Evidence: How Physician Associates improve patient outcomes and help Doctors in Emergency Departments

It is well-known that emergency departments in the UK are struggling with a shortage of trained clinical staff and unprecedented numbers of a patients. The purpose of this paper is not to examine the reasons for this situation but rather to look at the evidence suggesting how and why physician associates are an effective solution. To this end I am referencing four papers with a synopsis of each. 

Halter, M., Wheeler, C., Pelone, F., Gage, H., de Lusignan, S., Parle, J., Grant, R., Gabe, J., Nice, L. and Drennan, V.M. (2018) Contribution of physician assistants/associates to secondary care: a systematic review. BMJ Open [online]. 8 (6), pp.e019573-e019573. 

This review takes in findings from seven studies of PAs working in emergency medicine. In summary the findings were: 

• The presence of a PA significantly reduced the likelihood of a patient leaving without being seen (by 44%). 
• The odds of a patient being seen within the benchmark time was increased by 1.6x 
• PAs had a slightly increased length of time (8 min) compared to doctors but despite this PAs were associated with a small but statistically significant decrease in cost per patient. 
• There was no significant difference in wound infection rates compared to other clinical staff. And rates of reattendance within 72 hours are the same as for other clinicians. 

Hooker, R.S., Klocko, D.J. and Larkin, G.L. (2011) Physician assistants in emergency medicine: the impact of their role. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine [online]. 18 (1), pp.72-77. 

This is a literature review of 35 studies relating to the use of PAs in emergency medicine in the USA/Canada. The main findings are: 

• The rate of ED visits is predicted to double by 2025, while the rate of emergency physicians (EPs) entering the profession is flat. 
• 7,817 (10% of the PA workforce) worked primarily in EDs in 2009. 
• Patients were “very satisfied” with care rendered by a PA, with a mean patient satisfaction score of 93 of 100. Overall, 12% were willing to wait longer for a physician. 
• A 20‐year analysis validated that PAs do not increase legal liability and in fact may even lower the liability of a medical practice. 

Howie, N. (2015) A new kid on the block: the role of physician associates. Clinical Medicine (London, England) [online]. 15 (3), pp.309-310. 

This study looks at outcomes from four PAs who were recruited to work in a hospital in the Midlands. Outcomes were: 

• The four PAs concerned treated 7,133 patients over a 12 month period. 
• They employed a range of diagnostic and therapeutic procedures, some of which PAs have from graduation (for example suturing, venepuncture and cannulation), to more complex procedures (such as digital ring blocks and chest drain insertion) 

Drennan, V.M., Halter, M., Wheeler, C., Nice, L., Brearley, S., Ennis, J., Gabe, J., Gage, H., Levenson, R., de Lusignan, S., Begg, P. and Parle, J. (2019) What is the contribution of physician associates in hospital care in England? A mixed methods, multiple case study. BMJ Open [online]. 9 (1), [Accessed 1 February 2019]. 

This study reports evidence from a range of sources. The main findings were: 

• The PA’s constant presence on the ward meant they were easy to approach and PAs followed up items from the doctor’s ward round and spent time explaining decisions and management plans to the patients and relatives. 
• All of the patients and relatives reported that they saw the PAs working within the medical/surgical team, PAs provided good care and referred back to senior doctors. All patients and relatives interviewed were content to be attended to by a PA in the future. 
• It appears that the use of PAs in EDs can favorably affect patient care. This may be through patient flow, differentiation of patients, offloading resident work hours, or augmenting staffing patterns. Improved clinical and financial outcomes are important findings in a few studies. Other studies have demonstrated additional areas of influence such as quality of care. 
• One of the most frequently reported impacts on the organisation was that PAs provided continuity of staffing in the medical/surgical team, that is, personal and team continuity 

• PAs were described and observed to undertake large amounts of non-patient facing clinical work for the medical/surgical team. All participants reported PAs helped smooth and improve patient flow. 
• The presence of a PA in the team was considered to release the doctors’ time to attend more complex patients and also to attend patients in outpatients and theatre. 
• All consultants, registrars and managers reported the PAs to be safe with no serious incidents or patient complaints. Many of the doctors reported that the PAs were careful to work within their capabilities and within guidelines and appropriately refer to the doctors within the team 
• Those that were able to offer views did so anecdotally describing reduction in spending on locum doctors, improved use of senior clinicians’ time and greater productivity of the medical/surgical team: 

In conclusion 

PAs provide an effective solution to ED staffing shortages because PAs are by nature generalists and ED is one of the last generalist medical disciplines. Consultants generally like working with PAs because PAs tend to stay; we do not rotate out to another department or hospital. PAs are associated with improved patient flow and less legal liability – that has to be a good thing. And PAs are cheaper than employing locums. 

Another solution is to recruit or train ANPs to plug the shortage, this is a reasonable solution if you can find the appropriate staff, the downside of recruiting ANPs is that it simply shifts the staff recruitment problem elsewhere. PAs are new staff coming into the system. 

In addition, PAs represent a flexible workforce, if you have a PA working in ED and it is quiet in ED and you are understaffed in Gastro you can move the PA across to fill the short-term gap.