Bringing the standards to life
This section supports our interim standards for PAs and AAs by using real life examples. It does not set new professional standards and is not intended to replace the formal guidance.
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Learn how physician associates (PAs) and anaesthesia associates (AAs) use their judgement to apply the principles of Good medical practice. PAs and AAs share below how they collaborate with colleagues, work within their competence, and give patients information in a way they can understand.
This section supports our interim standards for PAs and AAs by using real life examples. It does not set new professional standards and is not intended to replace the formal guidance.
Our guidance sets out the principles of good practice. All registrants must be familiar with our guidance, and take account of it in their day-to-day work. One of these principles is that you must appropriately apply your knowledge and skills.
As a registered professional you are expected to provide a good standard of care to patients. Among other things, this involves understanding the boundaries of your ability, and knowing when to refer or escalate to a colleague.
That’s why in Good medical practice we say you must recognise and work within the limits of your competence (paragraph 14) and seek advice from your supervisor where appropriate (paragraphs 15 and 16).
This is what the PAs and AAs we spoke to told us about how they do this.
Ria told us that during consultations with patients she tries to take a step back to think through her management plan. She silently asks herself questions such as ‘What do I need to do to make sure that this patient can safely leave the consultation room?’.
This involves her thinking about what investigations she’ll need to carry out. She also plans for future management of the patient and puts a safety net in place.
She also keeps in mind that there are certain groups of patients who are more clinically vulnerable than others. For example, people who are pregnant are a cohort where she needs to be doubly sure that she’s happy to send that person home.
Ria’s advice to new PAs is that they should have self-awareness about their deficiencies.
'It’s important to appreciate you’re not going to see every type of condition regardless of whether or not it’s on your matrix.'
She also says it’s important to not be afraid to escalate any concerns or doubts with your clinical supervisor.
'At the heart of it there’s a patient who needs to be looked after – and it’s important for the patient and your own mental health that you can go home without worrying about whether you should have raised something with your supervisor.'
Jamie works to a very clear rule that all new outpatient cases should be discussed with a consultant before the patient can be discharged. He doesn’t deviate from this. And in instances where he is unsure about how to provide the best level of care or treatment, he seeks advice from a more senior colleague.
'There’s no debate in my mind: if I ever question something, I escalate. I have a low threshold to discuss things with my seniors.'
Jamie also recognises that other specialties may be better placed to provide a more specialist level of care. For example, if after initial assessment he feels that one of his patients has a condition which it may be more appropriate for a cardiology colleague to see and manage, he escalates to his consultant supervisor with a view to discussing and referring the patient to the appropriate team. But Jamie is aware that it’s his responsibility to follow up on referrals he’s made.
Even though Toni’s an experienced AA, she never loses sight of the fact that she has her limitations. To ensure patient safety, she makes sure she always discusses her patients with her supervising consultant at the beginning of her list. Nine out of ten times the consultant is entirely satisfied with her proposed approach, but discussing every case gives Toni the peace of mind that she’s working safely.
More generally, Toni says her approach has always been a little glass half empty.
'I will always look at the patient and think, "What could possibly go wrong? And what are the chances of it going wrong? What could I do to mitigate those chances and what am I going to do if I need to call for help?"'
Toni received advice from a consultant anaesthetist on her very first day: 'If you think it, do it.'
In other words, if something sets an alarm bell ringing in her mind, she thinks there’s probably a good reason for it and she acts on it.
For Mark, good communication with his supervising consultant is key to working within the limits of his competence. As an experienced AA he has autonomy in his role, often working on a two-to-one basis (ie. two anaesthesia associates to one consultant). This means the consultant won’t necessarily see the patient themselves. Communicating his plan to the consultant is critical: 'We run the [patient] list ourselves', he says. 'The consultant doesn't actually get involved with seeing the patient.'
'I'll see my morning list of patients and then have a meeting with my consultant to tell them about the patients and my anaesthetic plan. If I have a concern about a patient, I’ll ask the consultant to see the patient with me.'
If a concern arises in Mark’s mind while he’s running the list, he calls the consultant straight away.
'It's pretty simple. This is people’s lives so, if there’s even a tiny little doubt, you need to talk to your consultant about everything. Absolutely everything.'
Better technology has also helped to improve communication with his consultant. His NHS trust use a wireless, landline phone, meaning it gets signal throughout the whole hospital. 'Before we had the phone we sometimes felt a bit vulnerable', says Mark. 'But now if a patient deteriorates, we can contact the consultant immediately and they can be there in 30 seconds. It’s been a game changer.'
And because Mark has already discussed the patient with his consultant, the consultant isn’t coming in blind.
Mark advises those AAs at the start of their careers to learn to walk before they can run.
'Recognising and working within the limits of your competence comes down to experience. First, learn how to give a basic anaesthetic. Then you can slowly start introducing yourself to extended roles and enhanced practices.'
Kyna pointed out that the limits of her competence have changed over time as she’s grown in experience. Ten years post-qualification, things that would have once caused her to escalate to her supervising consultant no longer do.
Nonetheless, she remains mindful of the advice she was given as a student.
'If anything goes wrong, call for help and do your classic ABC (Airway, Breathing, Circulation). That was drilled into us as trainees – get your consultant there immediately.'
Kyna has responsibility for students and says she drills home the message to get help early: 'It's so much easier to dig yourself out of a shallow hole than a deep one. So definitely get help early.'
She also says there’s no shame in asking for help when you need it. 'I would want a new AA to say, "Actually, I've never done this before. Would you mind showing me?"', she says.
She cautions against agreeing to do something if you aren’t confident to do it.
'If you have any hesitations – if you don’t have the confidence to do something – don’t just agree to it.'
Patients want healthcare professionals who work and communicate effectively with them. So as a registered professional you’ll be expected to establish and maintain partnerships with patients. A key part of this involves explaining what you do and how that fits in with the other members of your team – this is especially important as PAs and AAs are relatively new professions which patients may be unfamiliar with.
That’s why in Good medical practice we say you must give patients the information they want or need to know in a way they can understand (paragraph 32) and work in partnership with patients, sharing information they will need to make decisions about their care including your role and responsibilities in the team and who is responsible for each aspect of their care (paragraph 49).
This is what the PAs and AAs we spoke to told us about how they do this.
Toni’s aim when talking about her role and responsibilities in the team is to be clear and succinct. She always introduces herself using her name and job title – and explains why she’s there in a single sentence.
She also likes to keep it simple, turning medical terms into plain English where possible.
‘I tell patients, “I’m an anaesthesia associate. That means I’m going to be anaesthetising you: putting you off to sleep and waking you up. I'll be looking after you.”’
Toni is attentive to the fact that some patients may not have met an AA before and therefore don’t instinctively understand her place within the multidisciplinary team – so she makes it clear that she’s working alongside a consultant.
She’s also mindful that one size does not fit all. So, while there’s a minimum amount of information the patient needs to know, the level of detail she goes into depends on the patient.
‘There are times where it's not appropriate to go into lots of detail. I do a lot of breast surgery and cancer surgery on a Wednesday and I’m careful not to overwhelm those patients with too much information – they just want to know that they're in safe hands.’
Toni told us that it’s not just about what you communicate, but how. And that comes with experience.
‘There are some patients who want a lot of information, some you can be more informal with and some who want you to cut to the chase. I've been doing it quite a long time now and I like to think I've got better at gauging people and knowing how to tailor my approach.’
When introducing himself, Mark is unambiguous about his place in the team. He emphasises that he’s working alongside a consultant anaesthetist – but that he isn’t a doctor.
‘When I introduce myself, I let the patient know I’m an anaesthesia associate and what that means; namely, that I’ll be anaesthetising them but that it’s not just me who’s responsible for their care – they’re also going to get consultant input.’
Mark told us that this straightforward approach has been really effective.
‘I’ve been qualified for six or seven years now, and in that period of time I’ve only had one patient ask me questions about my job title.’
Kyna prefers to use layman’s terms when describing her role and responsibilities. And this has evolved over time.
‘When I was brand newly qualified, I was probably a little bit more formal. But over time I've developed my own style and rapport with patients’’
She uses her first name and emphasises the care she’s going to give - rather than focusing on her job title. And she always says she’s working as part of a team alongside a consultant. She tells patients, ‘My name's Kyna. I'm one of the anaesthetic team and I'm working with the consultant anaesthetist. I'm going to be looking after you today; keeping you asleep, keeping you safe, keeping you comfy.'
Jamie likes to keep it simple and has a consistent approach when it comes to explaining his role and responsibilities: ‘I have a standardised way of explaining who I am to patients. This is because I’m mindful that they might be very unwell - so I try not to make it too longwinded or convoluted’.
‘I basically say, “I’m Jamie. I’m one of the haematology team. I’m a physician associate. That means I’m not a doctor. I might look like a doctor, I do lots of things that traditionally only a doctor might do, but it’s important for you to understand I’m not a doctor’.
On some occasions this generates further questions – but most patients are satisfied that they understand his role within the team. ‘Mostly, patients aren’t too bothered about my job title. Sometimes I have to explain how I got here and what training I did. Or that that their care is overseen by their consultant and that I discuss their care with the consultant’, he says.
But even in these instances, it usually only happens during that initial contact – once patients are familiar with him, they often want to see him again.
‘Usually, after the patient has seen me a few times in the clinic, they ask to see me again next time. They like the continuity of care that I can provide as a PA’.
Ria told us that one difficulty for her in explaining her role and responsibilities is that, working in general practice, the patient’s initial contact is with reception. ‘Unlike some other healthcare settings, by the time I see the patient they have already agreed to seeing or speaking to me rather than a doctor.’
So it’s important, Ria says, to manage patient expectations. And that involves the entire team.
‘I’m aware that consulting with a PA may not be the patient’s first choice, especially if they don’t know me. So it’s important for the practice team to have a clear understanding of my role, and to explain this clearly to patients’, Ria says.
At Ria’s practice the reception team use care navigation, where reception staff take a very rough history from the patient to get an idea of the most appropriate person for them to talk to. Ria has worked with her reception team to describe her role and they use wording along the lines of ‘Ria sees similar things to a doctor, but she’s not a doctor.’
Reception staff reassure patients that Ria works alongside the other doctors at the practice and will seek advice from them if she feels she needs to. Nevertheless, if a patient specifically asks to see a GP, they are put on a GP’s list.
For those who attend face-to-face appointments, the door to Ria’s consultation room has her name and job title so it’s clear to the patient who they’re seeing. And she places information about PAs on her table. She has found that patients will often read this information when she leaves the room to get a prescription, or a sick note signed.
Ria says that time and continuity have also helped patients become accustomed to her role.
‘Because I’ve been at my surgery for about six years, most of our patients have some understanding of my role.’
Nevertheless, Ria emphasises that it can take time for patients and other healthcare professionals to become familiar with new roles like hers in general practice.
Our guidance sets out the principles of good practice which all registrants must be familiar with and take account of in their day-to-day work. One of these principles is that you must work with colleagues in ways that best serve patients' interests.
Patients expect PAs and AAs to work in partnership with one another: communicating and working together effectively. That’s why we say you must work collaboratively with colleagues, respecting their skills and contributions (paragraph 35 of Good medical practice).
This is what PAs, AAs and their supervisors told us about how they collaborate with their colleagues.
For Jon, the introduction of AAs at his Trust has led to better teamworking and patient care. In part, this is due to the nature of the role. Unlike trainee doctors, AAs don’t rotate – which means that over time they acquire an extensive knowledge of the department and people who work there. This provides stability and continuity of care.
‘AAs have become highly skilled at knowing what tests to obtain and how to obtain them, what hoops to jump through and the right people to speak to on the wards. So the whole thing becomes a much smoother operation.’
Jon told us that this has meant a faster turnaround and greater throughput on their anaesthetic lists.
Effective collaboration between AAs and doctors has also been to the benefit of junior doctors by freeing up time for training. For instance, Jon says ‘our AAs are incredibly competent, so they can work with some degree of independence which means consultants can spend more time with trainees - or the AA can take the trainee down to the ward to do an assessment with them whilst we're running a list’.
Jon noted that some trainees are anxious about AAs taking away their learning experiences. But he sees AAs as a help not a hindrance.
‘When I’m doing a trauma list, I will be very glad to see there's an AA on the rota with me, especially when I know I've got to teach somebody.’
Collaboration between AAs and their colleagues has also meant that Jon and his team were better able to meet the challenges thrown up by the pandemic.
‘The pandemic was a challenge for us all, but our AAs helped us to keep our service going as many of our consultants and trainee anaesthetists were needed in intensive care as part of our COVID-19 response.'
The ability to communicate with colleagues quickly using messaging technologies has facilitated collaboration where Kyna works.
‘We have an encrypted internal messaging system which we use to raise any queries we might have with a consultant during pre-assessment. We also have a WhatsApp anaesthetics group chat which has 200 members in it. And if you ever have a query, you can draw on the experience and knowledge of that hivemind and get a response within five minutes.’
In Numan’s department, collaboration has been enhanced by PA involvement in inductions for junior doctors. Tom, one of the PAs that Numan supervises, delivers the induction talk and will explain what PAs do and how they fit in with the rest of the team. ‘That’s really helped teamworking between PAs and juniors’, Numan told us.
Following these inductions, junior doctors worked more closely with PAs. The junior doctors better appreciated their PA colleagues’ clinical skills and knowledge of the department – whether that was knowing where to get an ID badge, how to arrange blood tests or who to speak to regarding a particular patient.
Teamwork and communication have also been improved by PAs.
‘Consultants may not be there every day and junior doctors rotate every six months – but PAs are a constant feature within the department’, Numan told us. ‘So they naturally become a linchpin.’
This continuity has also benefitted patients, Numan explained.
‘They know the patients inside out because they're on the shop floor. This makes them a vital part of the multidisciplinary team’.
This has allowed consultants to spot potential problems much sooner and ensure that interventions are provided on time. This partnership has ‘optimised the care we offer to patients – that’s been quite tangible’, Numan says.
Numan refers to the continuity provided by PAs as ‘departmental memory’ and says patients are the ultimate beneficiaries.
‘When the juniors change after six months, the knowledge they’ve acquired is gone. But the PAs maintain that memory and are able to share that with new starters.
‘They take ownership of patient management with the juniors who are on the wards. For instance, they can identify patients that need discharging and are able to pre-empt and deal with hurdles which might arise, such as organising social care.’
Mark told us that working in partnership with colleagues has been especially important for him during the pandemic. His hospital became a surge centre, taking in patients from overwhelmed areas – and he worked as part of a “transfer team”, working closely with a consultant to bring in patients who were unwell with COVID.
‘We were receiving COVID-positive, ventilated patients from the whole of East of England and London. And my role as part of the “transfer team” was to go out with the consultant in the back of the blue light ambulance as a specialised pair of hands to help transport the ventilated patient back to our hospital’, Mark said.
Mark and his AA colleagues have also improved collaboration at their Trust by starting to take on some weekend work in order to reduce the pressures on trainees and consultant.
‘Traditionally we've only worked Monday to Friday, 8am to 5:30pm. But we recently started to work one weekend in four where we’re attached to an emergency and a trauma team. So whereas you would usually only have one consultant and a trainee, you now have one consultant with a trainee and an anaesthesia associate.
‘That means that, for example, we can see patients that are booked onto the emergency list to make sure that they're ready, suitable and consented for anaesthesia. So it stops the list from becoming delayed. It makes it more efficient and effective and we've already started to see a positive change.
‘A lot of consultants have said that us being around on a weekend makes a massive difference because it means we can see patients for them, relieve them for breaks or act as another pair of hands if a difficult case comes in.’
Wal told us that the PAs he supervises have greatly enhanced teamworking in his department
‘[PAs] are a great link between us as consultants and what's going on in the ward. It’s sometimes hard to keep up with where the junior doctors are because they might be on a zero day, study leave or on the on-call rota. But our PAs are here Monday to Friday, pretty much 8am till 5pm, so they provide a great continuity of care for patients and nurses on the ward – and improve communication.’
Working in partnership with colleagues has been particularly important during the pandemic when staff have been required to work flexibly or work in other areas. Sharon, a PA supervised by Wal, told us she has spent a lot more of her time working on a ward where few of the nursing staff knew her. It soon became apparent to the nurses that, in addition to her clinical skills, her knowledge of the department – and ability to connect staff – was a huge asset.
‘The nurses all quickly learned that I knew how to get in touch with the right people,’ Sharon said. ‘They no longer had to go through a long list of bleeps to find the right doctor, because I was able to identify the appropriate person for them. So they used me as the first port of call and really appreciated that I could do that for them.’
Sharon also ran telephone clinics from home when she was shielding and could not work in the hospital. This meant that her consultant colleagues could use their time more effectively.
‘Sharon’s telephone clinics freed up our consultants to see the more specialist work,’ said Wal. ‘She increased our capacity by about 40–50%, which meant that we were able to tackle our backlog while patients were seen more quickly and were able to have longer, more complex consultations.’
One of the ways in which Ria works with colleagues to best serve patients' interests is to be available while GPs are making home visits.
‘When I first started working here it was agreed I wouldn't join in with the regular visits. This was because I was still reasonably inexperienced. And the GPs were better placed to do home visits for patients that were either too elderly or complex to attend the surgery.
‘Additionally, if there was an emergency on a home visit, the legalities around a non-prescriber giving emergency medication in the absence of an on-site doctor were not quite clear to any of us'.
One benefit of this was that Ria was able to develop relationships with the nurses and reception staff at the practice.
‘Because I don’t routinely do home visits in between my clinics, I’m available to give advice to other members of the practice team such as the nurses and the reception team. And I can catch up with tasks generated by clinics, such as bloods and letters’.
Ria has also worked in partnership with colleagues by seeing an increased number of patients with mental health issues due to her special interest in this area. As a PA she feels she is more protected than the GPs in terms of her workload: even though she has the same amount of time per consultation as a doctor. This allows her to take time to delve deeper into a patient’s mental health problem, which can be beneficial.
As Ria explains: ‘We’ve seen poor mental health increasing quite dramatically in our patient population and it can take time to peel away the layers to understand what’s really going on.
‘I see some of those patients because I can afford to spend a bit more time with them. This is particularly helpful where patients have intertwined physical and mental health issues. And I think patients appreciate one clinician managing both aspects where possible, with advice from my seniors where needed.
‘I have also found that being a permanent member of the team means that patients benefit from continuity with me, and I have built up several “regulars” throughout my time at this practice which is a real joy for me’.
In haematology, Jamie and his PA colleagues have collaborated particularly well with the registrars in his team by relieving them of some administrative and procedural tasks - such as bone marrow biopsies.
‘Bone marrow biopsies used to be the preserve of the registrars. But undertaking biopsies in addition to their usual clinic duties meant they were often stretched. So I and my PA colleagues took on greater responsibility for this work – and now a large proportion of biopsies are performed by PAs in our department’.
As a result, the registrars now have more time for study, attending clinics or reporting the bone marrow findings.
Yet while taking on a greater share of this work, Jamie is also alert to the continuing need for training opportunities for his doctor colleagues.
‘There was discussion of further reducing the proportion of biopsies done by registrars, but I opposed it. Registrars still need an ongoing opportunity to be trained and maintain competence in this area.’
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