Physician assistant

(Redirected from Physician associate)

A Physician Assistant or Physician Associate (PA) is a type of healthcare professional. While these job titles are used internationally, there is significant variation in training and scope of practice from country to country, and sometimes between smaller jurisdictions such as states or provinces. Depending on location, PAs practice semi-autonomously under the supervision of a physician, or autonomously perform a subset of medical services classically provided by physicians.[1]

The educational model was initially based upon the accelerated training of physicians in the United States during the shortage of qualified medical providers during World War II. Since then, the use of PAs has spread to at least 16 countries around the world.[1][2] In the US, PAs may diagnose illnesses, develop and manage treatment plans, prescribe medications, and serve as a principal healthcare provider. In many states PAs are required to have a direct agreement with a physician.[3] In the UK, PAs were introduced in 2003. They support the work of the healthcare team, but are dependent clinicians requiring supervision from a physician.[4] They cannot prescribe medications nor request ionising radiation investigations (e.g., x-ray) in the UK.[5] PAs are widely used in Canada. The model began during the Korean War and transitioned to the present concept in 2002. Skills and scope of privileges are similar to those in the US.[1]

Nomenclature

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The occupational title of physician assistant and physician associate originated in the United States in 1967 at Duke University. The role has been adopted in the US, Canada, UK and Ireland, each with their own nomenclature. The role has been adopted in the US, Canada, United Kingdom, Republic of Ireland, Netherlands, Australia, New Zealand, India, Israel, Bulgaria, Myanmar, Switzerland, Liberia, Ghana, and by analogous names throughout Africa, each with their own nomenclature and education structure.

Jurisdiction Title Abbreviation Test Certifying Authority
United States Physician Associate/Physician Assistant PA-C Physician Associate National Certification Exam National Commission on Certification of Physician Associates[6] with accompanying state-level certification.
Canada Canadian Certified Physician Assistant CCPA Entry to Practice Examination Physician Assistant Certification Council of Canada[7] with accompanying provincial certification
United Kingdom Physician Associate PA-R Physician Associate National Certification Examination Royal College of Physicians[8]
Republic of Ireland Physician Associate PA none none
Kenya Clinical officer CO Clinical Officers Licensing Examination Clinical Officers Council
South Africa Clinical Associate[9]
Malaysia Assistant Medical Officer Malaysia Medical Assistant Board (Lembaga Pembantu Perubatan Malaysia)
India Physician Assistant/Physician Associate PA National common Entry and Exit Examination. NCAHP, Ministry of Health and Family Welfare, Government of India.
China Assistant Doctor[10]
Papua New Guinea Health Extension Officer[11]
Former Soviet Union Feldsher[12]
Israel Physician Assistant[13] PA-R

Services

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Physician assistants or associates may:

  • conduct patient interviews and take medical histories
  • conduct physical examinations
  • order and interpret diagnostic tests and exams (in some countries)
  • diagnose illnesses
  • formulate treatment plans
  • coordinate and manage care
  • perform medical procedures
  • prescribe medications (in some countries)
  • conduct clinical research
  • provide patient counselling
  • offer advice on preventative health care
  • first assist in surgery[14]
  • Can serve as a clinical tutor, assistant professor, associate professor, or professor (depending on academic qualifications along with experience).

Workplaces

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Physician assistants or associates train to work in settings such as hospitals, clinics and other types of health facilities, or virtually via telemedicine. PAs are commonly found working in teaching and research as well as hospital administration and other clinical environments. PAs may practice in primary care or medical specialties, including emergency medicine, surgery and cardiology.[15]

Training

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Physician assistant (or associate) education is shorter than a medical degree required to become a physician. It also typically does not involve residency training, although this is increasingly offered in a variety of specialties.

Renewal of certification is usually required every few years, varying by jurisdiction.[citation needed]

History

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In 1961, Charles Hudson recommended that the American Medical Association create new medical provider certifications. Eugene A. Stead of the Duke University Medical Center assembled the first class of physician assistants in 1965, composed of four former US Navy Hospital Corpsmen.[16][17] He based the curriculum of the PA program on his first-hand knowledge of the fast-track training of medical doctors during World War II.[18] Two other physicians, Richard Smith at the University of Washington, and Hu Myers at Alderson-Broaddus College launched their own programs in the mid-late 1960s. J. Willis Hurst started the Emory University Physician Assistant Program in 1967.

The Liberian model of PAs was a curriculum intended for graduates to work in areas absent of physicians as physician substitutes. Advisors for this program included UNICEF, American physicians, and Agnes N. Dagbe, MS, RN, a Liberian nurse educated in the US. Additional training was done in the USSR. The Liberian government inaugurated the program in 1965 with Dagbe as PA program.[19]

Beginning in January 1971,[20] the US Army produced eight classes of physician assistants, at 30 students per class, through the Academy of Health Sciences, Brooke Medical Center (academically accredited by Baylor University).

In 2017, approximately 68% of physician assistants in the United States were women and approximately 32% were men.[21]

The profession expanded globally. It can now be found in Afghanistan, Australia, Canada, Germany, Ghana, India, Israel, Liberia, the Netherlands, New Zealand, Saudi Arabia, and the United Kingdom. As a profession, physician assistants have greatly influenced the theory and conceptualization of socially accountable health professional education.[22]

Jurisdictions

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Australia

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In 2011, Health Workforce Australia began developing the role of physician assistant throughout the country culminating with registration and a PA Program based out of James Cook University.[23] The Australian Society of Physician Assistants in 2011 published a code of practice.[24] Despite all initial indicators showing that the new profession would be successfully integrated into the health care system, in 2013 it was reported that the progress had floundered resulting in the majority of PAs in Australia being unemployed.[25]

Canada

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As of October 2018, there are approximately 800 physician assistants working in healthcare settings in Canada.[26] The first formally trained physician assistants graduated in 1984 from the Canadian Forces Medical Services School at Borden, Ontario.[27] The Canadian Medical Association (CMA) recognized physician assistants as a health professional in 2003.[27] Physician assistants are able to perform medical functions such as ordering tests, diagnosing diseases, prescribing medications, treating patients, educating patients and performing various medical and surgical procedures. Physician assistants are labeled under the federal government national occupational classification code 3124: allied primary health practitioners.[28]

Education and certification (Canada)

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The first civilian physician assistant education programs were launched in 2008 at the University of Manitoba and McMaster University.[27] In 2010, a third civilian program was launched by the consortium of physician assistant education (University of Toronto, Northern Ontario School of Medicine, and The Michener Institute) while further programmes were added in 2024 at Dalhousie University[29] and at the University of Calgary.[30]

In Canada, the education of a physician assistant generally consists of three years of professional post-graduate university education. The education is delivered over a two calendar year time-frame by completing fall, winter and summer semesters for both years of the program in either a master level university physician assistant program or post-graduate professional university bachelor level physician assistant program. Physician assistant graduates become eligible for the certification exam by being a graduate of a Canadian physician assistant program that is recognized by the Physician Assistant Certification Council of Canada (Canadian Armed Forces physician assistant program, University of Manitoba, McMaster University and the consortium of physician assistant education all of which are accredited by the Canadian Medical Association).[26]

Scope of practice (Canada)

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As of 2023 PAs in Canada may:

Physician assistants resemble and provide many of the functions of Physician Assistants (PA) are academically prepared and highly skilled health care professionals who provide a broad range of medical services. PAs are physician extenders and not independent practitioners; they work with a degree of autonomy, negotiated and agreed on by the supervising physician(s) and the PA. PAs can work in any clinical setting to extend physician services. PAs complement existing services and aid in improving patient access to health care. A relationship with a supervising physician is essential to the role of the PA. "[31] Physician assistants may be compared to the role of nurse practitioner by the general public and may be confused as the same profession. Nurse practitioners in Canada practice under an advanced nursing model.[32] Physician assistants practice under a medical model, similarly modeled after medical school (physician) education.[33] Nurse practitioners practice within their defined specific scope of practice autonomously and sometimes collaboratively. The defined scopes of a nurse practitioner include the areas of (family care, adults and paediatrics). Physician assistants are permitted to practice in all medical specialties by mirroring the practice of a physician with a full range of skills and scope by practicing both autonomously as a clinician and collaboratively with physicians when required. Some examples of practice areas for physician assistants include (emergency medicine, critical care medicine, cardiology, psychiatry, community and family medicine, neurology, surgery, orthopaedics, internal medicine, oncology, gastroenterology, military medicine, respirology, dermatology, women's health and many more specialities). Physician assistants may perform certain roles which have been traditionally only provided by physicians in clinical practice, making the PA's medical training over other providers unique in this regard.[citation needed]

Compensation (Canada)

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Physician assistant salaries in civilian practice in Canada are relatively new and can range from approximately $80,000 CAD for entry level positions to $142,000 CAD a year for experienced providers which are not on call and up to $178,000 CAD for experienced providers which are on call.[34] The physician assistant profession is newer to civilian practice in Canada. The compensation report published in 2019 by the Canadian Association of Physician Assistants outlines the typical salaries across Canada being an entry median salary of approximately $80,000 CAD and an experienced median salary of approximately $105,000 CAD.[35]

Regulation (Canada)

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Physician assistants are currently practicing across Canada in the Canadian Armed Forces as commissioned officers in domestic and international environments and have been in practice since the 1960s.[36] Physician assistants outside of the Canadian Armed Forces practice usually in the public health care system in the provinces of Manitoba, Ontario, New Brunswick, Nova Scotia, and Alberta.[citation needed] Physician assistants have been regulated in Manitoba since 1999 and in New Brunswick since 2009[37] and are registrants of their respective provincial college of physicians and surgeons. In Ontario, Alberta and Nova Scotia the profession is not regulated at this time.[citation needed] Physician assistants in Ontario were introduced in 2007 to the public health system as a joint venture between the Ontario Ministry of Health and the Ontario Medical Association.[38] In Alberta, a registry has been established for physician assistants under the College of Physicians and Surgeons of Alberta with future regulation underway.[39] In Ontario, future regulation has been discussed by the Ontario Ministry of Health in which physician assistants would be members of the [[College of Physicians and Surgeons of Ontario|College of Physicians and Surgeons of Ontario.[citation needed]]] Physician assistants are represented by the Canadian Association of Physician Assistants, which originally was formed in October 1999.[27] As of 2023, PAs scope of practice in Canada is described at their website:

The PA's scope of practice is determined on an individual basis and formally outlined in a practice contract or agreement between the supervising physician(s), the PA and often the facility or service where the PA will work. Activities may include conducting patient interviews, histories and physical examinations; performing selected diagnostic and therapeutic interventions or procedures; and counseling patients on preventive health care.[citation needed]

Germany

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Physician Assistants / Associates were established in Germany as a degree course in 2005. (de:Arztassistent [40]). Recruitment had initially been slow, but as of 2019 there were said to be several hundred de:Arztassistenten in Germany.

India

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The first PA program in India was established in 1992 with a focus on expanding cardiovascular surgery. Since then, eight additional programs have developed (in total seven baccalaureate and four master's level programs).[41] The profession is regulated by the National Commission for Allied and Healthcare Professions, Ministry of Health & Family Welfare, Government of India.

Ireland

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Physician Associates were introduced by the Health Service Executive in the mid-2010's. The Royal College of Surgeons has offered a PA postgraduate degree since 2016,[42] with 28 graduating by January 2021.[43] PAs may not write prescriptions.[43]

Israel

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Physician Assistants were introduced in Israel in May 2016 to help augment a shrinking physician workforce. The initial training programs have been overseen by the ministry of health directly, but transition to academic training is planned.[citation needed] Israeli PA education is modeled after United States' and Netherlands' approaches, and has focused on former paramedics with bachelor's degrees.[citation needed] As of 2022, the 100 or so PAs in Israel work exclusively within Emergency Departments. While PA scope of practice includes many emergency procedures, Israeli PAs are not currently allowed to prescribe or administer medicine in non-emergency settings.[13]

New Zealand

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In February 2015, Health Workforce New Zealand completed a Phase-2 trial of PAs who worked for a period of two years (2013–2015) in four clinical settings.[44] Specifically, the sites included one rural emergency department and three primary care settings (two rural and one urban) located on the North and South Islands of New Zealand.[44] At conclusion of the trial, several clinics continued to employ PAs while the process of health regulation makes its way through the government bureaucracy.[citation needed]

United Kingdom

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The position of physician assistant was established in the United Kingdom in 2005. It evolved from that of physician assistant, developed in the US in the 1960s.[citation needed] In 2012, a group of physician assistants voted to change the name to physician associate, this title is however exceedingly close to the title Associate Physician, which represents a senior medical doctor. Hillingdon Hospitals NHS Foundation Trust was asked to manage the recruitment of 200 physician associates who are expected to come from the US for 40 NHS trusts in September 2015.[45]

Physician Associates are not regulated and are therefore not registered healthcare professionals. They are not able to prescribe or order tests which require ionising radiation. Legally, Physician Associates cannot work autonomously, as the provision of treatment is regulated by the Health and Social Care Act, which explicitly legislates the protected professional titles of the registered healthcare professionals that can undertake the regulated activities of providing treatment.

In 2022 it was reported that private company Operose Health, owned by US company Centene Corporation, which had acquired many UK National Health Service (NHS) GP practices, was using many PAs—at less than half the cost of a GP[46][47]—and allowing them essentially to act as GPs, without required supervision. A BBC reporter worked undercover at an Operose practice for six weeks, reporting on many problems.[46] A senior GP said that the company was prioritising profit, putting patients at risk.[4]

In July 2023, the death of Emily Chesterton raised questions about the naming of physician associates in the UK. Emily died from a pulmonary embolism after seeing a physician associate twice in the weeks proceeding her death, who had misdiagnosed her and asked for her to be given anxiety medication. Emily was under the impression she was seeing her GP, and not a physician associate. After her death, Emily's mother and her local MP, Barbara Keeley, called for more regulation around physician associates and for the role to be renamed to avoid confusion.[48][49]

In July 2023 a motion was brought forward for discussion by the British Medical Association to rename PAs clearly as Physician Assistants in the U.K. to avoid role confusion with Physicians and for them to be registered with the Health and Care Professions Council.[50]

In February 2024 a story broke about make up artist Christopher Tucker receiving a cystoscopy despite symptoms of a urinary infection. He received no antibiotics for the infection or as prophylaxis after the procedure. He died less than 48 hours later. The Physician Associate involved then took part into the investigation of their own practice in the case.[51]

Faculty of Physician Associates, Royal College of Physicians (UK)

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The Faculty of Physician Associates is the professional body for Physician Associates working in the United Kingdom.[citation needed] A joint venture between the Royal College of Physicians of London and the previous professional body, the United Kingdom Association of Physician Associates, the Faculty officially launched in July 2015, taking over all professional responsibilities.[citation needed] The Faculty oversees the managed voluntary register, which all practising associates are encouraged to join, and sets and runs the National Assessment Examination and National Recertification Examination which is optional for PAs.[52]

Scope of practice (UK)

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In the United Kingdom, PAs are dependent practitioners, and they must practice under the supervision of a physician.[5] Physician Associates/Assistants are trained under the medical model, similarly to physicians, to deliver medical care in primary, secondary, and tertiary care settings.[citation needed] They perform some tasks relating to diagnosis, taking medical histories, ordering and interpreting laboratory tests.[53] PAs cannot legally request ionising radiation investigations such as a CT scan or radiographs,[5] they also cannot legally prescribe any medications.

There is no nationally agreed upon scope of practice for Physician Associates in the United Kingdom as of 2024, despite them working in the United Kingdom for over a decade.

In early 2024, the British Medical Association published their recommendations for doctors supervising PAs[54] in an effort to formulate a scope of practice aligned to the education received by PAs.

The six core principles of this guidance are:[55][56]

  1. This is an assistant role to doctors helping with simple practical procedures, administrative tasks, and working with patients in a supportive and specified role.
  2. This does not extend to seeing undifferentiated patients in any situation.
    • In a hospital setting, this means that they should not work in an emergency department setting unless a supervisor reviews each patient in person
    • In a GP setting, a GP should first triage all the patients and decide which ones a PA can see for some protocolised reviews in stable patients
  3. When seeing differentiated patients (those already triaged by a doctor as appropriate, or already assessed, diagnosed, and on a treatment plan by a doctor), MAPs must be directly and closely supervised.
  4. PAs/AAs/SCPs must not make independent management decisions for patients nor be responsible for initial assessments of patients and diagnosis.
  5. MAPs must make it clear in all communication to patients and to other staff members that they are not doctors and be clear about their specific role.
  6. Statements such as 'I am one of the medical team' must not be used unless also stating their own title.

Points five and six are aligned to the existing guidance from the Faculty of Physician Associates.[57] Who advise that Physician Associates should not use any title that may confuse patients, giving some specific examples: 'GP physician associate', 'GP PA', 'PA surgeon'. The Faculty is also clear that "PAs must not use the prefix 'Dr' or title 'doctor' in any clinical environment or interaction with patients."[57] the faculty highlight that a PA could use the title Dr if they hold a recognised Level 8 qualification when in an academic context/environment, but not in the clinical setting.

The British Medical Association highlighted a number of activities that they felt PAs should not be undertaking.

Procedures
Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT:

Perform, train in, or consent others for invasive or life-threatening procedures including:

  • Any procedure under a general anaesthetic (GA), under sedation, or regional anaesthesia (including spinal, nerve, Bier)
  • Giving a GA except in the case of an AA giving it under the direct and immediate supervision of an anaesthetic consultant
  • Endoscopy (any)
  • Surgical procedures under GA, spinal anaesthesia, or local anaesthesia (LA), including caesarean section.
  • Diagnostic and therapeutic abdominal paracentesis
  • Angiography, echocardiography, pacemaker insertion or valvular intervention
  • Pleural procedures
  • Interventional radiology procedures
  • Vaginal delivery of a baby, including
  • instrumental delivery of a baby
  • Lumbar punctures
  • ABGs with lidocaine (therefore, excluding most ABGs)
Assessments
Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT:
  • Undertake outpatient work in clinics unless this is within a predictable, protocol-led role within the department (e.g., surgical pre-op assessment) where no diagnosis or medical decision making is expected and there is a clear pathway for escalation of unwell or unstable patients
  • Assess, diagnose, or manage undifferentiated patients (this includes areas such as ED, the acute medical take, and general practice)
  • Make independent decisions regarding initial management or ongoing care of patients
  • Have input into DNACPR decisions/ ceiling of care/or escalation decisions (other than as a supportive role) nor sign DNACPR/RESPECT forms
  • Perform medication reviews
  • Be consulted for, or provide, specialty specific advice unless documenting on behalf of a consultant/senior registrar in that specialty (it must be clearly stated/ documented as such)
  • Triage or vet referrals received to the specialty/department/practice in which they are employed
  • Issue a formal radiology report
  • Undertake Mental Health Act assessments, diagnose or manage any mental health condition for which inpatient care is required
  • Accept devolved responsibility for the physical health of patients under the inpatient care of a psychiatrist
  • Use any 'workarounds' to get access to credentials for prescribing or requesting ionising radiation
Communication with Patients and Colleagues
Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT:
  • Clinical documentation must not include prefixes such as 'Dr' or 'Mr/Miss/ Ms' that could imply status as a medical practitioner (or surgeon)
  • Direct/instruct a doctor or other professional to prescribe a medication or to alter an existing prescription
  • Direct/instruct a doctor or other professional to request an investigation or procedure
  • Direct/instruct a doctor to perform any task based on the PA's sole assessment
  • Be involved in end-of-life discussions, except as a source of information or in a supportive role. The decision-making and related paperwork must be completed by doctors
  • Be involved in giving specialty advice (unless repeating a consultant/senior registrar's advice and making it clear who the advice has come from)
  • Take consent for procedures that they themselves do not perform
  • Notify public health in cases of notifiable infectious diseases nor make any public health decisions regarding infectious disease unless specifically instructed to by a doctor or public health specialist working in health protection
Daily Work
Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT:
  • Cover, share, or participate in a rota designed for doctors at any level
  • Sign a death certificate or cremation form
  • Make any independent treatment decisions
  • Attend, prepare, or give any teaching or seminars to doctors as part of their specialty or foundation teaching. PAs or AAs are not eligible to attend doctor teaching of any specialty unless offered to the wider MDT
  • Be the sole person taking PICU/ICU step-down or transport handovers without a doctor present
  • Discharge patients independently
Clinical Governance
Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT:
  • Publish or be involved in publishing research about the effectiveness of the PA/AA/SCP role without declaring this as a conflict of interest
  • Operate in any supervisory or leadership role in which oversight is given over medical staff (e.g., clinical or medical director, clinical or educational supervisor, responsible officer)
  • Be involved in revalidation of medical staff except as a colleague giving feedback
  • Be involved in disciplinary or fitness to practice investigations at departmental, Trust, Board or MPTS level other than as a witness
  • Prepare reports for coronial inquests / procuratorial inquests or act as an expert witness in a civil or criminal trial (though it is permissible to act as a material witness like any other member of the public)
Anaesthetics and Intensive Care Unit
Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT:
  • Formulate anaesthetic management plans or lead the brief for the anaesthetic team
  • Assist in any paediatric anaesthesia (<18 years)
  • Assist in any emergency or trauma anaesthesia
  • Assist in anaesthetising any patients in remote environments (i.e., outside of main operating theatre suites)
  • Assist in anaesthetising any patients outside of normal working day hours (0800-1800) Monday to Friday
  • Administer any medicines by any route to patients
  • Induce anaesthesia
  • Undertake laryngoscopy or endotracheal intubation
  • Undertake any advanced airway procedure
  • Conduct emergence of a patient from anaesthesia without direct supervision by a consultant anaesthetist
  • Undertake Rapid Sequence Induction, or advanced airway procedures
  • Anaesthetise any patients with a known or predicted difficult airway (such as previous grade 3 or grade 4 Cormack-Lehane view)
  • Anaesthetise patients for any high-risk elective surgery, including any cardiac, thoracic, neuro-surgical, and obstetric surgery
  • Perform total intravenous anaesthesia
  • Undertake neuraxial or regional anaesthesia
  • Perform conscious sedation
  • Perform central venous or arterial cannulation
  • Percutaneous drainage or needle aspiration of contents of any body cavity
  • Undertake any anaesthetic work with less than a 1:1 supervision ratio, except where the supervising consultant is supervising a senior (post-FRCA) anaesthetic trainee or SAS doctor in an immediately adjacent operating theatre and 1:1 recommended for all but the most experienced (10 years plus)
  • Undertake any anaesthetic work with less than a 1:2 supervision ratio under any circumstances
  • Cover any vacancy on an anaesthetic or intensive care doctors' rota
  • Hold a specialty bleep, take specialist referrals of any kind, nor be involved in vetting referrals
  • Discharge patients independently
  • Use the titles 'consultant', 'registrar', 'specialist', 'resident' or 'senior house officer'
Clinical Radiology
Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT:

Formally report imaging in any modality including:

  • Plain film
  • Computed tomography (CT)
  • Magnetic resonance imaging (MRI)
  • Nuclear medicine
  • Ultrasound

Approve, vet, or protocol imaging in any modality including:

  • Plain film
  • CT
  • MRI
  • Nuclear medicine
  • Ultrasound

Perform, train in, or consent for invasive of life-threatening procedures including:

  • Fluoroscopic procedures
  • CT-guided procedures
  • Ultrasound guided procedures
  • Any endovascular intervention

Lead or coordinate MDT meetings Interpret imaging for MDT meetings.

  • Hold a radiology referral bleep or mobile device
  • Take specialist referrals of any kind or give specialist advice
  • Be on the radiologist rota at any level or be used interchangeably with radiologists in any way

Auxiliary roles within an intervention theatre:

  • Diagnostic radiography
  • Radiation planning
  • Radiotherapy delivery
  • MDT coordination
  • Use the titles 'consultant', 'registrar', 'specialist', 'resident' or 'senior house officer'
General Practice
Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT:
  • See undifferentiated patients*
  • Consult with any paediatric patient (<16 years)
  • Be sole practitioner on call or duty clinician
  • Be sole practitioner in the premises
  • Be responsible for clinical triage
  • Undertake direct supervision of GP registrars, FY2s or medical students
  • Undertake teaching of doctors
  • Undertake debriefs for GPRs/FYs/medical students
  • Undertake EoLC discussions and documentation (DNACPR or RESPECT forms)
  • Complete cremation forms
  • Undertake home visits involving undifferentiated patients
  • Perform minor surgery, IUS/IUD/Nexplanon insertion
  • Undertake 6/8-week baby checks
  • Steroid injections or any intra-articular injection
  • Do referrals to secondary care (scheduled) or advice & guidance, unless reviewed by a GP
  • See any patient that has not a) been clearly informed at the point of booking that the appointment is with a PA rather than a GP b) subsequently consented to the appointment with a PA
  • Use the titles 'generalist practitioner' or 'registrar' or other titles that imply equivalence to a doctor *Unless the patient is also reviewed by a GP, immediately and in person
Medicine
Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT:
  • Lead a ward round
  • Provide specialty advice other than when documenting or communicating advice from a consultant or registrar in that specialty
  • Hold a med reg bleep or equivalent
  • Clerk, triage or accept referrals for acute medical take, unless relating to protocolised assessment on a defined pathway under direct supervision

Perform, train in, or consent for:

  • Endoscopy
  • Cathlabs
  • Pacing
  • DCCV even protocolised

Respiratory:

  • Change NIV settings
  • Undertake pleural procedures including pleurodesis, drain insertion, or pleural aspiration
  • Perform and interpret thoracic ultrasound imaging
  • Perform thoracoscopy

Clinical oncology:

Should not perform any of the following auxiliary roles within an intervention theatre:

  • Diagnostic radiography
  • Radiation planning
  • Radiotherapy delivery
  • MDT coordination
  • Be on the doctor rota at any level or used interchangeably with doctors in any way
  • Hold referral bleeps, be involved in vetting referrals, or be acting in a way where they need to give specialist advice
  • Discharge patients independently
  • Use the titles 'consultant', 'registrar', 'specialist', 'resident' or 'senior house officer'
Ophthalmology
Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT:
  • Consent patients for surgery
  • Perform any intraocular or extraocular surgery under any circumstances (not including non-emergency intravitreal injections)
  • Consent patients for or perform any laser procedure
  • Triage, review or examine any undifferentiated patients in eye casualty
  • Review or examine any undifferentiated patients in outpatient clinics
  • Independently request investigations or ionising radiation imaging
  • Cover any trainee/registrar shifts during absence/sickness of doctors
  • Review patients independently on ward rounds
  • Discharge inpatients independently
  • Be on the doctor rota at any level or used interchangeably with doctors in any way
  • Hold referral bleeps, be involved in vetting referrals, or be acting in a way where they need to give specialist advice
  • Use the titles 'consultant', 'registrar', 'specialist', 'resident' or 'senior house officer'
Paediatrics
Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT:
  • Hold a referral bleep for any specialty or be part of any referral triage or vetting role
  • Act as a registrar or senior doctor in any capacity
  • Take any PICU step-down or transport handovers as the sole receiver of the handover without a doctor present
  • Do the first post-operative review
  • Perform any UAC/UVC or long line insertion in an infant or any other central venous or arterial lines in any age
  • Carry the crash bleep on the NNU or children's wards
  • Attend deliveries as the SHO or registrar or as anything other than an observer or assistant role
  • Be on a transport rota in the role of a doctor
  • Intubate infants with endotracheal tubes, nasal endotracheal tubes, or apply NPA
  • Give any routine immunizations
  • Decide that a child is fit to undergo chemotherapy
  • Undertake an LP for ICP or sepsis, or any neonatal indication
  • Make any changes to any medications or direct any doctor to do so
  • Undertake any part of safeguarding reviews or NAI assessments
  • Be involved in any palliative care decisions or end of life conversations with parents, unless there in a supportive role only to parents
  • Attend any outpatient clinics or participate in any outpatient work in clinics, unless assisting under the direct supervision of doctors e.g., taking bloods
  • Lead any ward rounds
  • Be on the doctor rota at any level or used interchangeably with doctors in any way
  • Hold the referral bleep in any capacity nor be responsible for giving any specialty advice at any level.
  • Discharge patients independently
  • Use the titles 'consultant', 'registrar', 'specialist', 'resident' or 'senior house officer'
Psychiatry
Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT:
  • Undertake Mental Health Act assessments, diagnose or manage any mental health condition for which inpatient care is required
  • Accept devolved responsibility for the physical health of patients under the inpatient care of a psychiatrist
  • Be a substitute for doctors when a patient presents with physical symptoms
  • Consent for or initiate treatment
  • Make decisions that deprives a person of their liberties (MHA/MCA/DOLS/LPS)
  • Be involved in decision making or delivery of experimental (psychedelics, rTMS, etc.) or invasive treatments (ECT, or similar therapies)
  • Be on the doctor rota at any level or used interchangeably with doctors in any way
  • Hold referral bleeps, be involved in vetting referrals, or be acting in a way where they need to give specialist advice
  • Discharge patients independently
  • Use the titles 'consultant', 'registrar', 'specialist', 'resident' or 'senior house officer'
Surgery
Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT:
  • Perform, train in, or consent for invasive or life-threatening procedures including:
    1. Endoscopy (any)
    2. Surgical procedures under GA, spinal anaesthesia, or LA (local anaesthesia)
    3. Chest drain insertions
    4. Cystoscopy
  • Act as first assistant in the operating theatre
  • Have their own theatre list
  • Removing cholecystostomies
  • Removing or flushing neurosurgical drains including but not limited to external ventricular drains and post-operative drains following the evacuation of a subdural haematoma' from/in any space within the central nervous system
  • Lead ward rounds
  • Review or clerk new acute patients in the ED, Surgical triage units, surgical admissions units etc.
  • Be on the doctor rota at any level or used interchangeably with doctors in any way
  • Hold referral bleeps, be involved in vetting referrals, or be acting in a way where they need to give specialist advice
  • Discharge patients independently
  • Use the titles 'consultant', 'registrar', 'specialist', 'resident' or 'senior house officer'
Women's Health
Physician associates (PAs), anaesthesia associates (AAs), and surgical care practitioners (SCPs) MUST NOT:
  • Undertake outpatient work in clinics unless in an assistant role (e.g., ANC, PMB clinic)
  • Assess women for labour, PPROM, SROM, APH, HTN/PET, or reduced foetal movements, or any acute presentation in pregnancy
  • Have any role in maternity triage
  • Be involved in surgical management of miscarriage, surgical termination of pregnancy, medical management of miscarriage, medical termination of pregnancy unless taking an assistant role under the direction of a doctor
  • Act as first assistant in the operating theatre Perform, train in, assist with, or consent for invasive or life-threatening procedures including:
  • Caesarean section, Instrumental delivery, Perineal repair, Cervical cerclage, Hysteroscopy, Hysterectomy, Laparoscopy, Salpingo-oophorectomy, Prolapse repair, Colposcopy
  • Vaginal examination including speculum and bimanual examination (in inpatient and outpatient settings)
  • Ultrasonography of the pelvis, either transabdominal or transvaginal
  • Insertion or counselling in long-acting contraceptive methods, including IUS, IUD, implants, and injectables
  • Administration or counselling in methods of hormone replacement therapy (HRT)
  • Initial fitting of vaginal pessaries for organ prolapse
  • Be on the doctor rota at any level or used interchangeably with doctors in any way
  • Hold referral bleeps, be involved in vetting referrals, or be acting in a way where they need to give specialist advice
  • Discharge patients independently
  • Use the titles 'consultant', 'registrar', 'specialist', 'resident' or 'senior house officer'

In March 2024, the Royal College of General Practitioners issued a statement[58] about the activites suitable for a Physician Associate when working in Primary Care. They stated that:

  • Physician Associates working in general practice must always work under the supervision of qualified General Practitioners.
  • Physician Associates must be considered additional members of the team; rather than substitutes for General Practitioners.
  • Physician Associates do not replace General Practitioners nor mitigate the need to urgently address the shortage of General Practitioners in the United Kingdom.
  • Physician Associates must be regulated as soon as possible.
  • There must be an improvement to public awareness and understanding of the Physician Associate role.
  • Training, induction and supervision of Physician Associates within general practice must be properly resourced and designed.
  • At a time of significant workforce challenges in general practice, funding allocations, resources and learning opportunities within general practice must be prioritised for the training and retention of medical doctors (i.e., General Practitioners).
  • The significant responsibility and skills required for supervision of a Physician Associate must be appropriately recognised and resourced; with General Practitioners able to choose whether or not they are willing to undertake supervision of Physician Associates.
  • Physician Associates should not be employed unless sufficient supervision is provided.

Voluntary register (UK)

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The title physician associate is not a protected one. PAs in the U.K. are not able to legally prescribe or legally request ionising radiation imaging.[52] No regulatory body governs PAs. Since June 2010, physician associates have been able to obtain membership of the Managed Voluntary Register for physician associates.[59] This database, run by PAs for PAs, aims to identify all qualified PAs who are able to practise. Its intent is to maintain high standards.[60] To remain on the voluntary register, physician associates are required to re-certify every 5–6 years.[61]

In 2018 Matt Hancock announced a plan regulate PAs. The General Medical Council agreed to be the regulatory body for PAs, with regulation aiming to begin in 2022, this was pushed back to 2024.[citation needed]

Training (UK)

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Training is through a two-year training programme (MSc) in Physician Associate Studies, although some PAs in the United Kingdom only hold a PgDip in Physician Associate Studies. As of 2017 at least 32 universities offered these programs:

Entry requirement vary, especially in terms of required first degree subject.[citation needed] For example, University of Bradford requires a 2:1 (or above) undergraduate degree in a Life Science, Biomedical Science, or Healthcare subject. Under exceptional circumstances, experience in healthcare practice may contribute/compensate absent the above requirements.[63]

United States

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Nomenclature (US)

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In accordance with the American Academy of Physician Associates (AAPA), the official title of the profession in the United States is "Physician Associate".[6][73] While this is the official title used by the national organization, utilization of this title may vary on the state and local level based on state and local bylaws and policies.[74] Many hospital and healthcare systems still use physician assistant as titles, with some just resorting to using "PA" to avoid confusion with physicians.[75]

A physician assistant may use the initials "PA", "PA-C", "APA-C", "RPA" or "RPA-C", where the "-C" indicates "Certified" and the "R" indicates "Registered".[citation needed] The "R" designation is unique to a few states, mainly in the Northeast. APA stands for aeromedical physician assistant and indicates that a physician assistant successfully completed the US Army Flight Surgeon Primary Course.[76] During training, PA students are designated PA-S.[citation needed] The use of "PA-C" is limited to certified PAs who comply with the regulations of the National Commission on Certification of Physician Assistants and who have passed PANCE.[citation needed]

Students undertaking physician assistant or associate training may refer to themselves as a physician assistant student, physician associate student, student physician assistant or student physician associate.[citation needed] PA students may add "S" at the end of their student designation (PA-S).[citation needed] Students may also use the corresponding year of their training in their student designation.[citation needed] For example, students in the second year of their physician assistant or physician associate training may use (PA-S2) as their student designation.[citation needed]

The American Academy of Physician Associates has spent over $22 million since 2018 campaigning to change the word "assistant" to "associate" in the title of physician assistant. The campaign has been heavily criticized by physicians, but advocates argue that the revised title more accurately reflects the clinician's role on the patient care team.[77]

In the United States, the profession is represented by the American Academy of Physician Associates. All PAs must graduate from a nationally accredited ARC-PA[clarification needed] program as well as passing the national certification exam.[78] In 1970 the American Medical Association passed a resolution to develop educational guidelines and certification procedures for PAs.[79] The Duke University Medical Center Archives had established the Physician Assistant History Center, dedicated to the study, preservation, and presentation of the history of the profession. The PA History Center became its own institution in 2011, was renamed the PA History Society, and relocated to Johns Creek, Georgia.[80]

Education and certification (US)

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As of May 2019, 243 accredited PA programs operated in the United States, with dozens more in development.[81] Most educational programs are graduate programs leading to the award of master's degrees in either Physician Assistant Studies, Health Science (Master of Health Science), or Medical Science (MMSc), and require a bachelor's degree and Graduate Record Examination or Medical College Admission Test scores for entry. The majority of PA programs in the United States employ the CASPA application for selecting students.[81] Professional licensure is regulated by state medical boards. PA students train at medical schools and academic medical centers across the country.

 
Physician Assistant Program at ODU

PA education is based on medical education;[82] it typically requires 2 to 3 years of full-time graduate study like most master's degrees.[83] (Medical school lasts four years plus a specialty-specific residency.) Training consists of classroom and laboratory instruction in medical and behavioral sciences, followed by clinical rotations in internal medicine, family medicine, surgery, pediatrics, obstetrics and gynecology, emergency medicine, and geriatric medicine, as well as elective rotations.[84] PAs are not required to complete residencies after they complete their schooling (unlike physicians). Postgraduate training programs are offered in certain specialties for PAs, though these are optional and shorter in length than medical residency.[85]

PA clinical postgraduate programs are clinical training programs that differ from on the job training given their inclusion of education and supervised clinical experience to meet learning objectives.[86] Montefiore Medical Center Postgraduate Surgical Physician Assistant Program was established in 1971 as the first recognized clinical postgraduate PA program.[86] 49 programs address specialties such as Neurology, Trauma/Critical Care and Oncology. 50 programs joined the Association of Postgraduate Physician Assistant Programs to establish educational standards for postgraduate PA programs.[86][87]

In the United States, a graduate from an accredited PA program must pass the NCCPA-administered Physician Assistant National Certifying Exam (PANCE) before becoming a PA-C; this certification is required for licensure in all states.[88] The content of the exam is covered in the PANCE BLUEPRINT. In addition, a PA must log 100 Continuing Medical Education hours and reregister his or her certificate with the NCCPA every two years. Every ten years (formerly six years), a PA must also recertify by successfully completing the Physician Assistant National Recertifying Exam (PANRE)[89] There is a growing number of doctoral programs for certified PAs leading to a Doctor of Medical Science (DMSc) but there is no requirement for one to have a doctorate in order to practice. "National Physician Assistant Week" is celebrated annually in the US from October 6 through October 12. This week was chosen to commemorate the anniversary of the first graduating physician assistant class at Duke University on October 6, 1967.[90] October 6 is also the birthday of the profession's founder, Eugene A. Stead, Jr., MD.[91]

Scope of practice (US)

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Physician assistants have their own licenses with distinct scope of practice.[92] Each of the 50 states has different laws regarding the prescription of medications by PAs and the licensing authority granted to each category within that particular state through the Drug Enforcement Administration (DEA).[93] PAs in Kentucky and Puerto Rico are not allowed to prescribe any controlled substances. Several other states place a limit on the type of controlled substance or the quantity that can be prescribed, dispensed, or administered by a PA.[94] Depending upon the specific laws of any given state board of medicine, the PA must have a formal relationship on file with a collaborative physician. The collaborating physician must also be licensed in the state in which the PA is working, although he or she may physically be located elsewhere. Physician collaboration can be in person, by telecommunication systems or by other reliable means (for example, availability for consultation). In emergency departments the laws governing PA practice differ by state, generally allowing a broad scope of practice and limited direct supervision.[95]

During the COVID-19 pandemic, several state governments changed regulations regarding PA scope of practice, including:

  • On May 21, 2020, the law S.B. 1915 was signed by Oklahoma Governor Kevin Stitt. This law allows Physician Assistants to become primary care providers and receive direct pay from insurers. The reference of "supervision" was changed to "delegating" in regards to physician responsibility. This law also allows PAs to legally volunteer in the case of disaster or emergency.[96]
  • On May 27, 2020, Governor Tim Walz signed into Minnesota law the Omnibus Healthcare Bill S.F. 13. This law removes references to physician responsibility of supervision and delegation of care provided by PAs. The law also removes delegated prescriptive authority.[97]

Employment (US)

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The first employer of PAs was the then-Veterans Administration, known today as the Department of Veterans Affairs. Today it is the largest single employer of PAs, employing nearly 2,000.[citation needed]

According to the AAPA, as of 2020 there are more than 148,560 certified PAs in the United States, up from 115,547 in 2016.[98]

Money magazine, in conjunction with Salary.com, listed the PA profession as the "fifth best job in America" in May 2006, based both on salary and job prospects, and on an anticipated 10-year job growth of 49.65%.[99] In 2010, CNN Money rated the physician assistant career as the number two best job in America.[100] In 2012, Forbes rated the physician assistant degree as the number one master's degree for jobs.[101] In 2015, Glassdoor rated physician assistant as the number one best job in America.[102] In 2021, US News & World Report rated physician assistant as the number one best job in America.[103]

The US Department of Labor Bureau of Labor Statistics report on PAs states, "...Employment of physician assistants is projected to grow 37 percent from 2016 to 2026, much faster than the average for all occupations..."[104] This is due to several factors, including an expanding health care industry, an aging baby-boomer population, concerns for cost containment, and newly implemented restrictions to shorten physician resident work hours.

In the 2008 AAPA census, 56 percent of responding PAs worked in physicians' offices or clinics and 24 percent were employed by hospitals.[105] The remainder were employed in public health clinics, nursing homes, schools, prisons, home health care agencies, and the United States Department of Veterans Affairs[106] Fifteen percent of responding PAs work in counties classified as non-metropolitan by Economic Research Service of the United States Department of Agriculture;[107] approximately 17% of the US population resides in these counties.[108]

For PAs in primary care practice, malpractice insurance policies with $100,000–300,000 in coverage can cost less than $600 per year; premiums are higher for PAs in higher-risk specialties.[109]

Compensation (US)

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According to Bureau of Labor Statistics, in 2020 the median pay for physician assistants working full-time was $115,390 per year or $55.48 per hour, and the highest 10 percent earned more than $162,470.[110] Physician assistants in emergency medicine, dermatology, and surgical subspecialties may earn up to $200,000 per year.[111]

Federal government, uniformed services, and US armed forces (US)

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PAs are employed by the United States Department of State as foreign service health practitioners. PAs working in this capacity may be deployed anywhere in the world where there is a State Department facility.[citation needed] They provide primary care to US government employees and their families in American embassies and consulates around the world.[citation needed] An important part of their jobs is to get to know what resources are available locally that they can count on in an emergency. They have other important roles, such as advising their ambassadors on the health situation in the country and provide health education to the diplomatic community. In order to be considered for the position, these PAs must be licensed and have at least two years of recent experience in primary care.[112]

 
Physician Assistant in the US Army

Military PAs serve in the White House Medical Unit, where they provide care to the president and vice president and their families as well as White House staff.[citation needed]

They are employed by several organizations with the intelligence community, specifically the Central Intelligence Agency.[113] While much of the job description is classified, they work under the Directorate of Support and are deployed to "austere environments" where they provide medical care, including trauma stabilization, and teach in the fields of survival, field medicine, and tactical combat casualty care.[113]

United States Army PAs serve as Medical Specialist Corps officers, typically within Army combat or combat support battalions located in the continental United States, Alaska, Hawaii, and overseas.[114] These include infantry, armor, cavalry, airborne, artillery, and (if the PA qualifies) special forces units. They serve as the "front line" of Army medicine and along with combat medics are responsible for the total health care of soldiers assigned to their unit, as well as of their family members.[citation needed]

PAs also serve in the Air Force and Navy as clinical practitioners and aviation medicine specialists, as well as in the Coast Guard and Public Health Service. The skills required for these PAs are similar to that of their civilian colleagues, but additional training is provided in advanced casualty care, medical management of chemical injuries, aviation medicine, and military medicine.[citation needed] In addition, military PAs are also required to meet the officer commissioning requirements, and maintain the professional and physical readiness standards of their respective services.[115]

The marine physician assistant is a US Merchant Marine staff officer. A certificate of registry is granted through The United States Coast Guard National Maritime Center located in Martinsburg, West Virginia.[116] Formal training programs for marine physician assistants began in September, 1966 at the Public Service Health Hospital located in Staten Island, N.Y.[117]

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