear what a PA role is and the GP supervisor role is.

And I think also there's a lack of education of a GP supervisor roles and responsibility and how to assess a PA.

There is a core capabilities framework out there for medical stewardship professions, which was introduced in 2022.

[19:06] And again, if people want to have a look at that, it clearly outlines the different types of tiers and when to supervise in direct and direct supervision.

And it supports the employers. And again, these measures are put in place to ensure that we have patient safety as a priority and avoid errors as much as possible.

[19:26] Okay, so we're all agreeing about the importance of supervision.

But isn't that also under threat?

I mean, when I read documents really highlighting the importance to make sure supervision is there, it almost sounds to me like it might go.

And there is a bit of a worry that with regulation being handed over to GMCs, is would supervision eventually go?

Maybe at this point, it's just fear in the minds of some.

But the other point that's being, which is linked to that, I guess, is about supervision being appropriately resourced.

I think that probably is more of an immediate concern for some.

[20:01] But let me just share with you the example of a situation I was in.

So I had the opportunity to supervise a physician's associate who was starting her two-year course.

And I declined it. And the reason I declined it is because the payment wasn't great.

First of all, it was significantly less than what I would get for GP trainees.

And I'm not saying it's all about money, but it was something connected with that, which worried me more, which was whether I'd get adequate time to supervise and provide the support that was needed, because there was no document specifying exactly what that should consist of, like in terms of what extent.

I guess it's it's difficult to produce that kind of document.

And I couldn't understand why there's such a difference in terms of the resourcing and support and financial support that went towards a PA compared to, say, a GP trainee.

Anyway, I mean, it's a happy ending. She's now a wonderfully well-qualified PA who manages a lot of chronic diseases and various other things.

But you see my point. And yeah, so I suppose the big question is about, you know, will the need for supervision provision eventually go?

Is that legitimate concern? Or is it just doctors becoming worried unnecessarily about something?

And indeed, if it is here to stay, will it continue to be or will it be resourced adequately?

[21:16] Thank you for sharing that, Mania. And you're not the only one.

I have received that feedback from quite a lot of doctors.

First of all, I would like to say, nobody should be forced into supervision.

And if a GP is not comfortable in supervising a PA, they've never worked with a PA, they shouldn't be put in that situation. It's just not fair on them.

I mean, even when I was working as a PA in a general practice, a newly qualified GP asked me if I needed any prescription any signing or any support and I respectfully declined I said you're a newly qualified GP and it should be my senior GP should be supporting and do you know what GP is amazing I worked really well with them and there's not been any toxicity that I've experienced so far on the ground but again it's as a physician associate matured adult I know where my limitations I know who to go to and then I can make that sort of like that assessment making it very like making being more of an advocate in my role is really important to say it's best coming from a senior GPU who's got experience in being able to understand what level of competence I'm working at.

[22:19] And I think the supervision question, is it going to come to an end just because GMC coming into place?

No, the supervision element will not go anywhere.

I mean, NHS England, or even HEE, which was also known as, they have done a lot of work.

Like, for example, we have the educational environment and like the new educators in primary care PCN networks basically as multi-professional learning environments we also have the training hubs working and also they were there's been multi-professional supervision courses by the NHS England a lot of stakeholders are working hard endlessly to make sure that resources are out out there, we need to just make it more aware to everybody that there is support there and where to tap into. And it's your local training hubs as well.

The supervision is not going to go anywhere. The document that I mentioned, the core capabilities framework, supervision over time can be reduced.

So as that PA gradually works into the first year, it's a lot on support, half an hour debrief, one-to-one case-based discussions, heavily on appraisal.

But over the two, three years, that PA will be more confident and they won't be requiring half an hour debrief or that an hour in the debrief in a day.

It could reduce to 20 minutes, knock on the door or any support.

And that's a trust relationship that needs to be developed by the GP supervisor and the PA.

[23:47] Okay, that's fine. I mean, that's all good and well. So we're agreeing on that point about the need for supervision or appropriate supervision, depending on their experience.

I still can't help but think, can two years of training actually replace five years?

I mean, if it could, why do we still need five-year medical curriculum?

[24:06] There's something called redundant learning and there's a lot of repetition in many of the courses in biomedical and medicine i agree with you not everything from medical comes in use perhaps that's why the medical degree apprenticeship are introduced in less time same length i think we're moving towards modern times as well healthcare is evolving it's changing the needs of patients are changing and there's certain things that you do not require a gp tend to be like for example physiotherapists and nurses can issue sick notes now and again we're just trying to reduce the burden or workload for our GPs and try to take on support as much as we can by working collaboratively together and yeah so that's to take into consideration.

Yeah I suppose in fairness actually the GMT position has always been clear to always work within one's professional competence to be aware of where your limits are and to stay within that And I guess that just is true for doctors and no less true for physicians associates.

So I guess that's the key thing here, isn't it? That it's not like you've done five years in medical school and now you know it all.

Of course not. Even experienced, very experienced GPs still come across things all the time and consultants, I'm sure.

[25:20] Things that you just think, oh, I'm not really sure what to do here.

What's important is to know, is to recognize that and then to know where to find the right support and help to answer that question. Right?

Exactly. I would like to say, when I started a physician associate course, I did wonder patient safety a lot.

It was on my mind all the time and in post-qualification.

And then one thing I learned is that if we all strive to clinical excellence, put the self-righteous out, just pray out the window, the ego, and we have clinical consciousness is really important and work really well collaboratively with your GPs and have trust in your own ability.

We're in this profession to support patients as much as we can.

Why would we go into a role to not support them and create more obstacles and problems? We're not here to do that, clearly not.

And I do echo exactly what you just said about GMC.

It's for all of us. Okay.

[26:16] Okay, so let me try and conclude this part then, Mariam. Hopefully you'll agree with this.

First of all, I say patient safety is not necessarily compromised with physicians' associates.

There are various safeguards in place, etc. But it can be if they're not appropriately trained, regulated, supervised, and working with appropriate management structures. That's the first thing.

And I think it's fair to say that there's been some variability in terms of the the supervision and support that PAs have had.

But hopefully this should strengthen with regulation, right?

Rather than be more at risk.

Really, the argument that I'm putting forward about theoretical, you know, maybe theoretically strong, two years versus five years, but perhaps in Steve's benefit, the point he was making was, well, there isn't really the evidence to say that.

And so we can't really just go on theoretical arguments.

[27:10] How's that sound? All good. Yes. yes so now let's come on to um the other next topic which of course nobody cares at all about.

[27:21] Money well look i mean that one's an easy one to answer isn't it like at the end of the day, we know that we know the facts right you you spend 10 years or whatever as i mentioned um and even if we say that um it's an equal training like five years in medical school versus five years for a pa because three years undergraduate plus two years and then PAs are usually paid as a band 7.

Now that's around the 40k mark versus the 30k mark approximately.

So I'm looking at 23, 24 figures here.

NHS employers say that NAPA at band 7 would get 43,742. That includes various add-ons, I think, versus 32,398 by the BMA in relation to junior doctors.

Now, that does not include supplements, so, you know, in fairness.

But even so, there is a stark difference.

I mean, that's just simply wrong, isn't it?

You know, with the equivalent years, the responsibility for supervision, the larger scope, and the tougher entry. That's got to be wrong.

[28:24] I mean, this question really evidences where the anti-map mask slips a bit, right?

Are we talking about patient safety concerns and a role being dangerous without evidence?

Or are we actually hitting the crux of the matter in the fact that there is a disparity in pay?

Are we persecuting maps because of patient safety?

Or is it because doctors have been so utterly and completely let down by those who were supposed to advocate for them?

Is it in fact that they've got to a point where they are so worried that the doctors will realise how let down they've been that they're directing that rage at our profession instead of it being allowed to fall on those who caused the problem in the first place?

So are we the scapegoats for failures of organisations outside of our control?

[29:13] Wouldn't it be better to be focusing on getting rid of the atrocious quality of life that junior doctors have like I would be focusing on looking at why my juniors are being flung to Northern Ireland from the South East instead of being able to settle down and have a family in their home county so you know Like, you know, prime example, what happened this year with this rotational training? It was abhorrent.

And my negotiations wouldn't just be about money and 35%.

I'd settle for 15% if I could make sure that juniors could actually live whilst training and not have to worry and reapply for jobs that they've rightfully won every few years and get that on the table.

Then we hit the actual real issue we've seen highlighted again and again for attacking PAs. And that's the locum market that's apparently shrinking due to PAs stabilising workforces.

Every week recently, we have heard the same thing from supposed like frontline GPs that they can't get work.

It takes us five minutes every time, 2,300 jobs across the NHS in primary care for salaried posts.

And well, that's odd then. We look at their LinkedIn and it's a locum. Oh, OK.

Well, they're all they're working purely in private practice.

Or they own a private surgery. So what they're actually doing is what they actually mean is I can't get £14,000 a month anymore for working freelance and £90,000 or £125,000 for a partner.

[30:42] Working with an EH is just not enough for me.

So let's look at why that is, because I've had this thrown at me a few times now.

If PAs aren't replacing doctors, why are they squeezing the locum market?

Well, the short answer is we are force multipliers that effectively allow consultants and GPs to be aware of and manage more cases.

And then, you know, obviously through the use of qualified, skilled semi-autonomous practitioners.

And that being said, the Royal College of Sessional GPs said recently, the locum market is bigger than ever.

The problem that they've seen is that there are more locums.

So all along, it's the locums squeezing and competing for their own in market.

But once again, PAs are the punching bag and the scapegoat.

[31:26] Just a minor correction there. Steve realised he had misquoted the organisation name and asked me to let you know that it was the NASGP, National Association of Sessional GPs, that he meant to reference.

But Marion, what do you think of all of that?

So just listen to what Steve has to say again. I definitely agree.

Doctors should definitely get paid more.

[31:47] It is really sad. I have witnessed it myself when I was working in the hospital as a PA.

And I witnessed where junior doctors are getting burnt out, bless them, on late nights, on call, working ever so hard.

Also moving around across different, you know, regions and trying to get their secure and their training.

I definitely agree. I understand why they're very angry, Muneer.

One thing is to say that the doctor's career path is deeper into higher pay in the future whereas PA we are just on band seven to band eight and if you're only band eight if you're on leadership positions but we don't really progress I know PAs have been qualified for over 10 years and they're still in the band seven and which is like around probably about 44k so again I don't see really much progression for a lot of PAs and we're in the agenda for change as well so the salaries will change according to NHS every year.

One thing also I would say GP practice it's usually a doctor that makes a decision who takes whatever for a locum but then arguably you can say well PAs are taken by the ARS funding from the PCNs and it's government supported and there's a lot of inflation market and like you said at the beginning there's a lot of politics but it could go either way right Muneer?

It could yeah I guess and all of these points you're making are completely valid.

[33:09] And yeah, you're absolutely right. The point you make there about GP practices making that decision, albeit within confined budgets and certain rules that effectively make it difficult for them to be as fair as maybe seeing.

I think there is something inherently about, well, here's some ARS funding, but hey, you can't use it for your nurses or your GPs.

That's not going to go down well with nurses and GPs or those who are low-comer salaried anyway.

But one thing I want to say is that while I totally agree with Steve's point about there there being more logums in post than ever before, you know, his reference to the NASGP, I do think that the existence of other professionals does have an impact.

At the end of the day, it does boil down to demand and supply, doesn't it?

I mean, if you increase supply by the provision of alternative healthcare professionals providing care, then that is going to reduce demand on doctors and GPs, which can impact on what they're worth, what they get get paid.

And to some extent, I think that will play out. And I think it is playing out.

Now, one might try to counter that argument by saying that there's actually, lots of unmet need, and there's enough work for everybody. And I agree there is.

But there is an unlimited supply of resources. And sometimes difficult decisions have to be made based on what is the most cost effective way of getting something done.

[34:26] So really, in conclusion, given the complex responsibilities they are taking, physicians associates are not overpaid.

I think that's the first point I would make. I'm sure you'd agree, right?

Because there is a lot of responsibility still all be in a supervised capacity.

You're not being constantly supervised. And so there's a lot of risk, a lot of responsibility, a lot of hard work.

But doctors are, junior doctors, that is, are being underpaid.

Made but then there's doctors and the bma who can articulate this far better than i can so enough said and look doctors are not in this for the money yeah it could be earning a lot higher with the three a's or a stars or whatever you get in a level it's a lot of opportunities are open you can do a lot of other things but that doesn't mean that one should be taken advantage of and and that money should just be ignored it is important um you know it is doesn't make the the world go around as people say and people need to get on a property ladder at that stage in one's life as well uh you know me and so i do understand the frustration so other than pay.

[35:31] Right so yeah other than pay uh another issue that is particularly affecting junior doctors but actually it is affecting us in primary care as well is about training opportunities opportunities and and the reason i say that mariam is because the work that pas are doing is sometimes work that would have it would have been the experience that junior doctors get to develop so there's various procedures and opportunities in theater and so on where it's quite understandable why a consultant might want to have a pa there who's been there for a long time and understands and is a permanent member of the workforce but actually the junior doctors then are not getting the experience that they need.

Now, what's that going to do? That's going to mean that when those junior doctors continue in their training path, that they wouldn't have had as much experience.

And so they'll become even less capable.

And this is affecting a lot of people. You know, this is not just a few junior doctors whinging about nothing. This is a very genuine concern.

[36:32] And I say this affects primary care as well, because there's a lot of sort of subspecialization going on.

And I know chronic disease management, for example, has shifted to and various other aspects of work in primary care has shifted to particular roles.

So there's certain things that the physicians associates are doing now.

And in, you know, one could say there are certain things that clinical pharmacists are doing and etc.

And so the doctors, the GPs are simply losing the ability to do those.

And I can't remember the last time I did a diabetic review.

Why? Because it's all managed by other people. So you do start to become de-skilled.

Now, this could become a big conversation on its own. You know, does it matter?

[37:15] Are doctors discontent about anything else, or is it just a small handful of them?

This may surprise all of you to hear me say this due to the rhetoric, but I'm actually not a doctor and I can only summarize what I see in front of me.

We've just touched on some of this previously. I mean, look at the state of what's happened this year.

Juniors literally ripped from their families and flung across the country if they want to continue training.

Then we wonder why everyone's taking a gap year and going into trust grade posts or leaving the UK. okay, if it was me, I would be saying no as well.

And making doctors reapply for jobs they've well earned throughout their education is just distasteful.

Like pulling them away from their families and support networks and then putting them in trust that potentially have like shocking records of bullying and then have no support for them. Like this is how tragedies happen.

And we need to figure out how we fix this for them.

It like personally breaks my heart every four months when I lose the friends I've made in the junior doctor's team and see them go through so much pain and anguish.

It honestly kills me a little bit.

[38:26] And you have doctors now even struggle to find trainers in their own medical teams for procedures.

And luckily, we're able to teach them now things like lumbar punctures and ultrasound-guided cannulas, drains, taps, et cetera, because we've accrued these skills within the profession and we're always there.

But the point still stands the anti-map movement needs to wake up and stop bullying us and start concentrate on concentrating on getting more than just money for these people like by eradicating us you're about to seriously harm

[38:58] the little inward training uh prospects that they have left and there's another point though like gp funding what on earth was was that about this year like i do do not fully understand it.

[39:12] But if you're having a growing population with growing medical needs, then what on earth are you doing by causing real term cuts in funding like UMAPs, you know, the physician associates, etc, will happily stand by our GP colleagues to help them deal with this.

And you know, what's going to compound this is, so they lose all the help that we can give them, and then have to rely again on expensive locums they can't afford.

And that's the reason why some partners have not been able to get paid and take a salary. And that disgusts me, really, considering how hard they work.

You know, we've had to take advice from ACAS and we've had to instruct our own legal team.

It's obviously a significant step in becoming a union, but we're going to have to open up all options of recourse for those that have caused detriment to our members. members.

It's a step that's been forced on us with these redundancies and constructive dismissals that are completely unfair on our members.

[40:14] I used to work as a locum before. You know, I did it all over the country for a couple of years, and I really enjoyed it.

And yeah, it's true. It was well paid.

But then on the other hand, you know, it really was a case of helping out practices when they really, really needed that help.

You know, saving them, being there to the rescue. And they certainly appreciated it.

So yeah, but I do agree. It does cost practices a lot of money.

[40:39] Anyway, what's next? So the next question, professional identity.

Concerns that professional identity is getting blurred or could get blurred between a PA and a doctor.

What do you think, Muneer? you well this is one where i personally as an individual i'm not overly overly concerned about it at this stage in the short term i don't know what's going to happen in the medium or long term, but at this stage the this is a really important question actually that that has to be considered, i i think in terms of whether professional identity is actually getting blurred in the minds of the health professionals themselves and their organizations i think the answer is no all.

[41:25] Is there some confusion about an overlap or uncertainty when it comes to patients coming to see somebody? Yes.

I think that is a concern. If a patient comes to see you and they don't know whether they're seeing a doctor or a PA or a clinical pharmacist or an FCP or some other role, I think that is an issue because what that can do is potentially jeopardize patient trust.

It can diminish trust in all professions or whichever professions that refers to.

Because the patients don't know who they're consulting.

[41:56] Some people have made the case that the fact that the GMC is regulating, going to regulate PAs, that might add to the blurring.

I don't know. I'm not so convinced about that argument. But perhaps there are people who are more aware and in tune with this particular risk.

I don't see that because I don't think patients necessarily come and say, are you on the GMC?

They don't check your GMC status, but perhaps more of them are checking it now than before.

They just want to have their medical problems addressed.

But you know there is something about protecting your fall isn't there mariam look at the end of the day doctors have had a unique position we have right and you know we don't want to lose that and and actually you know something isn't that what any professional would do is you know that's what professions do we we should defend our profession um you know it is incredibly hard is it not true you know to become a doctor and then the daily really long hours and the risks risks being taken and the training that the rigorous training and in fairness and I don't say this because I'm a doctor but don't doctors deserve the status they receive, because if not they'll take up other careers.

[43:05] Yeah, it would be dangerous if that happened, if identity does get blurred, and it would be unfair, and it would be wrong.

And it would be wrong for the, you know, be unfair for the public and patients.

It would lead to loss of confidence as well. That's the thing, because if the public don't trust us, then they're not going to come and consult us and present to us when they should.

And that could lead to poorer health outcomes as well. I definitely agree with you, Munir. I mean, and you're right.

They do deserve to protect their identity. They worked ever so hard.

[43:37] But PAs are trained on the medical model, but doesn't mean that we are doctors.

We are physician associates. We're healthcare professionals.

We're just adding a different flavor to the MDT mix.

And the thing is, I mean, so there are other regulators, such as the General Dental Council.

They have whole of the dental team which includes the dentist and nurses part of their regulator and then you've got the in the UK NMC with the whole nursing team and the midwifery team and nursing associates but if you look at other countries like Australia they have all professional groups under one regulator so the question is I mean just because we're part of the GMC does Does that mean we're doctors? No, it doesn't.

Also, as physician associates, our registration number will have an alphabet starting with an A, where a doctor's registration number is with numbers.

And then also, they've also put out some quite a lot of guidance on their website as well as worthwhile read for all the employees as well in primary care.

And I think most patients have not heard of GMC.

So just put them aside. Most importantly, I think we need to introduce ourselves as who we are, physician associates.

[44:55] Do you know previously mentioned that there's medical students with previous backgrounds or qualifications or multiple BSEs? Same goes for PAs.

There are PAs with PhDs and multiple BSEs and they also, they've got the doctor title and the FBA have released a document and they made it very clear that if you're a PA who has a PhD doctorate title, we cannot use that in clinical practice okay so this helps to not blur the lines and not mislead the public so you can use a doctor title in your research or what you like to do outside your pa professional but in-house it should be physician associate mariam that's my role got it um and that's how it should be introduced um and again that's all on fpa if anyone would like to read on that and interestingly i was was reading the other day there was one case a PA has said my name is xyz I'm a physician associate but I'm not a doctor and that's how we're introducing ourselves really gosh yes honestly.

[46:04] And that's how it is on our document on the FPA okay and the patients are like why are you telling I think it's because you're not a doctor.

Because of the confusion. Right, okay. So let me ask you, would you want to be called a doctor? What would your answer be to that?

No, because I'm not. I went into the Physician Associate career knowing I'm a PA to support the doctors and help them.

I'm not here to be a, if I wanted to be a doctor, I'd just go and do the five-year training and go on through that path.

But I chose this path because I was more passionate, more patient contact.

I was a radiographer prior to this in oncology and I know what I got myself into and I do not want to be a doctor and that's a respect for my seniors to have that title. And that's how I see it from that perspective.

[46:55] Quite frankly, this whole argument about not being able to be called Mr.

Or Miss, etc., is actually just classist nonsense.

I don't know how many times I've had to correct a patient who refers to my senior female registrar as the nurse.

And we must remember that patients are engaged in our world at their darkest times and not always in a receptive area for taking on information, regardless of how many times that patient's been told she's not the nurse, she's the doctor.

She still gets called it and if we're worried about that then we need to think about the whole workforce the role has been around for 20 years there's this period of education required for patients that's been shall we say slow going and definitely needs improvement, medicine is obviously a unique profession and it has this you know rectangular funnel that professionals flow through to the point of completion at the top and and becoming a consultant.

Only at the consultant level is there supposed to be a pyramid where they work through their respective colleges or managerial positions, for instance.

And no other profession has this. No other profession has a guaranteed spot as the CEO.

[48:12] Every other hierarchy in life is pyramidical because of this, you end up with rotational workforce of trainees for eight years.

And there's no natural service provision in a rectangular funnel that doesn't interfere interfere with their training in this model.

So, at the request of doctors 20 years ago, along comes the MAPS to provide that service provision and MAPS have a shared skill set with doctors for this very reason.

Our CPD is all written for medical doctors and that's what enables us to provide stability and cross train through those coming through.

Anyone who wants to be a doctor should study medicine. Anyone who wants to be a MAPS should go study PA studies or become an AA.

Okay thanks for that steve um bpas we have incredible respect for doctors including myself um but however the tension that is going on between the pas and doctors.

[49:01] If a somebody was to ask a pa do you want to be called a doctor it does add fuel to the fire and that's just sort of what would happen and i understand both perspective but yes Yes. So let's wrap this up.

So do PAs want to be called doctors? No, we don't want to be called doctors because there's a risk of that. Yes. Sure.

And in terms of professional identity getting blurred?

So time will tell, but we can't say issue is being ignored.

Okay. Right. Okay.

[49:36] The next topic, are PAs being blamed for this and are they the victim rather than the winner?

[49:44] Hmm i know the answer to this what do you think again whoa hang on hang on hang on victim the the pa profession is winning here isn't it i mean like they're getting something right their roles are developing decent starting salary regulation which is going to strengthen right it's going to strengthen that role further surely they're getting something big out of this and the doctors are the ones who are losing out or at least i can understand why doctors may feel that they're losing out but victim why do you say that well before jumping to conclusions mania there have been a lot of nasty texts in social medias where there's been um name and shame has happened on social media death threats as previously mentioned personal identities have been revealed wait did they have actually been death threats yes there definitely have been anonymous death threats to individuals and it's really sad with what's going on and And do you know, in one particular region in a local borough, seven out of nine PAs are on sick leave for mental health.

There's a lot of things going on recently. There's been concerns of bullying and harassment in departments.

[50:54] And there's been a lot of toxicity towards PAs. Now, some will say, well, PAs should not take it personal.

But look, when I finish my clinic at the end of the day, I go through my phone.

There's so much negativity and toxicity. And it does get to you.

It does bring you down. and it does make you feel doubtful of like you know double cross-checking it does knock your confidence you don't understand how thorough i have been and staying late end of my clinks by end of the day and it does impact you and there are pas who have come back from maternity some people stepping down and and i'm sure steve will go into quite a lot of more detail on this um fair enough i all right well i apologize for that insensitivity then no i didn't realize actually because yeah I mean doctors have a lot of reasons to be concerned but blaming PAs or aggressiveness towards them or the other way around of course as well I mean it's simply not acceptable.

[51:46] Look, Mariam, we've done episodes together, right? And we're proud of our professions and we defend our profession, right?

I think less of you, Mariam, if you didn't defend PAs.

But it's not a reason for anyone to get aggressive over these sorts of issues.

No, I agree. Well, let's see what Steve, because Steve would know more about, isn't it? Let's see what he has to say. But Maneer is just doing what's right.

And we should be mature adults as professionals and be able to give constructive feedback, criticisms, rather than throwing personal digs.

And I think if this was happening to a doctor, I would speak up.

If it was happening to a nurse, I'll speak up.

And I thought we're moving away from this negative culture, toxic environment.

And it's not acceptable, I'm afraid.

Well, you've listened to Steve's response, isn't it? So yeah, I'd be interested to hear that. Steve's response is also part of a survey and I have read responses across a lot of physician associates out there.

I didn't realize it was that deep-rooted.

So guys and Munir, you should listen to what Steve has to say and we'll save that for the second half.

[52:57] When I heard what Steve had to say about that, I was totally shocked.

Now, just to point out that various statements have been made throughout this episode, and as always, you can access references through the show notes.

In the second half, we ask again, are physicians associates replacing doctors, or other professions indeed?

And importantly, what is it that each of us can do or should be doing about the various issues that we've discussed?

We'll also be asking various doctors' organisations if they want to comment on this topic as well.

[53:30] And now it's over to you guys. So are Physicians Associates replacing doctors?

I'm not sure I'm any better equipped to answer that question than any of you are listening.

Is this just a handful of doctors making a fuss over nothing?

Or is there some genuine concern there?

And you can do that on social media. And you can also do that on our website, primarykuk.org. and a link to all of this is provided in the show notes.

And I'll be making sure I read every single response and incorporate these points when responding in the second half of this discussion.

So thanks for listening, guys. That's it. Do join us for the next podcast for the continued discussion.

A lot more interesting topics to be discussed.

As well as that, we're also going to get more NHS related news coming up.

That's going to be be presented by our colleagues Emma and Simon in the southwest of the country, and also a mini series about genomics, what we all need to know.

Finally, we try very hard to make these episodes as relevant and useful to you as we possibly can.

But how are we doing? Do you gain something out of these? Can you connect with them?

Please do let us know on Apple and comment and rate us, or on Spotify, because that is what keeps us going.

See you next time. Keep well and keep safe.

[54:46] Music.

[55:10] Primary Care UK was developed by Therapeutic Reflections Limited to.

[55:14] Music.