Why the use of Physician Associates can violate patient consent
Think back to the last time you went to your local GP. How would you feel if you believed you were seeing a doctor, but it turned out they weren’t really a doctor? They hadn’t gone to medical school, nor did they have the same clinical expertise. But they were diagnosing and treating you at your most vulnerable.
It may surprise you to know there is a small but growing number of Physician Associates (PAs) being employed in general practices around the country, doing exactly that. And while they have thus far only been allowed to practice under the supervision of a qualified medical practitioner, they have been lobbying to become regulated and practice independently – without this safety net.
What exactly is a Physician Associate?
Despite misrepresenting themselves as “medical professionals who practice medicine”, PAs have not received training in medicine, and therefore do not have the breadth and depth of experience needed to practice as a doctor.[i]
There is no established PA training pathway in New Zealand, and a huge variation in the training of this overseas imported cohort. They may have undergraduate degrees in homeopathy, computer science, banking, or even geography, and a two-year postgraduate qualification in a medical-adjacent training.[ii] Some training programmes have since lost accreditation for failing to provide sufficient instruction in patient safety.[iii]
By comparison, your local GP has at minimum undergone an extensive six-year medical degree, followed by further six to seven years of advanced medical training and clinical practice to qualify as a GP in New Zealand.
Lacking the necessary medical background and clinical expertise means that PAs pose clear risks to patient safety and health outcomes. We have previously detailed these risks, including cases of patient harm and deaths from PA misdiagnoses, locally and overseas.[iv],[v],[vi],[vii],[viii],[ix]
So, PAs are not doctors. But they are being associated with doctors.
Misleading title creates confusion
The intentionally misleading use of the term ‘physician’ in their title, combined with a frequent lack of disclosure to patients, have left patients misunderstanding who they are seeing and unaware of the level of skill and experience PAs possess. This hasn’t been helped by blatantly deceptive campaigns overseas misrepresenting PAs as ‘cancer specialists’ and referring to PAs as ‘physicians’.[x] Is it any wonder then that public confusion around the PA role persists? In fact, in the UK around a quarter of the public don’t understand the difference between a doctor and a PA.[xi]
But it’s not just patients who are confused. A coronial inquest into an avoidable patient death caused by PA actions in the UK revealed that the PA’s competence had previously been signed off by a nurse specialist who assumed he was a doctor.[xii] The Coroner subsequently declared “there remains limited understanding and awareness of the role of a Physician Associate both amongst medical colleagues, patients and their families… the title “Physician” gives rise to confusion as to whether the practitioner is a doctor.”[xiii]
The importance of informed consent
At the heart of this confusion is the issue of informed consent. Do patients know who they are seeing? And if they believe they were seeing a doctor, did they give their consent to being examined or treated by anyone else?
In New Zealand all patients have fundamental rights, set out in the Code of Health and Disability Services Consumers’ Rights. Informed consent is a key pillar within this (Rights 6 and 7) and includes the right to be fully informed about the identity and qualifications of their health service provider.[xiv]
Aside from the legal requirements for informed consent, there is also a moral obligation. Patients are inherently in a power imbalance with their healthcare provider, and often in a vulnerable state when seeking a health service. Informed consent therefore is vital in honouring the trust they place in providers and key to building a long-term therapeutic relationship. When there is confusion around who they are seeing, or what this person is qualified to do, persists, this is a fundamental violation of patient rights and trust.
Patients have a right to know who is treating them, and the right to receive treatment from a fully qualified medical practitioner. To compromise this at the expense of cost-savings is to do them a major disservice. Over time, a lack of transparency and confusion will lead to a loss of public trust and confidence in our providers and in our health system. This then becomes a further barrier to accessing healthcare, often for those who most need it. It undermines the health system, and it undermines the medical profession’s standards.
Why regulation is not the answer
The push to grow and regulate the PA workforce in New Zealand is ultimately not about protecting patient safety. Let’s be clear about what it is. It is simply a cost cutting exercise, giving the illusion that something is being done to fix our healthcare crisis, when what we really need are sufficiently medically trained and regulated doctors to cater to the needs of Aotearoa’s increasingly complex health needs.
The rush to regulation is only going to add to this confusion and cause further harm, especially when the proposed regulator – the Medical Council of New Zealand – is also regulating medical practitioners. This exact scenario has played out in the UK, resulting in the British Medical Association (BMA) taking legal action against the UK regulator; the General Medical Council (GMC).[xv] And it is why, following the numerous patient deaths and expert calls to do so, the government has finally responded by launching a full independent review into the scope and safety of PA roles.[xvi] Even in Aotearoa, doctors who are working alongside PAs have been outspoken – to the point of quitting – about patient safety being compromised and the resultant patient harms from the use of PAs.[xvii]
Let us learn from the UK’s mistakes, where the rush to regulation has resulted in confusion, role blurring, and significant patient harm, including multiple patient deaths. If we want to avoid a similar fate, we would be wise to heed these warnings.
References
[i] New Zealand Physician Associate Society. (n.d.). What is a Physician Associate? Retrieved https://nzpas.org.nz/whats-a-pa/
[ii] Donnelly, L. & Moore, A. (2024). Physician’s Associates qualify for courses with degrees including homeopathy and English literature. The Sunday Telegraph, 30 March 2024. Retrieved https://www.telegraph.co.uk/news/2024/03/30/physicians-associates-qualify-courses-degrees/
[iii] Marino, P. (2023). A CSUMB program, designed to alleviate the region’s physician shortage, loses accreditation. Monterey County Now, 9 November 2023. Retrieved https://www.montereycountynow.com/news/local_news/a-csumb-program-designed-to-alleviate-the-region-s-physician-shortage-loses-accreditation/article_9f6172c8-7e7d-11ee-9dfc-2bbca261751b.html
[iv] BBC News. (2023). Call for physician associate clarity after misdiagnosis death. BBC, 16 July 2023. Retrieved https://www.bbc.com/news/uk-england-manchester-66211103
[v] Ennals, E. (2023). Why did our daughter have to die? Family’s anguish after cancer death of mum misdiagnosed by medic with two years’ training. The Daily Mail Australia, 12 November 2023. Retrieved https://www.dailymail.co.uk/health/article-12739005/Why-did-daughter-die-Familys-anguish-cancer-death-mum-misdiagnosed-medic-two-years-training.html
[vi] Clegg, R. & Shoesmith, I. (2024). My wife died because the NHS used cheap labour. BBC, 13 November 2024. Retrieved https://www.bbc.com/news/articles/czxvww97pleo
[vii] Ennals, E. (2023). GP chiefs call for a crackdown on NHS physician associates following a string of life-threatening blunders. The Daily Mail Australia, 15 October 2023. Retrieved https://www.dailymail.co.uk/health/article-12630607/NHS-blunders-prompt-call-stop-physician-associate-recruitment.html
[viii] Hill, R. (2024). ‘He could have gone blind’: Concerns unregulated physician associates may put patients at risk. RNZ, 18 January 2024. Retrieved https://www.rnz.co.nz/news/national/506989/he-could-have-gone-blind-concerns-unregulated-physician-associates-may-put-patients-at-risk
[ix] Shaw, R. (2024). Doctors quit amid patient safety risk disagreement. Otago Daily Times, 25 November 2024. Retrieved https://www.odt.co.nz/southland/doctors-quit-amid-patient-safety-risk-disagreement
[x] Parr, E. (2024). NHS removes patient-facing material referring to PAs as ‘physicians’. Pulse, 17 June 2024. Retrieved https://www.pulsetoday.co.uk/news/workforce/nhs-removes-patient-facing-material-referring-to-pas-as-physicians/
[xi] Healthwatch. (2024). Am I seeing a physician associate or a doctor? 22 July 2024. Retrieved https://www.healthwatch.co.uk/blog/2024-07-22/am-i-seeing-physician-associate-or-doctor
[xii] Clegg, R. & Shoesmith, I. (2024). My wife died because the NHS used cheap labour. BBC, 13 November 2024. Retrieved https://www.bbc.com/news/articles/czxvww97pleo
[xiii] Courts and Tribunals Judiciary. (2024). Susan Pollitt: Prevention of Future Deaths Report, 31 August 2024. Retrieved https://www.judiciary.uk/prevention-of-future-death-reports/susan-pollitt-prevention-of-future-deaths-report/
[xiv] Health & Disability Commissioner. (n.d.). Code of Health and Disability Services Consumers’ Rights. Retrieved https://www.hdc.org.nz/your-rights/about-the-code/code-of-health-and-disability-services-consumers-rights/
[xv] British Medical Association. (2024). BMA launches legal action against GMC over dangerous blurring of lines between doctors and physician associates. BMA, 24 June 2024. https://www.bma.org.uk/bma-media-centre/bma-launches-legal-action-against-gmc-over-dangerous-blurring-of-lines-between-doctors-and-physician-associates
[xvi] Department of Health and Social Care. (2024). New review of physician and anaesthesia associates launched. UK Government, press release, 20 November 2024. Retrieved https://www.gov.uk/government/news/new-review-of-physician-and-anaesthesia-associates-launched
[xvii] Shaw, R. (2024). Doctors quit amid patient safety risk disagreement. Otago Daily Times, 25 November 2024. Retrieved https://www.odt.co.nz/southland/doctors-quit-amid-patient-safety-risk-disagreement