Thesis – A comparison of Medical school and Physician Associate training and how Physician Associate can fit into Emergency Department (ED)

Introduction

In the UK to date, all healthcare is provided free by the government. The National Health Service (NHS) was founded in 1948, its mission was to provide free public healthcare, and this was born out of the idea that excellent healthcare access should be available to everyone regardless of their financial standing, social situation, race and ethnicity^{1, 2}. Within the NHS organisation exists a large and varied team of healthcare professionals, these professionals work day-in and day-out to provide care; 24 hours a day, 7 days a week to those who are physically and/or psychologically sick, injured and in need of medical assistance. The healthcare professional’s roles range from healthcare assistants, nurses, occupational therapists, physiotherapists, doctors and biomedical scientists.

The latest demographic data shows that there are currently 1.2 million individuals employed by the NHS in England, working to help treat an English population of around 54 million individuals¹. Throughout the United Kingdom, the NHS employs 1.7million individuals to treat a total population of 64million people¹; with a ratio of 2.71 doctors per 1,000 people. As it stands, 1 million individuals from the English population are being treated every 36 hours in the UK, this is covering both routine and emergency care; this equates to 27,777 patients every hour and 462 patients every minute.

In comparison to the US, with a current population 312.8 million people as of 2012, a total of 131 million people visited the emergency department, this equates to 42 visits per 100³. In routine outpatient visits in 2011, a total of 125.7 million appointments were undertaken, this equates to 41 people per 100⁴. Overall meaning 488 patients are seen every minute in the US as of 2011/2012, combining both outpatient and emergency care.

With such a high UK population and patient levels, the NHS struggles to cope with the increasing demands placed upon it. These demands driven by an aging population, unrealistic and increased expectations have led to the NHS developing into a financial crisis that is spiralling out of control. This has been building for many years as the UK continually develops and grows its economic place upon the world stage. According to an article from 2006, the financial crisis has reached a staggering amount of £800 million debt, this had caused the NHS hospital trusts to announce that approximately 3,000 jobs will be lost in response⁵. Latest data predictions show that the NHS is now expected to be in debt by £1.85 billion by the end of 2015/2016, if nothing can be done in regards to this debt level, it could be raised to a staggering £22 billion by 2020/2021⁶, leading to more future job losses as a result. Alongside the financial crisis is an ever increasing staff shortage, the NHS has an ever increasing problems with not only recruiting staff but also retaining staff, especially with junior and training post doctors in all specialities⁷. When looking into Foundation Programme data, in 2011 71.3% of F2’s were progressing directly in speciality training, compared to 52.0% in 2015⁸, this drop off in junior doctors progressing to training posts leaves a gap in the middle grade doctor rota. Therefore, this is putting more pressure on the staff to make up for this gap, whether this is done by hiring locum doctors/trust grade or other healthcare professionals, the strain is ever increasing. There are currently approximately 320 training posts available for core training in emergency medicine. With such few places available, the competitive nature and the current state on junior doctor’s profession in the UK, many are now travelling to work in hospitals abroad for a better work/lifebalance⁹. With so few core training places and the highly competitive nature, many doctors who do manage to secure a place find themselves overwhelmed by the pressures and work-life balance entailed with the post⁷.

According to the Australian College of Emergency Medicine, they have seen a recent increase of UK graduates of up to 60% working in ED’s all over Australia⁷. This therefore raises a question, how can the current UK’s emergency and general medical services keep up with the current demands and staff shortages, if the future of medicine are leaving? Is there a profession with both the clinical skills and necessary knowledge to fit into both ED and general medicine? Back in the 1960’s a similar healthcare crisis occurred in the USA, as the demands for staff services and financial budgets overwhelmed the private healthcare system. The response from the USA government in 1961 was to create a new healthcare profession called Physician Assistants (PA), it was initially envisioned that the early programs would train military personal to assist the current doctors/workforce¹⁰. With this in mind the first PA programs were set up in the mid and late 1960’s. These programs were established alongside medical schools and in turn adopted the current medical school training model, although this soon changed to more innovative and visionary teaching methods¹⁰.

Educational teaching methods mentioned above are now what we would consider modern medical education, such as simulation, patient interaction, structured written/practical examinations and placement experience from day one of the beginning of their training¹⁰. From the starting programs to date, there are now 236 programs in the USA, the majority of these being postgraduate, however a few are undergraduate. These courses have continued to grow and develop physician assistants/associates into a highly successful separate profession from medicine, but not too dissimilar from medicine in knowledge and clinical skills. From the original 4 navy corpsmen who embarked on the first training program to modern day, the PA movement has been a huge success, with recent growth from 2010 to 2015 being over 35% and with certified PA’s now numbering approximately 109,000¹¹. PA’s successfully integrated into the primary care sector of the US and allowed for more access to healthcare, especially those who rely on Medicare and Medicaid¹². Medicare and Medicaid are the national social insurance and social health care initiatives for individuals over the age of 65 and those whose families/individuals with limited financial resources. Can the PA profession fit into the NHS and help to reduce the strain and demand on the services?

Due to the successful integration of PA’s into the American healthcare system, the UK decided back in 2002 to run a 2 year pilot project, this was to determine whether PA’s could be an important step in turning around the NHS staff shortage¹³. The project involved American trained PA’s working in the West Midlands as a demonstration of clinical knowledge and skills which can be brought into the NHS and to also officially launch the UK Physician Associate (UK name for PA’s) profession¹³. Eventually by early 2004, 12 US trained PA’s were employed and working in the West Midlands at Sandwell NHS¹⁴. In the same year the Department of Health performed an evaluation of the impact of PA’s, this was done through the Changing Workforce Programme; result’s showed that both patient and physician satisfaction was very promising and was in keeping with NHS goals of patient focused care¹⁴. Due to the success of the pilot project, UK based training programs began to recruit postgraduate students to begin their PA training as of the year 2005. From the initial universities who started the training programs, it has grown exponentially and continues to do so with the UK government setting themselves a target of producing up to 1000 physician associates working in primary care by 2020¹⁵. Despite these targets, as of 2013 only 35 PA’s graduated from UK accredited training programs, this falls far behind the government’s aims¹³. As of 2016 census results from the Faculty of Physician Associates, the figures of trained UK PA’s have been slowly increasing, with now approximately 865 eligible to be part of the census, 288 PA’s and 353 PA students¹⁶. Of the 865, 503 responded leading to figures of 130 graduated PA’s in England and 338 students and of these 31 working in general practice and 23 in emergency medicine¹⁶.

As it stands the number of Universities running courses has increased: There are now 27 full time postgraduate training programs available in the UK, with 2 more opening in 2017 and another 6 currently under development¹⁵. Whilst the majority are still a postgraduate diploma which is the minimum requirement to practice as a PA, there has been a steady increase in the number of universities offering a MSc and this number will only increase and provide a way to raise the standards of training and quality of graduates; by allowing individuals to complete a research based thesis, this can be crossed over to performing audits, as the necessary skills for data analysis and interpretation have been learnt previously. The role of the PA in both primary and secondary care is very similar to that of a junior doctor, such as being involved in the day to day running of the wards and undertaking consultation surgery slots in primary care. Although there are many similarities between these roles, there are however a couple of key differences in practice due to legal reasons. As such the PA role is currently unregulated in the UK, therefore they are unable to prescribe drugs or order medical investigations using ionising radiation (X-rays and CT scans).

Over the past 11 years since PA’s have begun graduating, there have been numerous articles and census data recorded about how PA’s have fitted in and whether they are safe to practice within the NHS. In a recent study into PA’s and GP’s in primary care, a comparison was done to assess consultation length and patient satisfaction¹⁷. The aim was to determine and compare the cost per consultation and outcomes of PA’s and GP’s, for this same day appoint records were observed and a patient survey was sent out; the methodology of this was valid and met the aims of which the study proposed. Results showed that there was no difference in re-consultation rates, investigations ordered/referrals/prescriptions or satisfaction of patient outcome¹⁷. In conclusion it was determined that the outcome and process for primary care appointments are similar but at a lower cost per consultation¹⁵. Although the study did show a positive outcome for PA’s, this study wasn’t a randomised control and therefore places some negative aspects on the validity of the study. In hindsight the study didn’t take into consideration time spent by the GP’s on the signing of prescription and requesting scans for patients due to the current limitations in PA regulation. In another recent study, a survey of British doctors was performed to find out whether they were satisfied with PA practice in secondary care¹⁵. Results demonstrated British doctors believed PA’s possessed good knowledge and clinical skills which offered beneficial continuity of care to patients and health care practice, patient feedback was positive about their interaction with PA’s¹⁸. Such positive feedback provided by both patients and physicians, the question as to whether PA’s can help fit into the NHS and provide a means to solving the staff shortage is overwhelmingly positive; therefore more needs to be done by the government to help in the regulation and recognition of PA’s, otherwise many potential students may be persuaded against becoming PA’s.

Another important question to be considered is, if PA’s are successfully introduced into more of the NHS and the profession develops with legal registration, will PA’s have a separate distinctive role from traditional medical graduates and nurses? Or are PA’s always to be seen as ‘doctors on the cheap’ and as doctors helpers? To date PA’s fit into the junior doctor rota, filling gaps which otherwise would have been given to locums, or fill a slot originally designed for a trust grade or ANP, whereas some PA’s speciality dependent have a completely separate rota but still work alongside the junior doctor/SHO team¹⁹. With the PA’s medical knowledge, clinical skills and ability to move between specialities, at any point during their career, it presents a very interesting addition to the NHS. However, many people have voiced concerns about PA’s, Doctors and Advanced Nurse Practitioners (ANP) having similar and overlapping roles¹⁸.

In contrast to the concerns about PA’s, many have expressed positive ideas about how the profession can fill a void where increasing number of both doctor and nursing staff shortages. As of 2000, there were 10,000 vacancy posts on NHS jobs, to cover these vacancies with bank/agency until a fulltime nurse can be employed, which would cost the NHS approximately £810 million²⁰. In a more recent analysis performed by NHS digital, from March 2014 to February 2015 there were 17,583 vacancies posted, this is a 175% increase over the past 15 years²¹. According to Health Education England (HEE) as of 2016 there was 7,419 level 1 training posts available on NHS jobs and only 6,673 of those posts had people accept the positions, leading to 740 (10%) unfilled posts²². With so many unfilled posts and the UK’s inability to train medical staff quickly enough, this leads to the question as to whether PA’s are the answer or just a stop gap plugging the leaking NHS? When legal registration is to be brought about, the UK PA’s will be able to act as an autonomous practitioner, therefore Pa’s will be able to act autonomous within the bounds of a supervising physician similar to their US counterparts. In turn helping to cover some of the vacant posts which can be done by a PA and in turn solidify the PA’s role within the NHS.

Aims and Objectives

The aim of this dissertation is provide an overview and comparison of medical school and current PA training curriculum’s in the UK, there will be extracts discussing the American PA training and course programs due to the limited literature surrounding UK PA training to date. This will be looked at in detail, there will be a comparison of knowledge, communication skills, clinical skills and legal status. Within the discussion section, I will look at how a PA’s knowledge and skills learnt through training can be used in front door medicine to help ease the ever increasing pressure, and the lack of doctors pursuing a career in Emergency medicine due to an ever increasing number of patients causing strain on the NHS Emergency system.

Literature Review – Medical School and Physician Associate Entrance and Assessments

There are currently 33 undergraduate programs and 14 postgraduate programs, all of which are members of the Medical School Council. The undergraduate programs tend to be 5 to 6 years in length, depending on each university and whether or not the students opt for an intercalated degree. The intercalated degree allows the students to develop a sub-speciality and another alternative for a future career path. Whereas in comparison, the postgraduate medical programs are 4 years in length, students will have a previous degree beforehand and previous working experience which will aid them in being postgraduate learners and therefore are able to progress quicker through the medical course.

Entry requirements for both undergraduate and postgraduate medical school will vary depending on each universities requirements, however the majority will expect individuals to be highly academically gifted and show work experience within healthcare settings, generally a minimum of 360 UCAS points in science related subjects such as biology/chemistry with maths/physics and primary/secondary care volunteer work. Alongside this undergraduate entry standards, students will have to sit assessment tests, currently UKCAT is used by 26 schools, BMAT is used by 7 schools and GAMSAT which is only for postgraduate is used by 7 medical schools²³. These 3 tests are specifically designed to assess students on key areas of cognitive processing/elements. UKCAT will assess students on five sections: decision analysis, abstract reasoning, non-cognitive analysis, quantitative reasoning and verbal reasoning²⁴. GAMSAT only requires testing on 3 sections: biological and physical science, written communication and humanities and social science reasoning²⁴. BMAT which is purely postgraduate assesses 3 sections: aptitude and skills, a writing task and scientific application and knowledge²⁴.

In the UK, each medical school has the authority to freely develop local systems and policies which aid in the progression and assessment of their students²⁵. In recent years there has been a lot of scrutiny surrounding the standards of the medical profession, primarily this has been more focused upon postgraduate medicine but very recently the undergraduate medical courses have been subjected to reviews and criticism²⁵. The local assessments in place have traditionally offered a suitable methods in which to ensure student performance has reached acceptable standards before becoming employed within the NHS. The local assessment method is a mixture of written exams and practical exams called OSCE’s (Objective Structured Clinical Examinations), these must be passed before students can graduate and apply for a deanery of their choice and be accepted onto the foundation programme. However, this tool has never been able to show a standardised comparison of student performance between each of the individual medical programs, therefore the General Medical Council (GMC) decided to work towards a national assessment system²⁶.

This new assessment method isn’t likely to be in place until 2021²⁶, whether or not this assessment will improve the quality of graduating doctors is potentially a very interesting piece of research to be undertaken. Even though medical schools are freely able to control their local assessments, each school is quality assessed by the GMC and must maintain standards by teaching and assessing certain areas. At Oxford University for example, these are such as understanding and knowledge of illness and health, doctor patient communication, research methods and critical thinking, social healthcare and ethical/legal framework²⁷.

In comparison to medical schools, as mentioned before in a previous paragraph, there are 27 postgraduate programs currently accredited for PA’s, the standard length for PA courses is 24 months¹⁵. Entry requirements for accredited programs are very similar to each other and are becoming much more competitive as the profession grows and becomes more well-known and the understanding of its place in the NHS. Students are required to either a 2:1 in a life/health science related degree, a 2:2 in a physical/engineering or social science degree or a diploma of higher education in nursing, paramedic or OPD plus 2 years’ experience in the role. Additional essential criteria are such as experience and interest of working in healthcare or an allied health profession, two references and a personal statement. Students will also undergo an interview process, the interview will differ between universities but will involve generally a group interview section, multiple clinical/ethical scenario questions and a solo interview. Due to the new nature of the courses, the majority of these will follow course templates from the existing Universities and adapt them as necessary to meet there needs.

Although each university is free to adapt the template, each course must meet specific requirements so that the students can be entered into the National Exam. These requirements are 1600+ clinical hours and a postgraduate diploma. The National exam is a two part process with both two 100MCQ written papers and 14 station OSCE examination, it was set up in a similar fashion to that of the American PA examination board, such as the requisite to recertify every 6 years. Recently the due to the larger scale of PA’s in America their recertification has changed to every 10 years²⁸. This recertification is in an effort to show the NHS and the government a continuation of learning in a bid to be able to apply for legal registration here in the UK, allowing PA’s to grow and develop as a profession. It is similar to how previous mentioned that medical students are assessed, although the breadth of knowledge isn’t as in-depth compared to the first 3 years of medical school, there is a curriculum framework of clinical conditions which must be learnt in great detail. In comparing a PA’s university core curriculum to the medical example above, it should be noted that due to the nature of PA training length, not everything can be learnt in such extensive detail.

However, the Faculty of PA’s has a set guidelines in terms of how many clinical hours must be spent in both primary and secondary care areas. In the second year a minimum total of 1600+ hours must be completed before being able to be entered into the National Exam, these hours are split in specific areas as follows: Community Medicine 180 hours, General Hospital Medicine 350 hours, Front Door Medicine 180 hours, Mental Health 90 hours, General Surgery 90 hours, Obstetrics & Gynaecology 90 hours, Paediatrics (acute setting) 90 hours.

Literature Review – Knowledge, Communication, Clinical Skills and Legal Status

The basis of both medical school and PA school is first and foremost to become safe and competent healthcare practitioners; ultimately this is accomplished by the ability to order correct and safe investigations, produce a differential diagnosis and knowledge of how to organise management and treatment plans for the correct diagnosis. These skills aren’t learnt in day one of training, but take time to develop as more experience and time spent interacting with patients with clinical conditions will aid in the growth of skills. In the UK, the PA profession is a non-regulated healthcare practitioner, currently all qualified PA’s are unregistered but are asked to become part of the managed voluntary register; this allows the government to see how many are working within the NHS, how this number is growing and helping the NHS, so that regulation can be fast tracked and approved.

In the past 2 years the GMC and Health & Care Professions Council (HCPC) have both meeting board meetings with the relevant parties to discuss the regulation of PA’s, both governing bodies took the view that PA’s should become a regulated profession. Both the GMC and HCPC are in the beginning stages of exploring models for regulation if asked to by the Government^{29, 30}.

Anatomy, Pathophysiology and Pharmacology

When looking at what knowledge, communication and clinical skills graduates from both medicine and PA schools should graduate with, there are some immediate cross over areas in both anatomy and physiology. As stated by the GMC previously, new foundation doctors should have the capacity and ability to function as both a teacher and a mentor effectively³¹. This can be true of any profession and should be instilled from day one as a student. Currently, in medical schools students are taught a wide range of different areas to help prepare them for employment. Anatomy and Physiology is a big part of first and second year medicine, this can be taught by a range of ways, such example used currently are practical labs (using PC’s to look at x-rays, CT’s, MRI’s), dissection of cadavers and multi-disciplinary labs (using digital captures to facilitate large scale demonstrations). Pharmacology teaching in PA and medical school plays a big part in how future medical professionals understand the pharmacokinetics and pharmacodynamics of the medications for which they will be prescribing to patients in both primary and secondary care. Even though PA’s aren’t currently able to prescribe medications, they do possess the ability to suggest treatment/management plans for patients therefore knowing pharmacology is a very important aspect to be taught.

According to a recent article the teaching of anatomy in both undergraduate and postgraduate settings is apparently on a downward spiral, mainly due to the shying away from the traditional didactic lecture system and complete dissection lesson has almost in a way deskilled students³¹. During PA training from first-hand experience, dissection wasn’t part of the curriculum; not being able to fully appreciate the human anatomy from first-hand experience from my point of view plays a big part in individuals not being able to manage when presented in emergency/elective procedures. Therefore, this potentially could lead to errors during surgeries/emergencies as individuals don’t understand difference variances of human anatomy but only the textbook versions.  In the 1990’s an article called Tomorrows Doctor was published, this publication issued statements around how the medical curriculum was going to change for the future, this meant the time spent teaching the basic medical sciences was being significantly reduced. Following this publication a review was completed to look at how the new teaching of anatomy has impacted upon a student’s surface anatomy knowledge, results showed that the introduction of a new system which is modern medicine has caused a negative impact on surface anatomy knowledge³².

Anatomy comes part and parcel with physiology and especially prudent in medicine is the pathophysiology of conditions. Clinical conditions and pathophysiology are learnt throughout medical school, pathophysiology is studied in depth during the first 3 years, from cellular beginnings to the disease process ending. When students reach 4^th and 5^th year this is when generally they will undertake longer primary and secondary care placements and be expected to be able to describe the pathophysiology of conditions along with clinical presentation of common and important conditions. In comparison to anatomy and pathophysiology learnt by PA’s, the basis of knowledge learnt is based around 4^th and 5^th year medicine. In contrast to medical schools, even though PA’s anatomy and pathophysiology is based on 4^th and 5^th year medicine there is a lack of descriptive information surrounding the precise details of what is taught/learnt, therefore many PA programs will develop anatomy curricula in isolation³³. This will therefore produce potential inconsistencies in the depth of knowledge learnt during the training process; because of these inconsistencies we are unable to determine to how much this lack of anatomy knowledge impacts on professional practice. Currently in both medical and PA programmes, pharmacology is taught by lectures and seminars. According to the GMC, ‘junior doctors feel very poorly prepared for prescribing due to a lack of clinical pharmacology and therapeutics (CPT) , leading to prescribing errors’ ³⁴. Since 1993 the GMC has provided guidance on CPT, this was up for revising at university level as in 2009 as ‘Tomorrow Doctors’ article was published³⁴.

As of a 2010 article it was noted there was no published data describing what is being taught within the current UK medical school programmes, this lack of information doesn’t allow for support in the context of future changes to be made based on areas considering to be lacking. Following this information release an online questionnaire was published to the head of CPT in each medical school in the U.K. 30 of the 32 medical schools responded to this questionnaire, results revealed 72% have an integrated CPT course built within the teaching program, 87% of the pharmacology teaching is taught by an NHS clinician with first-hand experience of the taught knowledge area, 90% of this is delivered in lecture format with 50% of the 30 schools having e-learning packages for the students³⁴. 90% of the schools included CPT within the content of their written examinations, of this 90% CPT inclusion many believed there students were fairly to well prepare for foundations years one and two, subsequently 37% of these schools collect and gather data on graduate competence³⁴. In comparison to this PA programmes do include CPT, some have separate modules for CPT, whereas some of the programmes are primarily PBL based and therefore inclusive. There is no up to date data and information available for UK PA programmes and how they base and rank pharmacology teaching in the curriculum. The teaching of CPT within PA programmes requires special timetabling and careful planning of material depth and time constraints. It is difficult to fully fulfil the pharmacology needs of PA students when entering working life due to the time constraints of the course length.

Lecture and seminar based CPT style of teaching has been in place for numerous years, however as the depth of teaching within programmes progress so does the style of teaching in the programmes³⁵. Concluded for effective CPT teaching to be taught in 100% of programmes, graduate data gather must be obtained, this can help to ensure developments are made based upon real world practice and not purely textbook practice. In 2010 an article was released discussing the benefits of team-based learning (TBL) for teaching second year medical students pharmacology in comparison to the more traditional style of teaching³⁵. TBL has been shown to improve student performance in various other health care courses³⁵. Following two case based modified TBL methods for second year medical students, was a significant improvement over the previous second years marks on pharmacodynamics and pharmacokinetics learning³⁵. However, no significant difference was noted when comparing other CPT topics taught in either teaching model³⁵. Results suggest an alternative method for effectively teaching CPT, whether this will and should be adopted requires more research and data to be collected.

Generally speaking PA’s should be able to describe in detail the pathophysiology of conditions, along with the clinical presentation of the most common, important and potentially life threatening conditions. During the first year, which is spent in lectures and seminar environments for the vast majority, cellular and molecular biology will be learnt to some degree, however this isn’t in depth but more of a brushed surface overview. Anatomy and pathophysiology in the UK for PA’s is generally a lecture based system, there is access to interactive websites which can be accessed for individual study but no time is devoted to the use of seeing anatomical structures first hand through cadavers/dissection. For PA’s due to the generalist nature of what is learnt, more importance is placed upon the most common clinical conditions such as asthma, headaches, chest infections etc. In a recent study in America, a few medical educators involved in PA training discussed and looked at models for teaching specifically for PA’s and what they need to know and how it differs from Medicine. The study produced a PA and Medical study module to assess spatial reasoning, basic knowledge and structure function knowledge. PA’s followed an introductory lecture, dissections and clinical procedures, workshops, radiology lecture and then a summary lecture³³.

Results demonstrated a 12-23% improvement in long term recall across all 3 sections on approximately 40% of the assessment questions provided³³. These results are significant considering PA students have to cover in 12 months or less, what medical students are expected to cover over 24 months³³.

Embryology

Embryology is the study of the life cycle of embryos in relation to their biology and medicine development from the beginning stages through to the end stages. In the understanding of anatomy, there must also be an understanding of embryology as all starts from here. In the UK PA courses, embryology has a very small part in the teaching schedule, this is primarily because of time constraints and the depth required to fully understand embryology wouldn’t be feasible in a 2 years masters. Although PA student must complete a paediatric placement of 90 hours as well as a community placement of 180 hours, these placements are done in a variety of settings such as hospital paediatrics and community hospitals. Meaning that very little embryology will be required for completion of these placements, however in the written National Exam papers a very section will be embryology questions; quite possibly only 2 to 4 questions. In comparison to this, medical school teaching places a substantial amount of time on embryology and beginning cellular biology teaching especially within the first two years of medical school. From journal searches undertaken there are no papers discussing the inclusion and depth of embryology in PA programmes both in the UK and US.

Limited research accurately underpins how little teaching in embryology is given, primarily to due time constraints on behalf of the accelerated nature of the PA courses. For medical school as mentioned above, a lot more time is spent on embryology during the first 2 years of training; underpinning future gross anatomy teaching, however there is no research pertaining to the exact depth of teaching and how embryology is taught. This lack of information for both PA and medical school embryology doesn’t allow for any comparison between required knowledge and retained knowledge following graduation. We’re also unable to make a comparison of teaching styles as no up to date research pertaining to teaching styles/methods found through journal searches, however as we do know a lot of teaching is performed through didactic lectures and seminars with interactive elements built in; this can be true of both PA and medical schools on a generalist basis.

Communication Skills

Communication skills in medical school were once ranked and considered as a minor subject but now has become one of the most important core skills for students to learn and excel at³⁶. Back in 1998 a communication skills training (CST) program was implemented into current medical school training, in an effort to help improve future medical student’s interactions with patients. Before this was implemented, students usually only had CST for a few sessions at the beginning of their medical education and being assessed unfairly through OSCE’s without any formal complex training.

Now it has developed so far as CST is taught throughout medical school, but with the addition of different learning modalities, such as lectures, problem based learning groups, role play, videotaping with feedback, history taking and the Calgary Cambridge for communication skills teaching³⁶. Even with this change of CST, there still appears to be a widespread deficit in both written and verbal communication between doctor-patient, leading to poor communication becoming part of the top 3 most common complaints for doctors in the NHS as of 2015³⁷. Whether or not this is because of a decline in the undergraduate student’s empathetic understanding towards a patient’s condition, is something which has been noted over previous years to be developing and is something within can be altered through interventions by medical educators³⁸.

PA education has a very similar structure to how a student’s communication skills are taught during their training, this is a mixture of lectures, problem based learning, role playing, history taking and feedback either verbal or video from OSCE’s. There are no specific modules such as medical school has, but is a much more integrated subject when performing practical skills. In turn this does create some disparity between students in how efficient they can interact with patients and with healthcare colleagues’, these disparities are similar to discussed about by medical students and are routinely assessed during OSCE’s, therefore feedback can be provided. However, it would be prudent to implement a specific module for communication skills if time would allow, so a student’s communication skills were more efficient and effective when interacting with individuals. Even though there are no set formal CST for PA students and can be some disparity of techniques, it should be noted that generally PA students have a much more effective communication technique and feedback has been provided in saying, ‘PA’s are much more receptive and able to spend the time to listen and respond to any concerns which there may be.’

This is potentially due to the majority of PA’s having previous experiences in healthcare settings, most generally have spent time working in healthcare but decided they would like to further their career but unsure what route to take. Many of these individuals will find the length of postgraduate medicine daunting especially if they have a family to provide for, therefore with PA’s being only 2 years postgraduate this opens up the opportunity for high skilled individuals to progress in the profession, using their many skills acquired and honed in previous employment.

Enhancing communication skills has been shown to at a minimum level, to help patient behaviour during consultations, as this develops it can help improve patient knowledge, give them decision making abilities, enhance a patients self-care, improve a patients self-efficacy, improve adherence to medications/appointments, promote greater mental well-being, reduce financial healthcare costs, improved lifespan and better control of clinical conditions³⁹. Even though this feedback is very supportive of PA’s, in the future as younger students decided to undertake training; there does need to be a shift in which formal communication skills are integrated into the course. Otherwise as younger student’s progress through training they may not possess the necessary communication skills as previous mature students to cope and interact with health care professional and patients meeting a PA for the first time.

Practical and Clinical Skills

Practical and clinical skills are an essential set of skills and some of the most utilised in both primary and secondary care setting for either a doctor, PA, healthcare assistant or nurse. These can range from performing venepuncture, cannulation, peak expiratory flow, cardiovascular examination to manually measuring blood pressure. All of these for medical students are recorded on an online portfolio (e-portfolio), this e-portfolio will help students develop writing skills and attain the habit of reflecting upon learning activities. These are essential skills for any medical practitioner and the basis by which continuing professional development was devised. The e-portfolio provides evidence to medical educators surrounding your exposure and undertaking of a wide variety of tasks. The e-portfolio requires a supervising clinician to sign off the skills performed and provide feedback to help and aid in improving performance.

In medical school the last two years involve the larger section of clinical experience, presenting the challenge to students in applying the knowledge and skills learnt to help understand what is wrong with the patients⁴⁰. OSCE’s are the standard format for many if not all universities in the assessment and competence of practical/clinical skills and all students must meet the minimum requirements to be competent and safe to perform such skills on patients. In UK medical schools, OSCE’s are performed at every stage of training, from 1^st year through to 5^th/6^th year. OSCE’s have become the mainstay of clinical examination for quite some time, they have a high validity and reliability in portraying much more genuine and true to reality scenarios for students⁴⁰. Any shortcomings which a student may have can generally be picked up through an OSCE, this can be beneficial for a student’s future learning and performance⁴⁰.

In 2007 in America, an article looked into what deficits can be picked up in a student’s ability to perform safe and competent skills through an OSCE assessment⁴¹. The assessment was split into 3 distinct sections: non-cognitive, cognitive and technique, these represent a range of difficulty challenges to be overcome, similar to what will be encountered when employed. In the technique OSCE section, it uncovered a lot of discrepancies in both examination technique and history taking structure, such as not having correct patient exposure levels – not removing a patient’s gown appropriately, rather examining over the gown. Another technique issue noted was that sometimes the students didn’t realise what examination needed to be performed, whether this is due to lack of clinical reasoning or knowledge or purely because they did not care that it need to be done (professionalism) ⁴¹. In cognitive the most common downfalls were excluding diagnoses, many students will pick up on key positives and focus on those rather than consider other possibilities, whether this can be related to some performing a head to toe history taking that they don’t get time to perform a physical exam⁴¹.

Non-cognitive demonstrated related to a lack of professionalism and communication skills in both non-verbal and verbal instances, therefore not taking into account how the patient’s demeanour was, answered any concerns or purely treating patients as a symptom/puzzle rather than a person⁴¹. Overall some students blamed their poor performance during OSCE’s on external factors such as the environment and time pressure rather than a lack of knowledge and communication skills.

In relation to PA training of clinical skills, the basis of which is very similar. PA’s are expected to be competent across a wide variety of clinical skills, as being part of the junior doctor team will utilise a lot of these skills. OSCE’s are performed during all stages of training to assess how students are progressing and whether they are safe to pass onto the next stage of training. Apart from university OSCE’s to pass the postgraduate diploma section of training in the 1^st year, at the end of the 2^nd year as mentioned previously, students must sit OSCE’s as part of the National Exam to be certified to work along with two written exams. When on clinical placement during 2^nd year, PA’s will generally have a portfolio whether online or paper based which is required to be completed as proof of undertaking clinical skills. These are similar to that medical students/doctors perform and require a signature from the supervising clinician before being deemed competent to perform them alone. Feedback can also be given to help improve performance and technique for next time. In comparing how medical students and PA’s perform in OSCE’s, an article performed an assessment to see just how different the results would be. Results of the assessment showed medical students scored 66.9% (+/- 5.7) whilst PA students scored 64.7% (+/- 5.8), these results demonstrate a very similar picture that practical clinical skills training is similar in standard between professions⁴².

From the literature review, we can see that both medical students and PA students have very similar training methods utilised throughout university. These methods have very high reliability and validity when assessing progress and assessing for any weakness a student may have which needs addressing. The educational model for PA’s is a very flexible with an adaptable concept, as mentioned previously there is no set formal structure for the 1^st year, whereas the 2^nd year must meet certain standards for certification purposes. This presents PA’s are highly flexible and adaptable individuals when the needs must to meet demands, this has led to a global interest into the profession with pilot programmes similar to the UK’s 2002 being run across the globe⁴³.

Legal Status and National Prescribing Centre

In the UK, the PA profession is a non-registered healthcare practitioner, currently all qualified PA’s are asked to become part of the managed voluntary register by the Faculty of PA’s. In the past 2 years the GMC and Health & Care Professions Council (HCPC) have both meeting board meetings with the relevant parties to discuss the regulation of PA’s, both governing bodies took the view that PA’s should become a regulated profession and are beginning to explore models for regulation^{29, 30}. Without legal regulation, as mentioned previously this stops PA’s from being able to prescribe medications and order investigations with ionising radiation. The national prescribing centre (NPC) is an organisation that deals with the overseeing of independent and supplementary prescribers; they also provide the competency framework to help prescribers be safe and effective. As of 2017 there is no set guidance in research for the future prescribing from PA’s once regulated; whether PA’s will be managed under non-medical or medical prescribers? For the NPC to consider adding PA’s into their competency framework; legislation and regulatory standards must be officially set up and passed by the government in parliament.

With the profession developing and growing globally as quickly as it is, the need for the public to become aware of the new role and accept the role will help speed up the regulation process as it becomes more of a main stay profession in the NHS⁴⁴. The department of health issued a statement back in 2014 stating that at that PA’s are currently working vital roles within the NHS and are particularly keen to increase their numbers to help support the doctors who have been under increasing pressures⁴⁵. However, even though PA’s can become a valued member of the NHS, their scope of work needed to be clear and precise so that they could provide intermediate level care to their best and reduce workloads⁴⁵. In comparison to this the American PA profession has subsequently been a regulated profession for many years, each state in America regulates PA’s based upon their own legal laws.

Even though each state has a role in the legal regulation for PA’s, this is overseen by the American Academy of PA’s (AAPA). The AAPA was founded back in 1968, they represent certified PA’s across all surgical and medical specialities, across the 50 states, District of Columbia and U.S. territories. All PA’s in the US, must pass a National Exam which is very similar to that of the UK, in the US it is called, ‘Physician Assistant National Certifying Examination (PANCE). The PANCE is the standard by which all students must pass in order to be able to practice in the US, this certification also allows US trained PA’s to work anywhere PA’s are in employment in the world. With new PA programmes starting up around the world such as Australia and New Zealand, these countries will face the same challenges that the UK is currently facing with regulation. When the UK regulation changes, it will allow the Governments of other countries to see how the profession is growing worldwide and make necessary proposals for regulation to be much swifter in passing.

Discussion

When looking at a PA’s role for working in ED, this ultimately depends on his or her experience and the preference of practice from the supervising doctor, as this will determine what role the PA will and may take in the future. From this the PA and doctor together can develop an understanding and the scope of practice for which the PA will adhere to, whether this is a mixture of majors and minors, or spending time in resus or paediatric emergency or whether this is becoming involved in the teaching of new juniors once they have become established within the emergency department. In the following sections, we will review and analyse the literature from above sections and see how this can be contextualised for PA’s to successfully integrate in ED’s across the UK. PA’s can play a key role in the NHS’s directive to see, treat, refer or discharge within four hours, a PA’s ability to see patients and treat them can help keep waiting times down and in turn improve patient satisfaction. In the previous sections we discussed the various differences which are seen between both medical students and PA students, in the context of what is taught during their training and to the degree at which it is deemed successful or not successful based on reviews and comparisons between programs and from NHS healthcare providers. For both medical school and PA school the entrance requirements are dependent on the universities at which they are applying to, however there is a similar level of education background deemed essential for both.

The education background is based around a biomedical/biological/healthcare knowledge and understanding, alongside this a level of maturity and confidentiality will be expected due to the intermit nature of patient interaction from day to day. Many if not all of the entrance requirements stipulate that potential students must be able to demonstrate previous employment/work experience in healthcare if not then a keen interest in pursuing a career in healthcare. Alongside these, students must undertake individual interviews as well as group work to determine whether they have the capacity and interaction skills required for healthcare work. These entrance requirements, interviews and exams are a set protocol to determine those who can be considered to fit this criteria and be good advocates for their respective professions, this is especially apparent and important for PA’s in the UK. With UK PA’s being such a new profession, there must be an increased level of scrutiny and consideration when interviewing the potential students. This is because PA’s as a profession do not want to come under fire about how the students who are the future of the profession are behaving poorly and showing a disregardful work ethic whilst representing the profession in the NHS and therefore damaging chances of becoming a fully integrated profession. As the profession expands and becomes more established, there will be a progression to the entry requirements and the level at which the course is taught. Such as the progression from a postgraduate diploma as is the level for around 90% of current courses, to Master’s level profession only. Some universities in America offer undergraduate level courses typically of 4 year length, as well as pre-physician assistant courses prior to undertaking the master’s level course. Whether this will develop in the UK as the profession grows, or whether the UK health care system will continue to function with PA’s trained at masters level, either way the changes will help PA’s to develop and fulfil the NHS’s staffing needs.

With the current level and types of assessments which medical students and PA students undertake during their training, a lot of similarities in the types of various assessment methods used are seen, these are including both multiple choice questions and OSCE’s. These assessments are designed to test the students across a wide variety of subject knowledge both basic and complex. These assessments which happening during the PA’s training help and allow the lecturers to keep to grips with the students’ knowledge and progression; overall I believe having regular examinations during training is very important because of the accelerated nature of the course. Keeping on top of student progress will help and allow for exceptional students to become leaders and drive the profession forwards. As it stands to date, medical students once qualified do not need to resit their qualifying exams but will sit examinations once they have decided on their specificity career path. Whereas PA’s must recertify every 6 years to be allowed to continue working as a PA within the NHS, allowing for a continued high level of knowledge and care to be provided in all speciality settings. This recertification process allows for a continual development of PA’s and shows the government that the PA profession is making steps to ensure competence is continual.

Due to the wide area that medicine entails, these assessments are targeted at a range of different difficulties in terms of the questions answered and practical OSCE station scenarios.  This allows for both medical and PA schools to see how students are progressing and where gaps in their knowledge may be found, so that changes can be made to address these gaps. These assessments will allow for best practice by PA’s to be completed, this will cross over into emergency settings and will allow for PA’s to become valued members of the team as supervising doctors will be confident with their practice in seeing varying clinical conditions and patient demographics. Leading to more responsibility and change in scope of practice as experience allows. If changes were to be potentially made to the overall level of PA’s, the assessment methods therefore would need to be altered to achieve a similar level of competency. Subsequently PA’s of the future would be of a higher calibre than previously; potentially leading to PA’s being able to achieve high staffing grades within the NHS. With staffing issues and retention of healthcare staff especially apparent in ED, this would allow for PA’s to become senior members of the team and help with the integration of junior members of the team.

In regards to what is taught during training and what can cross over from studying to working life for PA’s wanting to have a future in ED, there a number of cross over skills which can help PA’s to fit into the NHS emergency settings effectively and efficiently. The assessment methods are based on the different topic areas which are taught during university training, as mentioned previously, anatomy and pathophysiology of clinical conditions is a major part of understanding signs, symptoms and clinical condition progression. PA university training is centred on becoming a generalist, therefore with no speciality training whilst learning, they are therefore well adapted to be able to see a wide variety of clinical conditions, whether this is in primary or secondary care. Once qualified PA’s should be able to perform at a similar level to junior doctors, therefore having the ability to see patients, assessing them, coming up with management and treatment plans before seeking assistance from the supervising doctors.

With increasing numbers of patients presenting to ED’s everyday as mentioned previously, there needs to be a change in workforce utilised to help meet the demands and keep waiting times down. As PA’s become more apparently with working in ED and as mentioned in the paragraph above, this would allow for PA’s to become senior members of the team and help with the integration of junior members of the team. In healthcare with some many specialities being involved in the continuing care of patients, those who work in the NHS need to have competent and relevant knowledge to help support patient wellbeing.

In PA training such a wide variety of medical knowledge learnt and a wide variety of clinical conditions both simple and complex seen in the emergency departments every day in the UK, it is safe to say that PA’s could fit into working in emergency areas with their training. In ED, if a PA was to be employed in ED’s, the PA would be able to see a range of patients, seeking assistance when required, therefore this would allow for the middle grades and above to spend time on the more complex patients who are unwell in both Majors and Resuscitation. Currently as of 2016, there are 23 PA’s working in ED’s across the UK², these numbers are expected to grow as the profession grows and more hospital search for other healthcare practitioners to work in ED. However, even though PA’s can become a valued member of the NHS, their scope of work needed to be clear and precise so that they could provide intermediate level care to their best and reduce workloads⁴⁴. Alongside the generalist training which would help PA’s to fit into ED, is the communication skills which PA’s learn during their training.

Mentioned previously is that PA training does not include a specific communication module, but is learnt throughout the 2 year course through patient interaction and OSCE’s. Generally speaking because the majority of PA’s who undertaking training are postgraduates, their communication and social skills generally are more developed as many have been involved in jobs previously within healthcare or other face to face industries. This allows PA’s to be more comfortable when interacting with patients but also other healthcare professionals, this is very advantageous when examination patients, passing over information to healthcare professionals and interacting with healthcare professionals who have never seen or heard of PA’s before.

In Emergency departments, the basis of formulating a diagnosis is from the history and examination, therefore good communication, social skills and examination skills are essential in understanding and working out the underlying cause of what problem had brought the individual into ED in the first place.

Effective communication between patient and doctor is a clinical function that cannot be delegated, treating every single patient with politeness and considerately whilst respecting and listening to their views. In a case presentation in 2015 of a lady who presented with global weakness but no acute changes on her CT, it was thought her symptoms were due to an ischaemic stroke. However, during the post-take ward round, a thorough history and examination with the patient’s daughter’s collateral information, helped the medical staff to determine that this was a long standing problem which has been going on for approximately 18 months. However, the history taken subsequently led to further input from specialist care and the diagnosis of vasculilitic neuropathy⁴⁶. Without a thorough history being undertaken, this patient would’ve been managed incorrectly and may have developed further health complications. Therefore, with effective communication skills this can help unveil specific points and information which can rule out diagnose and point healthcare professionals to the correct diagnosis for patients. In ED, with PA’s generally being older and having effective communication, social and examination skills, this can help patients to be diagnosed quickly, leading to patients receiving the care required quickly and effectively. Avoiding any unnecessary investigations and discomfort and allowing senior doctors to focus on the unwell patients unless assistance is required.

Practical examination skills are another very important tool for healthcare practitioners to help in the aid of a diagnosis of patients. As mentioned previously practical examinations are taught from the very beginning in both medical and PA training programs in the UK and are assessed through OSCE’s, practical examinations form the basis of diagnosing patients alongside with history taking. With incorrect technique for examining patients, there are opportunities for relevant clinical pathology to be missed, leading to misdiagnosis and potentially therefore life threatening changes in the management of patients.

In a recent review of medical doctor (MD) and physician assistants in Netherlands (PA-N), a comparison of history taking, physical examination and communication skills were assessed based on the full scope of medicine based on five OSCE stations⁴⁷. Results showed that MD’s and PA-N’s scored equal on history taking (5.7±0.7 and 5.8±0.8), physical examination (5.4±0.8 and 4.8±1.3) and communication (8.6±0.5 and 8.2±0.8)⁴⁷. Overall, a conclusion of management plans was also recorded for a qualitative report, this showed MD’s and PA-N’s scored very similar as well (6.8±0.6 and 6.0±0.6)⁴⁷. This shows that both MD’s and PA-N’s are trained to a similar level in general clinical skills, showing that in the UK PA’s could fit into working into ED at a junior level and effectively contribute to assessing and managing patients. In practical skills are also clinical skills, these are such as venepuncture and cannulation, whilst at university medical students and PA’s learn these clinical skills in simulation and once deemed competent this will allow the students to utilise these on patients for therapeutic and diagnostic purposes.

These investigations are a very important step when helping to diagnose patients and also help the medical doctors time to be available for other tasks if PA’s are trained to undertake these practical skills instead. In ED, because PA’s are competent and able to perform such tasks, this helps for PA’s to become a more valued member of the junior team and fit into working in ED effectively. Essentially PA’s are classed as dependent practitioners, therefore are under the supervision of a consultant physician who in turn looks after the PA during there working life. This is similar to that of a junior doctor and an emergency nurse practitioners in ED as they report back to their seniors to clarify treatment/managements plans until deemed confident by their supervisor to act with autonomy, however for obvious registration reasons with prescribing and ionising radiation. So far with a PA’s medical knowledge, communication and clinical skills being to a similar level of the junior doctors, it can be shown that PA’s certainly do have the ability to fit in the ED junior rota.

The PA profession discussed in the above sections so far, does show that PA’s have the aptitude to work in emergency settings in the NHS. This capacity for emergency care work is essential for the continuing function of the UK’s NHS system, without working ED’s, patient immediate access to healthcare for potentially life threatening illnesses would be severely hampered and put more strain onto an already strained system.

Conclusion

In conclusion, this thesis has discussed the benefits and uncertainties of recruiting PA’s both into the NHS and ED’s. ED’s in the UK are in such a crisis with increasing patient numbers presenting each day that something urgent needs to be done before ‘Never Ever Events’ start occurring in multiple hospitals. As mentioned in the introduction, latest statistics demonstrate that the UK has 2.71 doctors per 1,000 people; the UK ranks 24^th out of 27 European countries surveyed¹. This is even behind some of the poorest EU countries such as Bulgaria, Latvia and Estonia; making the UK according to government health groups ‘worrying, unsafe and serious implications for patients and staff’. From the evidence discussed above in the earlier sections we can demonstrate how PA’s and medical student’s clinical skills and knowledge overlap to certain degrees. This provides a clear benefit to the NHS by integrating PA’s into their workforce, the overlapping ability of clinical skills can help not only in ED but throughout any primary and secondary care facilities the NHS is involved in. With an ever increasing number of PA’s being trained in the UK, this will help the struggling doctor workforce and hopefully change the NHS’s unsafe image in the eyes of governing health groups.

To date, many PA’s have very successful careers in a range of different specialities, ranging from GP surgeries to transplant surgery, this is primarily because PA’s have the ability to spend the time learning  the area such as those in training posts as PA’s will not rotate round from speciality to speciality unless otherwise agreed upon. This ability of a PA to not rotate combined with their clinical skills and knowledge makes PA’s appeal to specialities which struggle to fill training posts and whose staffing issues make it unsafe for patients. For the future there are some changes which could be potentially made to PA training, changes would allow for a more well-rounded and successful training programme: these are such as the integration of TBL for CPT, as discussed in above sections, results demonstrated an improved in pharmacodynamics and pharmacokinetics and similar performance in other areas of CPT. Therefore, improving a PA’s CPT knowledge still within the same time constraints as current. Another change which would be very significant for PA education would be the introduction of communication skills, current PA programme do not included such training as expect PA students to have these already in place; for the time being most are mature students and already have communication skills derived from previous experiences. However, as time progress’s and younger students begin to come through training they won’t possess the same communication abilities as those of previous years. Potential limitations to my thesis are such as the lack of UK based research on PA’s in regards to the structure of PA University programmes and what they are based upon. Others limitations are surrounding the lack of information relating to UK PA’s and their personal experiences working in ED, reason for this limitation in a lack of UK PA research but also laws prohibiting the Faculty of PA giving out the contact information of PA’s working ED; so therefore I am unable to send out questionnaires for data gathering.