Thread by @dr_ianjackson

The role of Physician and Anaesthetic Associates has hit the headlines recently – if you haven’t heard of these roles before, they are what were previously called Physician Assistants. Physician Assistants have been around since 2004 but the name was changed in 2014 to 1/n

‘Associates’, currently there are around 3200 employed across hospitals and Primary Care. Their role has become increasingly controversial as moves have been made to have them registered through the General Medical Council (GMC) – a move that has not happened for any other 2/n

profession allied to Medicine. In this thread I will consider the issues around registration and provide what I believe is vital background to us as members of the public. My major concern surrounds confusion on the role where members of the public believe they are seeing 3/n

a doctor and the length and depth of training of these roles which I fear will reduce patient safety.
Why do I feel qualified to comment?
I am a retired Consultant Anaesthetist, and I spent my career supporting the next generation of doctors. This was not confined to those 4/n

following me into Anaesthesia as a I spent several years as Foundation Training Programme Director supporting newly qualified doctors. I also spent my latter years in the health service using human factors training to improve patient safety not only in theatres 5/n

but across the patient pathway in my hospital. I have lectured across the globe on this topic. I started anaesthesia having completed 5 years at Medical School, 1 year of house jobs in Medicine and Surgery and then 6 months in Paediatrics and 6 months in Obstetrics and Gynae. 6/n

I had completed 7 years of medical training before even starting in anaesthesia. I then spent another 6 years getting my exams and ascending to my consultant job which was a couple of years quicker than the norm. Training a consultant anaesthetist these days has changed 7/n

slightly but really mimics my experience. 5 years at Medical School then 2 years of Foundation Training spent in multiple specialties and then 6-8 years of training in Anaesthesia.
So what about training Physician/Anaesthesia Associates?
You can find lots of details about this8/n

on the Royal College of Anaesthetists (RCoA) website. Entry requirements are Graduates with a biomedical science or biological/life science 2:1 honour degree or registered healthcare professionals (examples are nurses or operating department practitioners) with at least three 9/n

years clinical experience. Those entering the training get 2 years of supervised training which is combination of hospital based and University training – there are currently 3 Universities offering courses. I suggest there is a world of a difference between training an 10/n

already registered healthcare professional with 3 years of clinical experience (especially those who have extensive experience working in theatres) and those who have completed a biomedical science degree. I have concerns that this is a 2-year training programme as I suggest 11/n

the length of the training is an issue. Anaesthesia is a challenging specialty to learn with patient safety paramount throughout the process. There is a reason why our doctors spend years learning the craft. If we could do this in 2 years, then we would – wouldn’t we?
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It is a similar situation in other specialties – the long medical training is being replaced with a 2-year course and at the end point those qualifying can work do far more than any previous non doctor role. Let us consider this further.
What can Anaesthesia Associates do? 13/n

Information on the RCoA website states
‘As provide anaesthetic and perioperative patient care, usually with one consultant anaesthetist/autonomously practicing anaesthetist overseeing either one or two AAs depending on patient acuity. 14/n

In a 2:1 model, one consultant anaesthetist supervises two AAs, or a trainee anaesthetist and an AA, providing anaesthetic care in two adjacent operating theatres. For patients with more complex needs, a 1:1 model may be employed where one AA works directly alongside a 15/n

consultant anaesthetist to provide care for the patient.’
Their scope of practice is also available. Note it states this
For every case the supervising consultant anaesthetist must:
· be present in the theatre suite, must be easily contactable and must be available to 16/n

attend within two minutes of being requested to attend by the PA(A)
· be present in the anaesthetic room/operating theatre directly supervising induction of anaesthesia
· regularly review the intra-operative anaesthetic management
· directly supervise emergence from 17/n

anaesthesia until the patient has been handed over safely to the recovery staff
remain in the theatre suite until control of airway reflexes has returned and artificial airway devices have been removed, or the on-going care of the patient has been handed on to other 18/n

appropriately qualified staff.
I spent a huge amount of time managing anaesthesia services and trying to be as efficient as possible. For example, I tried to set up 2 lists with trainees and 1 Consultant overseeing them to maximise throughput while providing 19/n

supervision/training for two trainees. Sadly, it just didn’t work as there are so many variables in anaesthesia that catch you out. You have no control of where the difficult patients will be on a list – so the Consultant is needed in 2 places at once leading to delays. 20/n

What happens when both have patients ready for induction at the same time? Again, delays in the list or someone starts without cover. The pressure to start without cover is huge despite knowledge that this is one of the more hazardous aspects of anaesthesia. However, beyond 21/n

all this is patient safety – what happens if 2 patients being anaesthetised develop problems at the same time. This happens – it is a fact of life that Murphy’s Law applies. It might not always be the anaesthetic that is the issue – surgical issues such as massive 22/n

vagal stimulation or sudden major blood loss leading to major hypotension can occur. This is why anaesthetic training is so long – we are creating safe anaesthetists who can recognise and respond to a myriad of issues. I suggest a two-year training programme does not produce 23/n

someone who can be left in charge of an anaesthetised patient. Another issue is when someone calls in sick, so you have to move people around – when you have this 1 to 2 ratio of cover in your rota you are already limited and stretched as a department. So, what happens? 24/n

It becomes 1 consultant covering 3 individuals or the consultant ends up covering the 2 individuals while doing a list themselves, last resort is the list gets cancelled leading to disappointment for the patients involved. Some will claim that using associates on 25/n

a 1 to 2 ratio will release consultant time and so there will be more flexibility in the rota. Trust me that doesn’t happen – we were all stretched to the limit in my time and nothing I hear from colleagues suggests this has got any better. Indeed, the reason we are 26/n

creating these roles is in an effort to deal with current medical manpower issues. I am also concerned by some of the correspondence I have seen – in particular one that allegedly came from an Senior Hospital Manager about ensuring that the anaesthetic department abide 27/n

by the RCoA rules until the ‘heat passes’. For example, I suspect many are playing scant regard for the requirement to have a consultant present at induction or during emergence at the end of surgery. 28/n

Physician Associates and Anaesthetic Associates are undoubtedly being pushed for two reasons. Firstly, the manpower crisis where we have a lack of doctors and secondly because they are full time staff who are cheaper than GP’s and Consultants. There is already evidence 29/n

of them being appointed in Primary Care to replace currently employed GP’s in one area. For the record I will not accept being anaesthetised by a non-medically qualified anaesthetist for myself or my family. I believe those involved are trying to take short cuts in 30/n

dealing with the manpower problem and this will reduce patient safety. Where they are being used it is vital that patients are fully aware.