As a young GP, Dr Heather Ryan misdiagnosed a patient’s abdominal pain and they later died. Here, she outlines why she would not like to see a physician associate assessing undifferentiated illnesses
All doctors have a handful of cases that haunt them, and Winnie* is one of mine.
I had met the affable 62-year-old a handful of times in my first year as a GP partner, primarily to manage her COPD and its occasional infectious exacerbations.
One day, she was booked into one of my same-day slots with a history of acute-onset abdominal pain and vomiting after eating a takeaway the day before. She looked well and her physical observations were normal. I examined her – her stomach was more tender than I expected, but I rationalised it away – and concluded that she had acute gastroenteritis. I trotted out the usual script about seeking review if her symptoms got worse, and then made a mental note to avoid the offending restaurant.
The following week, I received a discharge summary from the local hospital. I learned that the day after I had seen Winnie, she had taken a turn for the worse. She had started vomiting blood and had been driven to A&E by her son. She died of a perforated peptic ulcer later that night.
Last week, a Tweet from Norfolk & Waveney ICS aimed at members of the public suggested that patients with abdominal pain might see a physician associate at their GP surgery. As my experience shows, abdominal pain is one of the more challenging symptoms to safely assess in primary care, with no point-of-care tests and without the luxury of observing the patient for several hours.
If I struggled after 13 years of training – six years at medical school, six years of postgraduate training, and a year as a qualified GP – then I worry that a physician associate, whose qualification involves just two years of postgraduate study, has the potential to be downright dangerous in this situation.
I can see that physician associates may have some utility in a hospital setting – for example, undertaking administrative tasks like discharge letters, which have limited educational value for doctors. In some circumstances, they may help with service provision by undertaking certain procedures – though care must be taken to ensure that doctors in training do not lose out on learning opportunities. But it is unclear how to use physician associates in general practice efficiently and safely.
A core feature of general practice is that we see patients with undifferentiated presentations. This is one of the hardest jobs in medicine and one with real potential for harm if done badly: not just in the tragic, rare cases that make the news, but also in countless mundane little errors that have the potential to make patients’ lives worse – a delayed diagnosis here, an unnecessary antibiotic there. In its definition of a GP, the RCGP references the ‘complexity, uncertainty and risk’ inherent in what we do.
Those who defend the use of the physician associate role in general practice sometimes cite a 2015 study that suggested consultations with physician associates result in similar rates of re-consultation, prescriptions, referrals and patient satisfaction as GP consultations.
However, I would question how applicable this is now, several years down the line: in the study, almost all of the practices that employed physician associates had protocols about which patients were suitable to be booked in with a physician associate. In turn, this may limit the extent to which these findings can be generalised to physician associates seeing undifferentiated patients.
I believe that the expansion of the physician associate role in general practice is a calculated political strategy. The Additional Roles Reimbursement Scheme (ARRS), introduced in 2019, funds PCNs – and, in turn, practices – to employ various non-doctor primary care clinicians, including physician associates. Some of the roles funded by ARRS, such as first contact physiotherapists, are regulated professions with a clear scope of practice, which has a useful place in primary care.
But it is hard to see the inclusion of physician associates as anything other than an attempt to replace GPs. The NHS England role reference summary describes the physician associate role as being to manage ‘undifferentiated, undiagnosed cases’ and recommends a minimum supervision frequency of just once a month. Given the fact that even GPST3 trainees – who have completed at least four years of postgraduate training after medical school – have weekly tutorials and a named supervisor for debriefs in-between, this is staggering.
Due to a prolonged funding squeeze, GP surgeries are under financial pressure, and many partners report earning less than the salaried GPs they employ. As a result, locum work is drying up as practices simply cannot afford to engage them. Primary Care Facebook and WhatsApp groups are full of GP locums who are essentially now unemployed. One previously full-time locum told me that she had gone from working five days a week to one because work in her area had dried up. Meanwhile, one locum agency encouraged GPs to reduce their rates in order to secure work in the face of competition from ARRS roles.
In the wake of the death of Emily Chesterton after a physician associate failed to recognise that she had a deep vein thrombosis, the Nuffield Trust’s chief executive Nigel Edwards called for a ‘very clearly defined scope of practice’, close supervision by GPs, and for patients to have the right to choose to see a doctor instead. Her mother, Marion, said that Emily did not realise she had not seen a GP.
Earlier this month, the Daily Mail reported the case of a 69-year-old man who had presented to his GP surgery with abdominal pain. A physician associate diagnosed the patient with irritable bowel syndrome, but sadly, he actually had bowel cancer, and died less than a year later.
How many more patients have to die before the powers that be recognise that physician associates are not adequately trained to assess undifferentiated illness with minimal supervision?
Dr Heather Ryan is managing director of Formby GP, a private GP clinic in Formby, Merseyside
*Please note that some details have been changed to maintain patient confidentiality