As a young general practitioner, Heather Ryan One patient’s abdominal pain was misdiagnosed, leading to their subsequent death.Here, she outlines why she doesn’t want to see a physician assistant evaluate undifferentiated disease
All doctors have cases that bother them, and Winnie* was one of mine.
During my first year as a GP partner, I saw this affable 62-year-old woman a few times, mainly 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 abdominal pain and vomiting after eating takeaway the day before. She looks fine and her body observations are normal. I examined her – her stomach was softer than I thought, but I rationalized it away – and concluded she had acute gastroenteritis. I pulled out my usual script, seeking review if her symptoms worsened, and made a mental note to avoid offending restaurants.
The following week, I received a discharge summary from the local hospital. I learned that the day after I saw Winnie, her condition took a turn for the worse. She began vomiting blood and was taken to the emergency room by her son. She died later that night from a perforated peptic ulcer.
Last week, a tweet from Norfolk & Waveney ICS directed at the public suggested that patients with abdominal pain might see a medical assistant at a GP surgery. As my experience shows, abdominal pain is one of the most difficult symptoms to safely assess in primary care, without point-of-care testing and without the luxury of observing the patient for several hours.
If I’m struggling after 13 years of training (six in medical school, six in postgraduate training, and one to become a qualified GP), then I’m worried that a Physician Assistant (whose qualifications only cover two years of postgraduate study) has the potential to be very dangerous in this situation.
I can see how physician assistants might have some use in a hospital setting – for example, taking on administrative tasks like sending letters, which would have limited educational value to physicians. In some cases they may help provide services by undertaking certain procedures, but care must be taken to ensure that doctors in training do not lose learning opportunities. But it is unclear how to use physician assistants effectively and safely in general practice.
A core feature of general practice is the lack of variation in patient performance we see. It’s one of the hardest jobs in medicine, and if it’s not done well, it can cause real harm: not just the tragic, rare cases that make the news, but the countless mundane little mistakes that have the potential to Patients’ lives get worse – a delay in diagnosis here, an unnecessary antibiotic there. In its definition, RCGP refers to the “complexity, uncertainty and risk” inherent in our work.
Those advocating for the use of physician assistant roles in general practice sometimes cite a 2015 study that showed consultations with physician assistants produced similar rates of return visits, prescriptions, and referrals as consultations with general practitioners and patient satisfaction.
However, I would like to ask how applicable this is now, a few years from now: In this study, nearly all clinics that employed physician assistants had protocols in place regarding which patients were appropriate for appointments with physician assistants. This, in turn, may limit the extent to which these findings can be generalized to physician colleagues who treat undifferentiated patients.
I think expanding the role of physician assistants in general practice is a well-thought-out political strategy. The Additional Role Reimbursement Scheme (ARRS), launched in 2019, provides funding for PCNs and practices to hire a variety of nonphysician primary care clinicians, including physician assistants. Some positions funded by the ARRS (e.g. first contact physiotherapists) are regulated professions with a clear scope of practice and a useful position in primary care.
But it’s hard to see how physician assistants are included simply to replace general practitioners. The UK NHS role reference summary describes the role of the physician assistant as managing “undifferentiated, undiagnosed cases” and recommends a minimum frequency of supervision of once a month. This is astounding considering that even GPST3 trainees (who have completed at least four years of postgraduate training after graduating from medical school) receive weekly coaching and have a designated supervisor to report to in between.
GP surgeries are under financial pressure due to chronic funding constraints, with many partners earning less than the salaried GPs they employ. As a result, agency jobs are drying up because practices simply can’t attract them. The primary care Facebook and WhatsApp groups are full of GPs who are now largely unemployed. One former full-time agent told me she had gone from working five days a week to five days a week because work had dried up in her area. Meanwhile, one agency is encouraging GPs to cut rates in order to keep their jobs in the face of competition for ARRS posts.
Nigel Edwards, chief executive of the Nuffield Trust, after Emily Chesterton died after a physician assistant failed to recognize she had deep vein thrombosis Nigel Edwards called for “very clear scopes of practice” to be closely monitored by GPs and for patients to have the right to choose who they see. Her mother Marion said Emily didn’t realize she hadn’t seen her GP.
Earlier this month, the Daily Mail reported the case of a 69-year-old man who presented to his GP surgery with abdominal pain. A physician assistant 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 must die before it is recognized that fellow physicians are not adequately trained to assess the authority of undifferentiated disease with minimal supervision?
Dr Heather Ryan is Managing Director of Formby GP, a private GP practice in Formby, Merseyside
*Please note that some details have been changed to maintain patient confidentiality