JMS Pearce
Hull, England

A recent high-profile death in London has led to doctors’ concerns about medical associate professions.^1,2 A thirty-year-old woman died from a pulmonary embolism after seeing a physician associate (PA). This led to the case being discussed widely in the media, on social media, and in Parliament by Barbara Keeley MP:

Emily Chesterton saw the same PA twice in north London with breathlessness and calf pain, while believing she was seeing a GP, Labour MP Barbara Keeley told the House of Commons on 6 July. Chesterton was misdiagnosed with a sprain, long covid, and anxiety, and prescribed propranolol shortly before her death in November 2022.

The coroner concluded:

“Emily Chesterton died from a pulmonary embolism, a natural cause of death. She attended her general practitioner surgery on the mornings of 31 October and 7 November 2022 with calf pain and shortness of breath, and was seen by the same physician associate on both occasions. She should have been immediately referred to a hospital emergency unit. If she had been on either occasion, the likelihood is that she would have been treated for pulmonary embolism and would have survived.”³

The British Medical Journal observes: “That is a heartbreaking statement, making clear the failings in the health system.” The MP Barbara Keeley said in Parliament: “This case raises questions about the wider use of physician associates and independent practitioners in the NHS, and particularly about allowing the provision of unsupervised one-to-one consultations in general practice.”

Physician associate (PA)

The first physician associates were introduced in the UK in 2003. There are currently more than 3,000 qualified PAs working in the UK. The General Medical Council expects the number to grow steadily in the next few years, with one study estimating a projected growth of 1,000% per year.³

PA students must have a bio-science-related degree. They then take a two-year postgraduate course in medical science and clinical reasoning. Depending on the place of study, up to 50% of the course can be based on supervised clinical placements in the emergency department, mental health, paediatrics, acute and general medicine, general surgery, obstetrics and gynaecology and community medicine.¹ To become a qualified physician associate (PA) in the UK, students are required to take the Physician Associate National Examination (PANE).

According to the Faculty of Physician Associates (FPA), PAs work with the supervision of a consultant or GP in a range of areas. They carry out tasks such as taking medical histories, physical examinations, and formulating differential diagnoses and management plans. Established by the Royal College of Physicians, the faculty crucially says PAs are intended to work “alongside” doctors and provide “medical care.”¹ But the level of supervision is neither defined nor regulated. The rights to prescribe are crucial elements.

The right to prescribe

In the UK, until recently, only medically qualified practitioners were granted the rights to prescribe any licensed medicine including controlled drugs. Like other former exclusively medical privileges, this right has been delegated. Suitably qualified nurses but not PAs can prescribe. The Human Medicines Regulations 2012 permits:

Independent prescribers (IP) are nurses who are registered with the Nursing and Midwifery Council as an IP. They are able to prescribe any medicine provided it is in their competency to do so. This includes medicines and products listed in the BNF, unlicensed medicines and all controlled drugs in schedules two – five.⁴

Parliament has not yet enacted legislation granting PAs independent or supplementary prescribing rights. Different legislation may apply in other countries. A PA’s scope of practice in the UK does not include the ability to supply or prescribe medicines, . But this is easily breached as in the Emily Chesterton case (and probably in others), highlighting the lack of statutory regulation. The FPA’s guidelines are easily broken with disastrous effects.

In the US, practices vary in different states. Generally, physician assistants (PAs) work under the license of a specific physician. They cannot practice independently, either in the hospital or in the office setting. They have the full prescribing privileges of a physician, and their affiliated physician does not have to co-sign or approve their prescriptions. Nurse practitioners (NPs) also function under the supervision of a specific physician—as a local rule, not a law. It is probable that the affiliated physicians take some legal responsibility. Unlike PAs, NPs are permitted to practice entirely independently, and can prescribe drugs just as a physician does. NP salaries are somewhat higher than those of PAs, possibly because they have the additional nursing degree. In many settings, they function interchangeably.*

Comment

Medical practitioners have in recent years passed on what used to be exclusive doctors’ responsibilities to other health workers. PAs and nurse specialists run general clinics including diabetes, cancer, cardiology, gastroenterology, gynecology, epilepsy, and dementia in both hospital and general practice.

In the UK, nurse specialists do valuable, skilled work and are popular amongst patients. They doubtless lighten the burden of doctors. This arose owing to increasing patient demands and expectations that over the years have taken more of GPs’ time. However, the burden of most general practitioners no longer includes duties of a former generation—weekend cover, night calls, and obstetrics—often performed by locums of varying competence.

Such delegation is not without danger. Standards of practice are precarious. Furthermore, patients often cannot discriminate between those who are medically qualified and physician associates and independent prescribers who are not. Emily’s mother, Marion Chesterton, reported: “We only discovered that the medic treating Emily was not a doctor the week before the inquest. This caused us extreme distress.”

Dr. Helen Salisbury, a GP, noted in the British Medical Journal:

When I’m feeling pessimistic, I worry the use of roles like PAs are a deliberate attempt to downgrade general practice where you get a two tier system and, if you are in a less affluent area, you rarely see a doctor.⁵

In 2012, the World Health Organization (WHO) emphasized the necessity of task-shifting from doctors to nurses.⁶ Led by administrators and bureaucrats, this dispersal of clinical practice both in hospitals and general practice has been accepted and tolerated by a culpable medical profession. Consequently, patients have been subjected to a potential impairment of standards of care; they often do not know who is treating them, and justifiably complain of lack of continuity and personal responsibility.

Sadly, it is always the patients who suffer. This tragic case should lead to the prompt revision of medical clinical responsibilities, standards of care, and safety.

Note

I am grateful to Prof John Godine, MD, PhD, of Massachusetts General Hospital for information about current US practices.

References

1. Dean E. Physician associates in the media spotlight: what’s the latest on the role? British Medical Journal 2023;382:1731.
2. Becoming a PA Information Portal. Royal College of Physicians Faculty of Physician Associates. https://www.fparcp.co.uk/becoming-a-pa.
3. House of Commons debate. Physician Associates. July 6, 2023. vol. 735, col. 1025-1034. Hansard. https://hansard.parliament.uk/Commons/2023-07-06/debates/D98F2ABE-7B33-4748-B88E-ED7243469131/PhysicianAssociates.
4. National Institute for Health and Care Excellence. Non-medical prescribing. https://bnf.nice.org.uk/medicines-guidance/non-medical-prescribing.
5. Salisbury H. Physician associates in general practice. British Medical Journal 2023;382:1596.
6. WHO Recommendations: Optimizing Health Worker Roles to Improve Access to Key Maternal and Newborn Health Interventions Through Task Shifting. Geneva: World Health Organization; 2012. PMID: 23844452.