Sharing the load
Along with the encroaching UK winter recently came the headline “Nine out of ten family doctors in England feel unable to offer safe care to patients because of mounting workloads”(1) It’s shocking but, in recent times, an all too familiar sentiment, inevitably destined to confirm a burden already felt by GPs and add ammunition to the existing anxieties of patients.
On reading the Telegraph article, I was struck particularly by the concept of ‘feeling unable to offer safe care’ and how damaging this can be not only for patients but also for those treating them.
The negative impact of increasing patient numbers and workload on our ability to consult as we would like to, especially when caring for those suffering emotional distress perhaps requiring more from our conversation, was a driving force to starting this work: the search for strategies that might allow us to cope with the pressures whilst not compromising the care we provide.
Despite the involvement of other community professionals, GPs can be notoriously isolated in comparison to hospital colleagues, often taking on much of the responsibility for multiple aspects of a person’s care. Widespread staff shortages, as illustrated in a recent BMA survey that found a third of GP practices run by partners in England have doctor vacancies they have been unable to fill for at least a year (2), have only added to the strain.
During my time in Chico, I observed certain roles within the practice that, in my experience, are not as widely utilised in the UK community setting. Considering how we might better share the burden within our own system made me think about these figures and what impact a larger presence might have on patient care and experience.
I’ve come across Physician assistants only a handful of times in the UK and usually only in a hospital setting. However, I am aware that the role of Physician associate in the UK is on the increase following the launch of the faculty of Physician associates in July 2015. The role, largely promoted to its development by American Physician associates working in the UK, is now described as:
“…a new healthcare professional who, while not a doctor, works to the medical model, with the attitudes, skills and knowledge base to deliver holistic care and treatment within the general medical and/or general practice team under defined levels of supervision.”
The two-year MSc programme takes place along side traditional medical training in part and is felt to be most suitable for those with a health-associated background such as nursing. Physician associates will be trained in history-taking, examination and diagnostic skills but as of yet aren’t able to prescribe.
The introduction of these professionals to the UK workplace has been welcomed by some and met with criticism by others. The article, ‘GPs shouldn't dismiss physician associates - my practice couldn't do without them’ by Dr Patricia Wildbore published in the June 2015 edition of Pulse magazine, reflects the positive experience of some GPs who have introduced the role to their practice. However, headlines such as ‘NHS trains army of doctors on the cheap’ as published in the Daily Mail in December 2014, are common on searching and perhaps illustrate the more negative viewpoint held by some members of the public.
The need for and development of the role in American practice has similarly come about due to a lack of family medicine or general practitioners. Having been in the States and talked to those in the field I do feel that, in places, the shortage of American GPs is at a point unimaginable to those living in the UK (although worryingly, it would appear that the we are going the same way); there are many reasons for this, some similar to the issues we face at home and some not. This is something I will elaborate on in the future.
So, as many in the UK now argue that this role is vital, I was keen to experience the integration of the Physician associate in American general practice where the position has a longer-standing history and is now commonplace.
This opportunity came about readily as I found myself spending my very first few days in Chico observing a Physician assistant in practice as he consulted with patients. I was aware that he was supervised, working under an MD by law, but it quickly became apparent that he was very autonomous in his day-to-day work, diagnosing and prescribing independently.
Practically, he was set up with a similar space and team as the doctors working around him and from an outsider glance there was little to distinguish him other than the prefix on his office door.
I’d been made aware, both by certificates on the walls and by proud words from staff and patients, of the popularity of the practice and its staff within the local community and as I sat with the physician assistant in my first week, it was easy to see how his down to earth and personable rapport with patients had earned him accolade for patient experience. I would guess that him having a personal practice, as is often the case in the States, had enabled these relationships to develop more easily; his patients were more familiar to him, first names were used on both sides. Patients I spoke to often touched on his willingness to ‘fit them in at short notice’ or ‘go the extra mile’. They felt cared about, they felt like they had someone to turn to who knew them.
These were qualities identified in many of the providers in the practice as I interviewed more patients; the interesting thing was that these qualities did not seem to be determined by length or prestige of training. Often when patients relayed positive interactions they spoke of aspects of their practitioner that were more personal in nature, the ways that they showed caring or listened, things that perhaps cannot be taught. This opens a subject that I will talk a lot about in the next few blogs: the importance of the therapeutic relationship to patients and the place this aspect of care sits in the order of prioritisation in American healthcare.
But were there limitations to his role within General Practice either in the eyes of patients or the system itself? I wondered, as I explored further, whether I would find prejudices and dissatisfactions if I looked hard enough.
Exploring this subject further turned out to be an easy task as due to the aforementioned GP shortage in the States, the number of patients seeing a Physician assistant(PA) or Nurse practitioner as their primary provider, opposed to a doctor, is very high. The acceptance of these roles is, therefore, also higher in the States than I feel it would be currently within the UK as it is simply more the norm. Several themes emerged whilst interviewing patients in this situation.
Most reiterated the feeling of having a ‘personal relationship’ with their provider and being on first name terms, the lack of ‘Dr’ prefix perhaps making this more natural. The concept of receiving emotional support from their practitioner seemed more commonplace for those seeing a PA or Nurse Practitioner but this could be person-specific.
One of the most interesting points that emerged seemed to be true generally in the States but particularly amongst those seeing a PA or Nurse practitioner: a slight contrast in the perceived role of the primary care provider in terms of medical care in comparison to the UK. Many of the patients I spoke to very much saw their provider as a ‘gateway to medical care’, an advocate for them who would refer and direct them to the correct specialist so that appropriate treatment or investigation could be carried out. This is not to say that American GPs, PAs and Nurse practitioners do not diagnose, investigate and manage complex medical cases in the community but I did feel that there was more of a feeling amongst patients that the role of their primary care provider was to see them generally and refer them on. I wondered, therefore, whether this contributed to the acceptance of these roles as patient expectation seemed to differ in some areas to the expectations we encounter at home.
Ironically, I found some of the GPs I shadowed in the States to be working at a knowledge level higher than that commonly seen in the UK partly due to a shortage of specialists and partly due to the crossover roles of community doctors working within hospital and vice versa.
Despite this high skill level however, in the US referrals to secondary care are common (when a specialist is available) and the attitude towards this is undoubtedly affected by the healthcare system itself and how it functions. In contrast, in the UK GPs are increasingly actively encouraged to think twice about referring in order to lessen hospital burden and therefore end up taking on many aspects of care that in the past would not have been expected of them. Managing complex mental health needs is just one example that springs to mind.
Meeting and working with American PAs and Nurse practitioners as well as the patients they served proved incredibly useful in confirming for me many of the aspects of care that really matter to patients and indicated how we could perhaps deliver better care through the use of other professionals. At a time of great need, more of these roles could perhaps lessen the burden on GPs, not only leading to better patient satisfaction but also reducing burnout in practitioners struggling to bridge gaps in practices.
However, that being said, I do feel the success of these roles in the States comes in part from differing expectations of the individual seen in primary care and of the system itself. As the role develops in the UK, I suppose only time will tell…