E38 Are PAs replacing Drs (Part 2)

This transcript is AI-generated and will contain errors!

Are PA's the victim, or are they the winners?

Munir: Welcome back to primary care uk the podcast for all healthcare professionals working in primary care and across the nhs It's Munir Adam here and we're going to be continuing the second half of our feature topic Are physician associates replacing? Doctors. 

Now, needless to say, if you haven't already done so, do have a listen to the first half where we discussed important issues such as is patient's safety being compromised? And what about the difference in pay between PAs and doctors? And issues such as whether professional identity was getting blurred or not. And we ended that episode by asking the question, Are PAs the winners in this struggle, if you like? Or are they, in fact, the victims? and [00:02:00] What would we know? So we asked you that question through a poll, and we'll go through the results of that later on as well.

Marium: Hi guys, I'm Maryam Hanif and I'm a physician associate. So in this second half we'll be sharing our views on what each of us could be doing to make a difference for the better. We will also have some advice for the PAs and the doctors, and before that, we had Stephen Nash response to that question, Are PAs victims or winners?

And Steve is a PA, and he's a founding member of the United Medical Associate Professionals.

Munir: Now, to try and make this as representative as possible and as comprehensive as possible, we did ask for any input from the General Medical Council, from the Royal College of General Practitioners, from the British Medical Association, and from Association uk. We mainly got redirected to recent published [00:03:00] material on this with advice and guidance on how to proceed with this issue. And of course, we will provide links to this in the show notes and we make reference to it and we have reviewed it. 

The purpose of this is to educate like it is with all of the episodes that we publish on Primary Care uk. It is about reaching out to the frontline and educating and discussing important topics.

It's not about politics We're not politicians and this is less targeting large organizations and much more about reaching out to the busy frontline people working in primary care who want to find out more about this topic But that said There are strong feelings about this out there, and there are some strong opinions, and they will be expressed, and some people might find this disturbing, so do be warned if you're in that category.

If you're listening to the audio version of this, then just to let you know that much like the last episode, there is a video version that you may want to check out on YouTube as well.

Marium: Okay, so let's continue and hear Steve's response. 

Stephen Nash: Are PAs [00:04:00] being blamed for the concerns of the medical profession? Are they the victim or are they the winner? I think I'd like to expand this a little bit here, if I may, to provide some context to what's happened over the last two years. So two years ago an organization formed, and they used the promise of full pay restoration and revival of the, the medical hierarchy from the 60s to ignite this, this populist voting bloc.

 They then declassified a document explaining why their followers should attack ANPs, PAs, AAs, ACPs, and other advanced practitioners, as they were essentially attacked threat to the wealth of doctors, and they've set up these splinter groups and have manufactured the anti MAP campaign across all of the medical faculties, primary and secondary care. 

Over the last year, we've seen a myriad of horrendous occult behavior aimed at MAPs, and despite identifying AMP and ACP as a threat.

They've [00:05:00] until recently carefully managed the generated rage against MAPs, for fear of provoking the nursing and paramedic unions. Um, before they finished dealing with MAPs and frankly, what we've seen over the last year has been a demonstration of the worst, most overt and coordinated bullying campaign the NHS has ever seen.

You know, supposed esteemed colleagues, friends, and professionals have turned on the profession online, sometimes behind anonymous accounts or multiple accounts without evidence, and have manufactured the anti MAP movement to the point where That is now causing significant harm to students and professional MAPs.

 We've seen organized social media disinformation groups to dox and harass any pro PA members of the medical community, shut down any alternative narrative to that which they wanted to peddle.

Um, you know, attempts to threaten and coerce members of senior medical bodies, representatives being told to commit [00:06:00] suicide, finding out where PAs work online and submitting these spurious complaints and leaning on employers to let them go. You know, discussions online where they brainstorm how to undermine MAPs in the workplace so they can weaponize referrals to their employer.

You know, how to bully PA students in the workplace, to deny them opportunities to learn and to try and make them quit the profession. Like we've seen the real impact of this multiple times recently, and the publication of private data to initiate pylons. 

 You know, prime example of, um, of this was when, um, an anti MAP organization, shall we say, discovered that I'd set up new MAPs. Um, they tried to do a deep dive on me. An expose was written by the co chair who then posted it to Twitter. It talks about my employment history and made accusations that I'd committed crimes. It was taken down within 12 hours. Partially, but, um, but not before thousands of followers had seen it and anonymous posters had attacked me. Um, and this [00:07:00] pattern was repeated across all of the FPA hierarchy has been actively done to members of the RCP currently. Obviously it's designed to eradicate the abilities, uh, for PAs to support GPs and consultants in the workplace, like take from that what you will. 

And then to cap it off, you have this new rhetoric that MAPs, which have an exponentially more diverse ethnic and cultural membership, are part of a racist ideology being inflected on I. M. G. S. Like physicians online have literally said we're throw back to colonialism and the abuse of power, power status and hierarchy is absolutely striking.

It, it, it, it reeks. And as an organization, we've had to issue warnings to stakeholders across the medical profession that we're going to see a fatality on our workforce if this is allowed to continue. Um, we are already aware of incidents that are pretty worrying that have, having occurred.

Um, [00:08:00] you know, we conducted a survey of our workforce in February as to the impact of current climate on our MAPs. And the take home findings were as, you know, as follows, you know, 91 percent of the workforce is struggling with their mental health. 81 percent are considering actively leaving the profession.

75 percent have had workplace and home life effective. 57 percent are treated differently by their colleagues. You know, those are just headlines. There were hundreds of free text examples of incidents of harm occurring to MAPs and web. PAs have had to battle to protect patients who are very unwell from doctors blocking their investigations or treatment plans because it was a PA trying to refer or to ask for a prescription.

We've had PAs admitted due to the effect of this bullying. You know, we've, we've had students replied to the professional members survey and the reports were so harrowing we've now had to start our own student welfare survey. 

You know, if this is winning, you can have it.

Munir: Wow, this is serious [00:09:00] stuff. I mean, 81 percent are thinking of leaving the profession. Look, Mary, I'm listening to this, I mean, it's very obvious that Steve's had quite a tough journey with all of, you know, his experience, his personal experiences, and perhaps what he's been aware of. But, is it all true? I mean, are all PAs feeling this way?

Marium: So after just listening to what Steve has to say, I would like to emphasizing the importance of kindness. Resorting to bullying is never justified. And As we all know, there was a recent incident and a doctor, Dr. Kumar, she tragically took her own life in the Midlands due to a toxic hospital culture.

And we don't want this to repeatedly happen in other organizations, whether it's to doctors or PAs or other professionals, it shouldn't happen. And it's really sad. In relation to, Steve comments, I have come across something similar. I have seen some memes and comments being made. [00:10:00] And. We see it day in and out as a PA.

one may argue against the validity, um, favoring their perspective over Steve's. So we should be open to the counter arguments.

Munir: Hmm. Okay. Yes. No, you're absolutely right. And, we don't want to be too political and make this too much of a debate between extreme views at all. 

Marium: So guys. With Steve permission, we have edited references to organization in this episode and Steve, other responses, because they're not suitable for the podcast, but however, these events and experiences are real. some peers are feeling this way is actually a concern for all of us as well.

Munir: Yes. I agree with you that, I knew that doctors are having it tough, you know, being a doctor myself, And they are having it tough, and it's quite a tragic example you just mentioned. But what I'm hearing from you, Marium, is that PAs are not having it easy either. 

Are PAs replacing Drs? 

[00:11:00] 

Munir: Well, look, I'm certainly not condoning any of this kind of behaviour, but it does bring to the centre the key question of, that this podcast has been named on as well, which is are PAs replacing doctors?

Uh, because if that is a perception or what people feel is a threat, maybe that might at least account for some of the reactions that we're seeing out there. And we touched on this a little bit in the first episode, didn't we? When we talked about lost opportunities in training, for example. And it's a really important question.

In fact, it's so important we did the poll on that. and we'd be sharing the results of that soon as well. My view as a doctor is that there is at least some truth in that. Wouldn't you agree?

Marium: Plus, I wouldn't know many if I'm honest with you. it's just because we heard a lot of feedback, but there's no evidence there or research has been done. And again, [00:12:00] it's been 20 years and it would be good to have NHS or one of the organization to look into this because feedback has been there. Doctors are saying that, there's lack of opportunities for the training.

They're frustrated. So ideally somebody from a leadership position really needs to investigate that , but however, what I do know, there's never enough doctors, which means there's plenty of work for everyone.  NHS juggles to get more doctors and nurses.

And I don't think anyone will deny that. Um, so more staff, uh, better for the patients. Also, the average waiting time for a GP appointment is two to four weeks. Again, that's because of shortage of staff. And although NHS is introducing same day emergency appointments, and access, improving access for patients, um, and enhanced access as well, and evenings and weekends, you need staff for that.

And when there was a scarlet fever, or the pandemic, not many GPs or clinicians were out there. There was always shortage of staff. And we're always resorting to recruit internationally and try to [00:13:00] open those vacancies available as well because we're desperate,

Munir: I do agree that in terms of there being a shortage of doctors, I think everybody is aware of that and can see that. Um, and you need more doctors and you need more doctor hours, some I argue. Doctors seem to want to be working far fewer hours now.

Surveys of junior doctors, for example, show that they want to work much less now than they did in previous generations, if you like, and want to have a bit more of a work life balance. And why shouldn't they, right? But this is not something our predecessors did. Certainly not in primary care. You know, when you were a GP, you were the 24 7 on call person.

So, yeah, now with less hours, somebody's got to do the work. That said though, and I do want to go back about the point on demand and supply, which I mentioned in part one as well. That at the end of the day, PAs are taking over some work that GPs and hospital doctors did. And as such, those who are [00:14:00] making decisions about who to employ or who to give work to are making decisions to give that work to others and not necessarily doctors.

And as a result of that, the demand for doctors go down. Less demand, means less negotiating power. Because you see, yes, there is endless work. or at least how it would seem. There seems to be more work than any of us, all of us put together. We're still not going to be able to cover all patient needs.

But resources are not endless and sometimes those difficult decisions have to be made. So I think some doctors, they are seeing that play out now with, with, with less ability to negotiate than perhaps historically.

Marium: maybe. But, I would like to say doctors do have a clear path. to specialize, and PAs don't. So it's not so easy for PA, and I mentioned this in the previous episode as well, um, where doctors have a steeper pay progression, PAs don't. There's a lot more for doctors than, um, PAs to [00:15:00] do. And also, um, if you compare the ratio, there's a lot more doctors than PAs.

But in the whole, I very much doubt that PA would replace doctors. Um, and that's not why we came into healthcare. Certainly I didn't. I didn't come in to say, Oh, I'm going to replace a doctor. And all of a sudden after two years, I am a doctor.

It doesn't work like that, I'm afraid. Um, Steve comments backs me on this. So let's hear what he's got to say. 

Stephen Nash: So RPAs replacing doctors?

I think, my thoughts on this have been evidenced throughout really. MAPs are a supplementary, highly skilled, highly educated, semi autonomous force multiplier for consultants and general practitioners. We help the entire multidisciplinary team and look after patients as part of a shared responsibility with our medical or surgical colleagues.

Marium: So you see guys, we are a force multiplier, , and again emphasising the importance of working together, part of a MDT, [00:16:00] to look after patients and to have shared responsibility. So Munir, what does your poll show?

Munir: hmm. 

So in terms of the question, are physicians associates taking over doctors or replacing doctors, the responses showed that 9. 2 percent strongly agreed and 6. 2 percent partly agreed. So as a total of approximately 15 percent or 15. 4%, which do agree that physicians associates are replacing doctors. That leaves approximately 85 percent who believe that they are. They don't. 

Of this, 9. 2 percent partly disagree and 75. 4 percent strongly disagree. So overall we have about 85 percent that would say no, that's not the case. 15 percent approximately saying that this is the case. 

Now, it's interesting to then look at the respondents and how many were from each profession. And the responses are [00:17:00] 15 percent or 15. 3 percent were doctors, 69. 5 percent were physicians associates, and 15. 3 percent were others. And when I say others, almost all were allied health professionals. of one form or another. Now that is interesting. I think it's fair to say that as a team we have access to far more doctors than we do physicians associates.

So if anything, we would have expected a lot more responses from doctors. Uh, I'll let, I'll let you reach your own conclusions about that. But it does seem that the PAs were more keen to respond to this and make the point, whatever their point was, but overall very much in favor of physicians associates not taking over doctors. 

Thousands of doctors had an opportunity to respond to this, as did PAs. So, uh, we're going to go with these results. There we are. 

Marium: So well, it's [00:18:00] interesting to know how people feel about this. My conclusion on this topic is that even though there is some truth in the matter, currently we have 4, 000, even it goes to 10, 000 in the next couple of years. We're very small group of physician associates and doctors have much more important things to focus on.

The workload will still always remain there, but never enough doctors.

Munir: Yeah a fair point 

What if you're not a Dr or a PA?

Munir: Marium. I want to move on to another point now This is the issue about the other health professionals. But what does this mean for other health professionals out there?

 How much do you think they can relate to that? 

Marium: So, Munir, you probably know a lot more, um, because you've got various roles, um, but I also can share Steve's response if you'd like to hear that.

Munir: Yeah, let's hear it.

Stephen Nash: This debate is about doctor versus PA, but does this impact other professions?

I actually [00:19:00] disagree that this is a doctor versus PA debate. My colleagues are absolutely abhorred at the treatment of MAPS. 

. As far as UMAPS is concerned, this is the MDT versus extremists. And we've seen recently that the leaders of this attack are desperately trying to keep control of the attack on MAPS.

But it's. Already spreading against pharmacists, nurses, physios, and paramedics. You know, Pandora's box is open and it is now only a matter of time. Um, and the time to stand up and be counted to say no to this unacceptable behavior is now before harm is done or behavior becomes accepted as the norm again, within medicine.

Um, even in the last few days, the nursing bodies and reps have asked organizations, Anti MAP organizations for clarification, which they haven't been getting. Um, and there's a real issue there that the relationships built, uh, across the MDT over the last 20 years are about to be [00:20:00] completely torched.

The moderate caring and fantastic doctors that have abstained until now need to stand up and speak up because otherwise this is going to get a lot worse.

Marium: Right, so there's some really strong feelings out there. Attacks, there are some extremes as Steve put it. What do you think, Munir?

Munir: don't know what to say. I mean, this is, this is terrible. , and I sincerely hope that this is a small, a very small minority of doctors who fall in that category. But Marium, okay, that's one perspective, but I don't think it's the whole picture. It's not necessarily always you know, doctors or extremist doctors versus everybody else.

Sometimes it's more, um, how can I put it, the traditional roles versus the newer roles. [00:21:00] Like it may be that doctors and nurses, because they've been in these roles for a long time, they might feel threatened by the newer roles as a whole group, perhaps 

this issue came up, in fact, in the burnout episode. One of the nurses mentioned about this as well, that there are nurses out there who do feel a little bit threatened or a little bit uncomfortable that the things that they did are now being taken over by others. Uh, certainly in primary care that's happening.

So extremists aside, even the moderates, if I can describe most of us in that, with that term. , all of the moderates are not necessarily euphoric about this. I don't come across lots of doctors and nurses saying, Hey, we're so excited that we've got these new roles now and they're going to take some of the work away from us.

Now look, I'm not a nurse and nurses have worked very hard to establish themselves in primary care over a few decades. They've developed their roles, their identities much clearer. Certainly, the position primary care is, that's what I would know, but also they've developed their roles in secondary care as well.

[00:22:00] And now they've got competition. And you know something, I wonder whether there's even some tension between the different allied health professionals in that sense as well. Because the responsibilities are not mutually exclusive necessarily, 

Mariam, let me just be clear. I'm not saying that the new roles are not welcome at all. In fact, Primary Care UK exists to harness the benefit of having a multi professional workforce. It's there so that we can work together, we can learn together, and I very much welcome that. But, these feelings and possibly experiences do exist, and they need to be acknowledged.

They need to be discussed by large organizations, they need to be discussed by small organizations, they should be discussed in, um, you know, health professionals appraisals, um, and they need to be understood by all of us so that we can relate to each other more effectively. 

 Enough said. We haven't got those other [00:23:00] representatives from other professionals here, so we probably can't spend too much time discussing this issue. And anyway, it's not really the purpose of this episode as such. Um 

Marium: you are Munir 

How can each of us help resolve these issues?

Marium: So now let's move on . So how do we resolve these issues? And I would like to start with Steve's response, if I may.

Stephen Nash: How do we resolve the issues? I

think it needs to come back to doctors saying, not in my name, um, MAPs need to focus on healing and rebuilding the infrastructure within their profession and to improve standards, uh, and recapture this honor that they've had stripped of them. Uh, only then really can we start to rebuild that symbiotic relationship with colleagues, providing, uh, there's been a groundswell of honest doctors putting to bed this bullying campaign.

Regarding doctors quality of life, the stakeholders that [00:24:00] have let them down need to get their house in order. If doctors had been looked after, then there would not be mass outpouring of rage against a minority profession. The mortality rate of trainees would not be so high, and the NHS would not be falling over from doctors leaving.

Um There also needs to be recognition that the 4, 200 MAPs in the UK versus the 188, 000 doctors in the NHS are not the source of their issues. And they should reflect on this and recognize the solution to their concerns is actually much closer to home. Um, and we will support our medical colleagues, but they need to stop kicking the dog.

Munir: Okay, well, thanks for sharing this, Marium. So, uh, Steve puts this in a kind of, put your house in order first, sort of response. And, um, yeah, by [00:25:00] the way, I totally agree with this sentiment, you know, um, that doctors should be looked after. Uh, doctors should be looked after. Yeah, totally. Wise words from Steve there.

You know, I think some people, when they hear what he said, they're going to interpret it negatively. And they're going to think that, well, Steve is just passing the blame on to the doctors. You've created the mess, you sort it out. 

But I, I look at it differently. I see that as being empowering. I, what I'm hearing from this, is PA is saying, uh, look, you've got some control there. You know the system better. You've been there a long time. Some of, there are some internal issues within the profession that need to be addressed before the relationship with the other professions can be improved.

And, it conveys a bit of trust. Like, you're not going to say to anybody, do something, unless you've got some trust that they're going to be able to do it. So that's my take on this.

[00:26:00] But look, Mariam, first of all, it's, the way I see it, it's not our job to solve this. And it's neither is it within our power to do it. To some extent, it does depend on bigger entities out there. .

And it is about what large organizations need to be doing, um, and are doing and, uh, I would just again, once again, refer back to the statements. That being produced by the Royal College of GPs and so on, explaining what needs to be done. .

And then of course there's the GMC survey as well, um, which, is active now, right now. The GMC is looking for feedback on this and there's a consultation going on that people can respond to.

Marium: I kind of disagree with you when you said first, it's not our job to solve this. I think as doctors, you senior leadership roles, you have a voice in many different organizations, is really important that you find some sort of working together collaboratively with stakeholders to resolve the issue.

Because if [00:27:00] it's not yourself, then who will be resolving this? 

And I think being a advocate for both roles is really a responsibility for everyone, I think, in my perspective.

Munir: Oh, yeah, and to some extent I do agree with that, that there are people out there who have the ability to influence and make a difference and should do. I think the reality right now is that a lot of doctors are, for example, a lot of low incomes are finding it difficult to get a job um, salary job, doctors often feel that their work's off their feet and so on and, and may well feel very helpless about this. 

But in, in common with the point that you're making, I, I would like to say that, and with all episodes in this series, it's always about what can we do?

What can each of us do? And it does make sense to focus on our circle of influence and our circle of control. And I've got some thoughts about that, my own thoughts that I've, I'm happy to share some of the thoughts and really listen to what you think as well. What do you think? Shall we do that?

Marium: Yeah, go for it.

>Focus on problems not people

[00:28:00] 

Munir: made some notes here, right? So the first bit, um, yeah, of course, the first thing is don't blame each other. Now it sounds obvious. And, look, at the end of the day, doctors are doing this job for patient care. PAs are doing this for patient care. We're all doing it with the same sort of goals of improving the health of the population. We don't have to be each other's enemies to do that. And there are, of course, wonderful examples of how it's done really well in other places as well, 

as, as negotiators would put it, focus on the problems, not the people. Thank you. Does that make

Marium: yeah,

I, I definitely agree with that. And I think when you're focusing on people, then it will start to impact patient care and bring a lot of toxic energy, which nobody would want in the organization, , . And I think if we look at examples like the Francis report and basically it was poor collaborations amongst the multi professionals and leadership and people were not [00:29:00] coming forward. And it was a lot of blame game and scapegoating . So we want to move away from that.

Munir: Yeah, absolutely. 

>Recognising each other's contributions

Munir: Uh, the next point is to understand and value each other's contributions at work. Now, that might sound like a really obvious thing to say, but I bet you, Mariam, out there, if you ask, most people are, a substantial proportion won't actually know much about the other professions and what they can and can't do. So there is definitely a need for education there. And in fact, I realized this a long time ago and was fortunate enough to have a team of different professions contributing towards one of our recent episodes, which was called Workforce transformation in primary care, and it was led by, do you know, Rachel Roberts, the

primary care dean for London? 

Marium: Mm hmm.

Munir: So she led this, and we had some great contributions and thoughts. The burnout episode in season one, again, it had different contributions, and these, these are ways of [00:30:00] understanding each other, uh, the different professions and work, and so we can work better, more collaboratively, as you say.

Marium: Um, interestingly, you said that. The other day I read a post and it was by a doctor saying, I still dunno what PA would bring to an MDT in a diabetes. Um, MDT.

Munir: really? Yeah.

Marium: said that, and I understand the nurse, but what can a PA do again, it is just in the lack of understanding where PA role a PAs wouldn't role is no different to an advanced nurse practitioner.

Some PAs are specializing in diabetes and it's a big statement to make because you're looking down at your colleague and it's not

Munir: Um, and actually, if you don't welcome other people, then you won't know. It's prejudging, isn't it, really? That's the problem.

>Face the challenge

Munir: My next point is to acknowledge that these concerns exist. So, and these feelings. So on the one hand, you've got people who are very, very [00:31:00] political and kick a great fuss about these issues. On the other end, there are a lot of frontline professionals because we're so busy that we just don't want to know.

 We want to pretend everything's perfectly normal. And, I'm afraid that's not going to work. I mean, that's fine. If you can guarantee that you're going to be neutral, you can guarantee that you're not being influenced at some level, at some subconscious level. Not producing biases and prejudices, etc. But that's just not the reality, isn't it? And so if we're going to form a view, at least let it be an informed view. So if doctors understand what it's like for PAs about how vulnerable they feel and some of the experiences that you shared and Steve shared, then that will help us relate better to PAs.

And as for PAs, um, it's useful, I think, for PAs to try to understand what it's like for doctors, um, and perhaps for nurses who may feel threatened. Um, particularly junior doctors who have really worked and now aren't always getting the [00:32:00] best, may understandably see some of these roles as being threatening to their existence. And I think it's really important, going back to something you said earlier, about people in managerial positions. I think there's a very important responsibility for them to make sure that they show each individual of different, of individual professions. That you do matter, that we do value you as well, and your contributions and your unique contributions. How does that sound?

Marium: So there's two things here. One of my PCN manager once said to me. Why are you just not a advanced nurse practitioner? Why are you a PA? Like, why can't we not just say you're, and again, lack of understanding of the role and even management will not understand. So again, there's a lot of education that needs to be out there, workshops informing all management and leadership and doctors, everybody really, to explain what a PA role is. 

As in for vulnerability. I don't know if you watched the [00:33:00] episode online, Munir, when the House of Parliaments, when they were trying to push forward for the regulation for the PA. It was a huge debate. And what happened was, um, they gave one of the examples of pharmacists, clinical pharmacists, when they wanted to increase their responsibilities in local pharmacy, where pharmacists would start to examine and treat minor, Uh, 

Uh, minor 

illnesses, yeah.

So, but what ultimately led a lot of backlash in the last years, where they're saying that pharmacists should not be doing this, pharmacists should not be introducing antibiotics, pharmacists do not, should not be doing examinations. So, what they're saying is that Now they are doing it, but what this led is, they knocked off their confidence in doing so, and that anxiety, so now when patients do go to the pharmacist, I've had a few patients saying, yeah, I did see the pharmacist examine my ear, they suspect I've got an ear infection, but they said go speak to the GP about antibiotics starting.

Munir: [00:34:00] Ah,

Marium: quite a lot. Yeah. I said, why did they not start antibiotics? I said, no, they wouldn't. I think we have to be very careful in what we say. There's no, Peer reviewed evidence on comparison and what we're doing. And I think it's really, um, important to have, have that looked into.

Munir: mm. That's quite unfortunate, isn't it, really? Unintended consequences, probably arising from the wrong attitudes towards the other professions. Pharmacists, as you mentioned. 

>Beware of biases

Munir: , The next point I've got here is about, Uh, looking at things in the right context and avoiding pre set biases. Because we're all vulnerable to biases, really.

I think it's better to accept that and deal with it than it is to try and pretend that we're not. I just want to use an example, if I may. So, years ago, when I used to, uh, you know, go with people driving more, and when you'd have a car, somebody in front of you, and they do some, a silly mistake, like maybe don't indicate, or sometimes just going too [00:35:00] slow, And you see it's a, a female driver, and then, and then the guy with me would often say things like, Ah, women drivers. The thing is, you know, that if the person in front is a man, who made that mistake, they'd probably say, Oh, he's having a bad day. So, I think that, and by the way, women are just as guilty of making these kind of biases and these kind of comments. It's not just men. But I thought it was safer for me to use one where the man's making the mistake.

But the point here being, and if you're dealing with PAs, for example, then if a mistake has been made or something didn't go right or it's very easy to say, oh, because it's a PA. It's a PA. rather than saying because this is a specific individual who may happen to be a PA. And what would make more sense in that situation is to take each person as an individual.

What are their learning needs? You know, what went wrong? And of course, quite importantly, what are the system factors that may have contributed to this? 

Marium: So [00:36:00] as humans, we all have the habit of having some biases and stereotypical thoughts about anybody, like anybody walking through the room and we'll just start, like, you know, start judging them and not realizing, but I think We should be able to critically evaluate each scenario before jumping to conclusions.

So for example, whatever's in the media, whatever's in Twitter. You have to find out whether there's any validity or any evidence because majority of people are just posting their own opinions without evidence and some people will just take their word for granted. 

Munir: Yeah, I, I feel quite strongly about this particular point you made as well, that on social media, especially people post things without thinking about the validity, the accuracy, the reliability of that information. It's really so common to share things just like that. It is unfortunate, really, because you read something that sounds exciting and, um, very strongly opinionated, and you just go around telling everybody like it's gospel, that's really not the 

Marium: And it's those videos that go viral, believe it or not.

So if there's any [00:37:00] opportunity of, you know, just that somebody posts something and it's very controversial, you'll see a trend. Repost, repost, repost, and it's same group of people and spreading the word around. And 

Munir: Yeah, exactly. 

Marium: but then when you see other work, that good work that's been delivered or discussed about, you don't see those being reposted or discussed as much.

Hmm.

Hmm. Hmm.

Hmm. 

Munir: I Think this is more balanced. Um, but, okay,

I just want to go through the next two points here that I've done together and then hear what you think about that. Uh, and that's a bit about the broader picture. One is about raising issues. So, um, there are PA organizations, there's doctors organizations out there who are fighting our corner or trying to do the right thing for their professions and hopefully, for all professions and for patient care. that's what they're there for. If we hear something, we should listen with an open mind. If we do have an opportunity to influence, use it for the better. My point here is about not shying away from things [00:38:00] and, uh, to express your views in the right channels and discuss, debate, and all of that. . Regulation of PAs will help clarify some of this. Now, there is a GMC consultation going on at the moment. This is an appropriate channel through which to express those views. So, raising awareness is, is key. That's one point. 

>How you can raise public awarenesrs

Munir: And then the other point is to do with awareness for the public. Now, I think this really does need to be prioritized. I have now, no doubt there are a significant proportion of people out there in the public who really don't know much about the different roles, especially the newer roles.

Nobody can deny that. And the Royal College of GPs and BMA have also stressed this point as well. And, um, to some extent, this is mainly a message that goes toward, towards government and the NHS and the powers that be. But actually, you know something, Mariam, there is something that can be done at general practice level, and I would imagine in secondary care as well. [00:39:00] Whether it's posters explaining this, whether it's about making this clear on the website, maybe having a few paragraphs about the different roles, for example. Whether it's about a message that is relayed when a patient looks at an appointment about who they're going to see, , or whether it's just about the way we introduce ourselves and making sure that we do introduce ourselves because it's easy to forget to do that in a busy clinic.

But you know, I want to say one more point about this, which is, it isn't even just about making sure you know who you're going to see, but it's also something about credibility and making sure patients don't feel that they're just being flogged off. So, when I refer to a physiotherapist, when somebody comes with a musculoskeletal problem, for example, I don't say, well, look, I've given you a painkiller, it's not working, why don't you go and see our physio?

Marium: Hmm. Hmm.

Munir: That can be interpreted as being quite dismissive, right? Because people do see doctors as being at the top of the hierarchy, as it were., I don't mind that view, but I, um, I do think that physiotherapists have a lot to contribute, as do the other professions. [00:40:00] And so what I do is I say, well, look, I've done what I can. I agree with you that giving you multiple painkillers on top of what you've already got isn't the answer. There's actually somebody who works here who deals with this problem a lot more than I do, and they deal with it every day, and they're better at dealing with this.

And do you know what? They're not going to give you more painkillers. They're actually going to try and help you with your day to day functioning. Would you like to see that person?

Marium: Hmm.

Munir: then the patient feels that they're getting a golden ticket rather than being flogged off.

Marium: Even when I do the MSK referral, I emphasize they are specialists in that area. They know a lot more than I would do. And even with my nurses who are diabetes specialists, and again, it's explained to the patients that we're not fobbing them off.

This is why it's really important to have a skill mix in the GP because they, again, you have to understand a GP has 10 minutes, but a physio may have, would have half an [00:41:00] hour to have more time to spend with them. And as when you're talking about the roles. There's health and well being roles. The personalized care roles.

Nobody knows about them. Like, what are they supposed to do? What's their remit? And how are they introducing themselves? And is there overlap with that they should be making clinical or non clinical sort of decisions? And these debates have happened. 

 The receptionist I work with, they will say, look, you might be booking with a PA. They introduce, they explain what a PA is, and then they say you'll be either, um, spoken to a doctor.

Again, You're definitely, I agree with everything what you've just said. Um, there does need to be a lot more work, yeah. 

Munir: That sounds like a good way of doing it, absolutely, yeah. It's interesting you mention about the care roles as well now, because these have been, there have been various sessions taking place in the last few years to try and educate the, the workforce about what these care roles are, the three care roles.

 I definitely subconsciously developed a somewhat dismissive , attitude towards them. I, I realized that much later. And the truth, truth be [00:42:00] known, and I don't mind admitting this, even when I had the opportunity to do an, an, an episode on health coaching, I went into that with a sort of, maybe there'll be something relevant in there.

That was it. And at the end of it, I thought, oh my God, everybody. Should be listening to this. Everybody should be understanding this because this is so important, so impactful, so practical and real in terms of people's lives. And I was, I was a transformed person as far as this role is concerned.

Marium: see, I'm, so I'm always curious. So when they were introduced, and I was a PA lead, I wanted to know exactly what they did. So I spent quite a bit of time with one of them. Come on, when your GP is not going to be able to do that in 10 minutes. So I, it was really good to have an open mind why the roles have been introduced. And I think if you have that attitude. So have you seen those patients where they have appointment and then you see them again in four days , then you see them again in a week's time.

And ultimately it's because they're expectations are not met , and that's a [00:43:00] red flag. And that's like taking up so much NHS resources. But if you have the right people at the right place at time to support them, then that would have, and you're making the patients more expert, more autonomous in their own learning of their health problems..

Munir: Hmm. Totally agree. 

>Let's not forget the Supervisors

Munir: Alright, I've got, two more points here. So, uh, one is about supervisors. And I thought it's important to include this First thing to say is that the supervisor is often from a different profession, a GP often or a, a, a doctor in secondary care and I became aware of this challenge when I was involved along with a couple of others, um, another GP and a nurse for that matter doing um, sessions for the PA preceptorship program.

And there would be these monthly meetings, and these are newly qualified PAs, so they've, they've now lost those connections they had with, as students. And yet there was so [00:44:00] much learning to do, and so they valued this. But what I found is, we, what we wanted to do was gradually hand over the baton to them and let them take a lead on these sessions.

Our purpose was not, was not to be their teachers. But actually being able to hand this over to them was, proved to be very difficult. And, and I realized much later that I was still treating them as if this is a group of newly qualified GPs, uh, who might be at a different level.

They're on a different paradigm. They have a different level of, of, uh, confidence, et cetera. And so it is understanding that you're dealing with a different profession. And so I would say that what a supervisor should be asking themselves for anybody, but especially if you're supervising somebody from a different profession is.

How approachable am I? And, be self critical about that. And that will allow those opportunities for learning and development to come and concerns of, you know, distress and anxieties to be shared and so on. 

But speaking of that, flipping the coin the other way [00:45:00] around, it's also important to recognize that as educators and as supervisors, We're not necessarily immune from psychological stresses and burnout either. In fact, this is a growing problem, and this was led in another episode that we did, which was Burnout in Educators, where Dr. Mary Rose Shears, who was the Dean in South London, She led a team of multi professionals discussing this topic to realize because we're supposed to be the role models, we're supposed to be setting the example and we often cover the fact that sometimes we're having it tough as well.

And so I'm glad that there is an increasing recognition of that as well. So yes, this point about supervision is, is an important one as well.

Marium: And that's where there's a misconception that they don't need any more training, but matter of fact, they do. I get a lot of frustration from GPs, uh, who are trying to supervise PA. What level should I be catering this PA's learning needs? And I said, that's the sort of assessment you have to do initially when you interview them, when you get [00:46:00] to know how they are, 

so I, I think it would be great to see for Physician Associates, like, post qualification, year one, this is what they can do and what they cannot do.

Year two, now they've, you know, become a bit more, 

as a PA, it's hard for a doctor to step in a PA shoes because you don't understand what the PA, what training they have gone through for two years.

>Change itself - Embrace rather than fight it?

Munir: the last point I wanted to make was about change itself. With the NHS, there's always been change. Every few years, something new comes along. And doctors who have been in it long enough, and other professionals have seen that, get used to it, and change feels uncomfortable. So some of the anxieties or discomfort that people might feel, you know, a lot of it may be to do with the valid concerns that we've discussed, but some of it might simply be because of change itself. And so my message would be. to get on with it. I think we should just accept and get on with it. You know, this is, these professions have come along, 

let's try and make the most of it rather than [00:47:00] just shying away from this change and just, you know, having self pity about it. I think that's not helping anybody. You know, let's be mature and grown up about it and we're going to understand how to do that through dialogue. 

 This discussion, like a lot of discussions, it comes down to , I've just come up with this thing, uh, these three A of awareness, attitude, and acceptance. I think you can apply this to a lot of situations. Uh, one is to be aware of what's going on. Uh, and then the second attitude about being critical. Because, when we hear about things, the first thing we do is we think about what somebody else has done, what an organization has done, what them should be doing or shouldn't be doing and why they did this.

But actually, it's important to look within ourself and actually, am I producing the right attitude towards this? Am I understanding this properly, correctly? Is there something I need to be doing differently? . 

The third one is acceptance. Acceptance. [00:48:00] It's important to understand where we are, what can change, what can't change, where we should accept. And acceptance includes not accepting. So what are the things that need to be challenged and challenging those? So the three A's just coined it at myself. What do you think?

Marium: No, I definitely agree. I think the thing is nobody likes change. They rebel against it, don't they? And they get very, and the reason being why, because they're very uncomfortable when it comes to change. If you think about doing something for so many years and you're very comfortable in that zone and , it's a natural instinct. If I'm honest with you. NHS works best when it comes to reactive change. For example, when, um, they've been working so long to go towards more, uh, technology and telephone consultations and, you know, uh, video consultations but when COVID happened, We had no choice.

It was done by force. We had to

resort to technology. Exactly. So with NHS, um, if you bring into something, then there's a lot of hoo ha, debate, [00:49:00] anxiety, but when it's bringing by force, I think we take it on more easily

than, you know, yeah, yeah, 

exactly. We have no choice, have we? So, yeah.

, and now, what advice would you give, especially to those from other profession, um, Munir, and let's listen to Steve first, and then I would like to see here what you've got to say as well.

Stephen Nash: Thinking ahead, what advice would you give to those listeners from your own profession and to those from the other profession?

So as of next week, we'll have hit a major milestone for setting up our trade union and we'll be instructing solicitors for Our members to pursue anyone actually inflicting detriment on them and our advice to those MAPs Not already a member would be to join immediately and allow us to support you as we grow you MAPs together we will very shortly be the first MAP union in the uk with [00:50:00] the capacity to defend our members, deliver cpd and protect the profession's integrity standards and rights across the uk And i'd also like to say that wants you to know you're not alone.

Um, we are here and going through this together and the online community is a very safe space. Um, so if you are struggling to get help and support, that's where to go. If you need help member or not reach out to us is the other thing to say. Um, it's also imperative that we also learn. From what has happened over the last year, you know, whilst we've all learned from the small number of tragedies our profession has been involved in, we've also become aware of how the mismanagement of MAPs can create situations of potential harm.

Um, It's imperative as MAPS that we lead the charge on tightening up these procedures so that we can maintain and in [00:51:00] places gain the respect of the patient and medical colleague populations. Um,

my advice to doctors actually is simple. 70 percent of you abstained from the recent RCP EGM, uh, EGM. If you do not challenge the behaviour on display, it will become the norm, and it will have effects that there is no way to come back from.

Real people who are your trusted colleagues are being affected by this. You are the leaders of the medical sector, and I would ask you to stand up and lead the way out of this for your profession.

Munir: As a PA, you're a wonderful addition to the healthcare team and have loads to contribute in terms of patient care. Hopefully, most of you are having pleasant experiences with the doctors that you work with and the other professions that you [00:52:00] work with. Um, but if you do see a doctor who's frustrated and particularly if you feel that it might be towards other professions, do try to see it from their side as well.

You know, particularly the younger doctors who have worked extremely hard just to qualify and get where they are. And now they understandably feel that what they're getting back, it just doesn't cut it. And if you're, by the way, as a PA, subject to maltreatment, stay strong, hang in there, obviously raise it using appropriate channels.

And, you know, I sincerely hope, that things do get better for you. If you happen to be a doctor, much as I love the generalist role, and as much as I still defend the generalist role, Do take up a special interest. If you're struggling to find what you should take up, have, you know, get a mentor.

Work through it. Work out where you want to, which direction you want to go to. Speak to your boss. What are the opportunities out there for you? You've got to go with the flow. Things have moved on.

How about you, Marion? What advice would you give?

Marium: . I [00:53:00] think the only thing I would add in is for doctors to see and look at your, um, policies and, uh, governance structure within your GP. If you are listening to this podcast, there are many resources that we have outlined. Just go through them. 

Um, I Change has to start within yourselves as well. And again, um, there is a lot of employers responsibilities. And again, just check in on your PAs for the health and wellbeing and see how they're getting on. I mean, in my own experience, I've got really good support with my supervisors. They do check in on me.

We do talk about these matters and it helps a lot because it's be able to speak to somebody about it, what's going on, and to know that there's really good support network there. Unfortunately, not all PAs have that.

For PAs, um, just like Munir said, hang in there. Resilience is the key. Changes are happening. Hopefully there will be light at the end of the tunnel and there will be some positive [00:54:00] change because there's regulation. Everything's coming into place, hopefully. And there are a lot of stakeholders working together.

You're not alone. , any concerns, contact me or Steve and see what we can do. And for PA students, let's not forget about them. Um, any concerns, raise it up with your universities, with your employer. But again, um, but yeah, stay strong.

Summary and over to you...

Munir: So, are PAs replacing doctors? Well, we've shared our views and we've shared the views of others, we've made references to things, but I'm sure you will know that it actually wasn't just about that specific question, but about the much broader issues relating to these changes that are taking place, issues that are pertinent, and that people are discussing and concerned about.

Yes, there are legitimate concerns on both sides. Which hopefully will be addressed. No one is saying they won't. They are being addressed in some ways, as we alluded to earlier. But we can't blame each other for this. The fact is, most doctors and PAs are extremely hardworking individuals. They just want to get on and do their [00:55:00] job.

 Now, we've tried to cover as many issues as we possibly can. And we've included links and show notes as well that you can refer to on the website. But look, we're not experts. We're educators, we're just trying to do the right thing. We may have missed things, and if we have, we would like to know. 

We hope that you'll reflect on this and consider what you can do differently when you go to work tomorrow.

We apologize if we've upset anybody, by the way, it's not our intention, but we wanted to convey the reality of what's going on. But you know what? Let the discussion go on. If we've missed important points, let us know. Please let us know. The best way is through our website primarycareuk. org.

Marium: You asked me at the start of the episode of would I like to be a doctor. I'm going to turn the tables now around and ask you a question. Would you like to be a PA?

Munir: Oh , I Still I still feel something special about the title doctor [00:56:00] But you know, it's funny you asked that though actually Marium because one of my nieces she was thinking about going into medicine and in fact She got an offer from one of the hospitals from one of the universities in London as well You But she then decided that she wants to be a PA instead, when she thought about the career options in front of her.

And she said to me she chose that because it looked like it had a better work life balance and it just seemed like an easy, easier career path to get to where she wanted to. And I responded to her by saying that I think you've done the right thing.

Marium: I wouldn't say it's easy. I would say that yes, after two years qualifying, you will go into employment. And then obviously you have a salary paid job, um, where medicine, it's more prolonged learning and training and, you know, for 10 years. So I understand that but I keep hearing that. It's an easy course, I'm telling you, Munir, they can't, in two years, they cram so much [00:57:00] in university where the expectations of passing OSCEs and SBE and learning all of this, like I did not even have a life when I did a two years master course.

And they also, we did not even hardly have any holidays because we were constantly on placement. We had to do 1, 600 worth of clinical hours on rotational programs.. So those two years, I did not have no life. And I dedicated it to my studies and it's not as easy.

So, but again, longer, she's aware the difference between a PA and doctor, then that's fine because I do want people going away thinking it's a shortcut route to be a doctor, which it isn't because we're not doctors. Anyway, on that note, I am proud to be a PA and. I think you said the right thing as well, to your niece. But again, we'll let the listeners to decide.

Should have been you gave the advice to his niece to go do PA calls [00:58:00] rather than medicine. 

Munir: let's see what others think about that and about the discussion in general as well.

We've got an amazing list of other interesting topics that are in the pipeline, including in season three, we have upcoming more NHS news items being discussed. This is going to be led by Emma and Simon from the Southwest of the country, 

and also, we've got Claire and also Irina from Nottingham and myself who have the fortune of having an expert team from the Genomics Service, which is associated or linked with Great Ormond Street Hospital in London, talking about genomics and demystifying it for us. Introductory episode came out a couple of weeks ago. And do you have a listen to that as well? 

One more thing to say, if you happen to be a physician associate listening to this episode, and you want a PA specific podcast to complement the multi professional learning you would get out of Primary Care UK, then there is something just for you. In fact, it's called the Physician Associate Podcast, so you may want to check that out [00:59:00] too. 

Marium: rate us on Apple. Leave us a comment too. You can also do that on Spotify. And we'd love you to contact us on the website PrimaryCareUK. org. 

And if you're watching this on YouTube, please like us and subscribe and comment below. 

Munir: . Thank you for joining us until next time. From the Primary Care UK team, keep well and keep safe.

Marium: and be nice to your PAs.

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