From physician associate to medical student

The debate around physician associates (PAs) has grown from being confined to the shadows of social media and occasional remarks on wards, to a seismic debate which has brought the standing of a prestigious royal college into disrepute. As a former PA, now at medical school, I feel compelled to speak up.

Like many others, training as a PA was my plan B, after I lost the nerve to face another medical school rejection. My sticking point was the University Clinical Aptitude Test (UCAT). With funding for graduate entry medicine woefully inadequate, I was unable to afford to live away from home, limiting my applications to my local university. Just two years earlier I had discounted being a PA as a career option, as the scope of practice was limited, and the title had not long changed from “physician assistant”—I did not want to be an assistant. However, something changed, the connotation of “assistant” was lost, and the scope of practice gradually expanded. I could see doctors’ pay and working conditions worsen, learned of training bottlenecks, geographical instability, the endless hoop jumping of quality improvement projects, research, and exams. It became easier to convince myself a career as a PA was the right choice for me. I have no doubt that there are many others just like me.

My PA course was hosted within a reputable medical school, the one I had always dreamed I’d study at. It started with an intensive clinical skills block in which I believed I was learning all the practical skills needed to see patients. This included history taking, venepuncture, cannulation, a whole host of examination skills for the different body systems. But where is the context, I wondered, unable to understand how to interpret any symptoms or clinical signs. As the weeks progressed it became clear that lack of context would be the spiral running through the curriculum, as we learned conditions by rote from the, now defunct, PA matrix of conditions, with little pause for thought of the underpinning sciences. Minimal anatomy, a couple of hours of pharmacology, no physiology, immunology, histology, genetics, or microbiology. I was left academically unstimulated, with “we don’t need to know that” a frequent response to my enquiries. Why if doctors need to know it, would PAs not? After all, course leaders told us we were going to qualify at a foundation doctor level.

Though fleeting, the clinical year was better. I enjoyed placements and was seen on the wards late into the evening, absorbing all the knowledge I could from the doctors in the department. It was these experiences, and the inspirational seniors, that solidified my decision to apply to medical school just one more time.

Now a medical student, I spent my first year overwhelmed by how much more sense everything made with the benefit of preclinical knowledge. If I saved every penny that dropped, I’d be on a liveable NHS bursary! But not only has training to be a doctor made stark the gaps in my knowledge, it has highlighted that the answers I prepared for “why do you want to be a Physician Associate?” and the touted benefits of the role, are in fact the blueprint to solving the myriad problems troubling our profession today.

Reflecting on my experience thus far and talking with other PAs who have made the jump to medical school, those leaders seeking to navigate this mess would be foolish not to pick our brains for answers. If you’re reading, take note.

We must set national scope of practice for PAs. Seeing undifferentiated patients is an absolute red line. Most of the PA workforce due to be regulated come December will have qualified from unaccredited courses, up to 15 years ago, with little oversight or standardisation in quality, content, or assessment. Scope of practice must account for their varied knowledge and competence. Until we make this safe, there must be a recruitment pause.

PA numbers are being expanded in response to a workforce crisis, to which the answer is obviously recruit and retain more doctors. The PA role is appealing for all the reasons medical training is not. We must fix pay, endless rotation, lack of geographical stability, excess additional costs, and make medicine a viable and attractive choice for those who will otherwise leave or be tempted into a PA career. But we must not let standards continue to slip.

Existing PAs, whatever their motives, have been sold a lie. Many of them are capable and motivated to provide care to patients in the NHS, and with the right training, would make excellent doctors. Fund graduate entry medicine appropriately for all students, making it affordable for all those able and motivated. Only then can we consider negotiating routes for PAs to retrain. Those PAs left must work in appropriate scope of practice, supporting doctors, but never substituting them.