Physician associates: why we need a pause and an urgent review

A footballer knows their job. Where to stand, what to do with the ball, and where to run next. A cricketer knows where they will bat or bowl, and how to bat or bowl, depending on the match situation. There is no role confusion. Every member of an orchestra knows when to play and how to play their instrument. There is absolute clarity. A company of actors knows each actor’s part. A troupe of dancers knows each dancer’s step, pirouette, and flourish. A team works to a high level only if we each know and understand our roles and responsibilities—and each other’s.

In 1965 the US researcher Bruce Wayne Tuckman proposed his four stage theory of group dynamics. After “forming,” said Tucker, a team goes through “storming,” “norming,” and “performing.” With the introduction of physician associates, the multidisciplinary team in healthcare is stuck in a storm. A period of storming, as Tucker describes, is inevitable, but healthcare’s perpetual storm is undesirable and damaging.

A doctor’s role will continue to evolve, and healthcare is undoubtedly a team game (doi:10.1136/bmj.q155).1 Optimally “performing” teams will improve productivity (doi:10.1136/bmj.q130) and, for example, be better equipped to respond to outbreaks of measles (doi:10.1136/bmj.q159) that are partly fuelled by vaccine hesitancy and polarisation on social media (doi:10.1136/bmj.q147, doi:10.1136/bmj-2023-076542).2345

We must, however, accept some ground realities. First: a population’s growing health needs, from coughs and colds (doi:10.1136/bmj-2023-075306) to venous ulcers (doi:10.1136/bmj-2023-078321), will not be met by doctors alone.67 Better, more compassionate care requires team members to contribute in their different ways (doi:10.1136/bmj.q129).8 Second: any new professional group able to influence patient care needs appropriate and clear regulation. Third: it is important to respect professional colleagues and resist tribalism.

When it comes to physician associates, the storm isn’t then about the “why” but more about the “what” and the “how.” Confusion among patients about professions isn’t new. Women are still often assumed to be nurses and men to be doctors. Tackling such casual sexism is an ongoing battle, but the confusion is meant to evaporate once a health professional has introduced themselves.

Yet that is no longer the case. Patients are confused by who is and who isn’t a doctor. Even correct use of the term “physician associate” is easy to misunderstand. Similarly, identifying doctors by their training grade can leave patients unsure if they have been seen by a doctor. Our current poll (bmj.com) finds that only 15% of responders want to continue to use the term “junior doctor,” and fewer still want to be identified by training grade.

A way forward might be to adopt the American terms of internist and resident, which has some support in our poll, or revert to a variant of house officer, senior house officer, and registrar. There is also support for replacing “junior doctors” with “doctors,” but it doesn’t resolve the issue of how to distinguish this subgroup of doctors. The solution requires further discussion, but it’s clear that the confusion in distinguishing doctors from physician associates demands an urgent resolution.

That problem now extends to regulation. The UK government’s intention for the General Medical Council to regulate physician and anaesthesia associates adds to that confusion, given that the public perceives that the GMC regulates doctors. The move is being vehemently opposed by the BMA and the UK Doctors’ Association (doi:10.1136/bmj.q156).9 Some medical royal colleges are also up in arms, while another, namely the Royal College of Physicians of London, has caused uproar among its members by supporting the government’s plan (rcplondon.ac.uk/news/extra-ordinary-general-meeting-request-and-rcp-council).10

The political decision is premature, if not downright foolhardy. There is some indication that the GMC is beginning to change its internal processes after the independent review of its handling of the Manjula Arora case (doi:10.1136/bmj.o3015),11 but we are yet to see a demonstrable improvement in outcomes or a resurgence of professional confidence in the GMC. Even if it were right in principle, burdening the GMC with regulation of physician associates, when itself is besieged by criticism, may be the final straw.

The principle, too, seems suspect. The GMC does not regulate any other health profession—not dentists, nurse prescribers, or prescribing pharmacists. They have their own regulatory bodies or are regulated by the Health and Care Professions Council. The logic for GMC regulation of physician associates seems to be driven by political expediency, not sound judgment.

Rushing such a disruptive regulatory decision is imprudent and will cause long term harm and deepen distrust. The most sensible next step would be to pause any legislation for an urgent review of the role definition, training, and regulation of physician associates. This would safeguard the public by replacing confusion with clarity, conflict with common purpose—and not replacing doctors with physician associates, whether in reality or perception. Committed staff—doctors and physician associates—are being disenfranchised by a systemic failure to deal with core problems.

“Stormin’” Norman Schwarzkopf, military leader of the allied forces in the first Gulf war, may have best defined commitment. If you think of a full English breakfast, he said, a chicken is involved but a pig is committed. The modern healthcare team needs more pigs: people who are committed and who know their role, responsibilities, and regulation.