This chapter presents the findings from the perspectives of the patients, relatives and carers. Twenty-eight people were interviewed across the six hospitals: 21 patients and 7 relatives. All were adults, with a range of ages, including very elderly people. They were recruited, following introduction by a PA, in the ED, medical and surgical wards. Those patients in the ED had relatively short and contained interactions with a PA. Those participants who were inpatients were variously admitted: as emergencies via the ED, for planned surgery, for medical investigations or with acute medical problems. They had been inpatients for varying amounts of time: described as for ‘3 weeks’ and ‘since last week’. Many patients, including those recruited in the ED, had experiences other recent episodes of acute care, although not necessarily in the same hospital. Many patients had ongoing and chronic conditions. Three of the patients had met more than one PA because either their medical/surgical team included more than one or they had met one in the ED prior to their emergency admission to a team that included a PA/PAs. Relatives were interviewed with their family members. Each interview commenced by checking with the patient (and relative) that they recognised the person the interview was about and that the person had been involved in their care.
The focus of the interview was on their interaction with the PA and their experience and understanding of the PA role. Themes emerging from patients’ and relatives’ interviews were similar and are reported here together. The data are presented under the following themes: experience of the PAs’ involvement in their care, their understanding of the PA role and views about the introduction of the PA role within the NHS.
Experience of the physician associates’ involvement in patient care
Within this theme, we describe the variety of ways that the PA had been involved in patient and relative treatment and care, the overall response to the PA involvement in their care and the contribution they observed the PA(s) making.
Types of involvement
Those patients recruited in the ED described the PA’s clinical assessment, initial diagnosis and management planning within a team that included the triage nurse and a senior doctor:
When I first came in [to ED] I presumably saw a triage nurse who took my blood pressure, took some bloods and then subsequently I saw the lady [PA] who diagnosed me and interviewed me, told me what she planned to do. So, she did an examination, yes, and she scanned me, a urinary scan . . . She then went to consult her superior before she outlined the treatment she was giving.
Those patients recruited in the inpatient wards described the PAs involvement (as part of their medical/surgical team) variously, from those reporting that it was quite limited to those reporting frequent involvement that included clinical reassessments and undertaking clinical procedures:
I’ve only seen him once or twice . . . it was just, a very brief chat about, about what they [the surgical team] were going to do.
I had a crowd round me, Dr [consultant’s name] and whoever else, doctors, trainees and [PAs name] . . . and he’s [PA] since been round . . . He’s explained things to me in layman’s terms . . . he put a needle in my side and drew a big lot of yellow stuff out of me.
Some patients described the PA involvement preoperatively, such as the PA telephoning them at home to confirm details about pre-admission processes or to inform them of postponements and rearrangements. One relative observed a contrast between the work of the PA in the ED, who undertook ‘information gathering, suggesting what was wrong’, with that of the work of the PA in the inpatient team who undertook more organising.
Inpatients frequently described the PA as being the person keeping them informed of their management plan and progress:
Well he’s [the PA] been quite informative . . . keeping me up to date with what’s happening prior to the operation.
One patient commented that the PA had also asked their permission and then taught some trainees (although unsure of which discipline) about an aspect of physical assessment because their medical condition made this useful learning for the trainees.
Overall view of the physician associate involvement
All of the patients and relatives were positive about all the treatment and care they had received from their health-care team. Some of those interviewed in the ED had been there for many hours and some inpatients also shared that they were anxiously waiting for results or the next steps in their management plan:
I’ve been here 3 weeks; the care has been excellent. I feel as if I’m going around in circles a bit because the left hand is still chasing the right hand as to what’s wrong.
Some patients could not particularly distinguish the PAs’ contribution to their care from the care provided by the rest of the team, which may reflect the level of contact. Those participants who could distinguish the PAs’ contribution to their treatment and care were very positive:
Yeah, he’s [the PA] put me at ease, he’s told me everything he was going to do and why and so forth . . . he’s terrific.
Observed contribution of the physician associates
The participants in the ED reported that the contribution the PA made was to conduct a satisfactory assessment, plan and treatment of their presenting problem. One patient and one relative described that they had not waited as long to be seen this time as on other occasions and speculated whether or not having PAs had been instrumental in that.
Inpatients and relatives particularly valued the contribution of the PAs in keeping them informed (previously discussed), in explaining their condition and plan (including self-management information) in a way that they could comprehend, as well as the responsiveness and accessibility of the PAs. An example is given from an observation in Box 5.
The researcher observed a PA checking on a patient in another ward to their main ward. The patient was under their consultant’s care but was on a different ward due to pressure on beds. The PA asked the ward nurse for an update on the patient’s condition. Another nurse overheard the conversation and called to the PA ‘here, doctor’, passing the patient file to the PA to look at. The PA and the nurse discussed how some management plans and requests had not been actioned and what needed to happen.
The PA approached the patient, who was seated on a chair. The patient’s son sat at the end of the bed. The PA knelt down to address the patient, saying ‘good morning. Sir, how are you today?’. The patient appeared confused and his son said that they had not been given up-to-date information on his father’s condition/management plan. The PA clearly outlined the patient’s care to date, the treatment he had received, the reasons for that treatment, which results they were waiting for and what the next steps were. The PA used layman’s terms (e.g. discussing his ‘waterworks’) and recapped the main points at the end of the conversation, to make sure it had been fully understood. Both the patient and the son asked lots of questions, which were all answered by the PA. The PA spent around 15 minutes with the patient and son, ending the conversation with a handshake, followed by a joke about the PA and their ‘cold hands!’. The PA returned to the nurses’ station to type up the notes and fill out forms for further tests.
Some participants described the PA as the ‘liaison’ and ‘a go-between’ the consultant and themselves. Comments were made about the PA helping the patients understand what the management plan was, why it might have changed and what it meant. Several patients commented on the PA’s helpful use of ‘layman’s’ language:
I was waiting all weekend to be set about and sorted out and it wasn’t until the Monday afternoon the gentleman [PA] in question came down and explained to me what was going on and he got it through to me more than anybody else, the consultant and all . . . they [the doctors] were talking before but I didn’t understand what they were saying.
Many of these types of comments about the PA’s role as an information giver and communicator also indicated a perception of responsiveness by, and accessibility to, the PA for inpatients. This was contrasted with the doctors by some participants, who were described as ‘coming and going’ and ‘buzz off after the ward round’:
He’s been quite instrumental in helping me understand things because when doctors come they say things that people are writing down and then they walk away. And you find out that they have changed your medication and obviously I need an answer as to why, so I go to him [the PA] and he explains.
This patient also commented that the constant presence of the PA on a ward was reassuring as this improved access to someone from the medical/surgical team in an emergency:
He’s [the PA] here all the time so it would be a shame if a role like that didn’t exist in the NHS especially in wards like this where things could be life-threatening and people need to react very fast.
Some of the relatives described the PA involvement with them in providing information and reassurance as distinct from the patient:
The initial contact was [PA name] phoned [another relative’s name]. Dad had a bad turn in recovery, he had a respiratory arrest, but I think he choked, but that was the first contact, and then she [the PA] was here as soon as we arrived and she explained everything that was going on.
One relative described the PA responding to their concerns about an elderly patient’s wound as having ‘put my mind at rest’, by checking the wound and then asking the nurses to change the dressing. Another relative of an elderly patient also described how the PA was actively following up (and reporting back to them) on referrals and elements of the management plan to make sure the patient was progressing to discharge. This was described a ‘relief’ as on a previous hospital admission it had not felt that way and had been much more burdensome for the relative.
Finally, a few of the inpatients suggested that the PA contributed by helping the senior doctors and consultants work more efficiently. For example, they observed that the PA had items like records, investigation results and scans ready for the senior doctors and consultants to clinically review rather than spend their time gathering or requesting that information.
Although patients and relatives were able to describe the PA involvement and contribution to their care, they did not necessarily understand what a PA was. This is discussed in the following section.
The extent of understanding of the physician associate role
None of the patients or relatives who were interviewed had met a PA prior to this hospital episode. None of them had an accurate understanding of what a PA was. We describe this first before turning to describe their views on the extent to which this concerned or mattered to them.
Understanding of what a physician associate was
None of the participants knew what a PA was, even those who were able to recount that the PA had introduced themselves or been introduced:
She introduced herself as such and also, I saw from her badge, because I sort of saw the title and thought ‘what’s that?’.
A few of the participants said they had not realised that they had met a PA until it was pointed out by the interviewer. This was also said in the context of some participants observing that there were large numbers of people involved in their health care and not necessarily knowing exactly who or what many of them were.
Some participants offered accounts of mistaken identity and described thinking that the PA was variously a junior doctor in training, a ‘floating doctor’, ‘like a supply teacher’, a senior nurse or ‘a nice member of staff in the clerking department’.
Some participants took their clues as to the identity of the PA from the clothing or equipment like stethoscopes:
Because of her uniform I gathered she was in nursing, rather than like you with casual clothes on.
Some took their clues from the context and the work the PA had been doing:
Box 6 illustrates the mistaken identity of PAs as doctors even when they introduced themselves as PAs, as seen in the observations.
The researcher observed a PA completing follow-up jobs from the ward round on a surgical ward. This included completing discharge paperwork, chasing test/scan results and taking bloods. The PA approached a patient on the ward who required a cannula. The patient was lying in bed, with her husband beside and a young child in a pram. The PA approached the bed and introduced themselves, explaining that they were a ‘physician associate, part of the medical team’. The patient commented that they were an ‘experienced’ patient and having seen the cannulation trolley, declared with a wry smile, ‘I know exactly what you are doing here!’. The PA, patient and the family spoke in good humour while the PA prepared the equipment. The patient kept a close eye on the PA, monitoring what they were doing at each stage and inspecting their work carefully. The patient discussed a previous cannulation, which had been very uncomfortable and explained that was the reason she was so cautious. The PA reassured the patient and explained each step of the process as it was being done. The researcher noted that throughout the process, the patient repeatedly addressed the PA as ‘doctor’, despite being introduced to her as a PA. The PA was focused on the task at hand; the cannulation and on reassuring the patient. The PA did not correct her.
The context for most participants was that they saw the PA within the medical team and considered the PA as part of that:
I just knew him as part of that team [the medical team], to be honest, that was with the lady, the consultant. And as I say, they’ve all been terrific, all of them.
I thought she [the PA] was one of the junior doctors actually because she was coming around with those . . . and thought no more of it [laughs] you know.
Those participants who thought that the PA was a junior doctor added that they were satisfied that the quality of the care the PA provided was very good:
I presumed that he was a fully qualified doctor, his approach and everything was absolutely 100%, that is what, particularly an older person likes, you know what I mean? Yes, to feel that they care and that’s how you felt with him.
Most described the PAs within a team context, which was delivering good care, and referring back to senior members of staff, and that was what was important rather than an individual’s title:
[I’m] perfectly happy with her [the PA’s] expertise. She then went to consult her superior before she gave me, outlined the treatment she was giving, very professional, excellent. And to be quite honest with you, these places are very complicated in the number of levels of different jobs, and it’s of little interest to me as a patient unless I’m unhappy with what I’m getting.
Some of the participants were curious about PAs and asked the researcher more questions about them to gain a more detailed understanding.
All patients and relatives were content to be attended to by a PA in the future based on their experience in this episode.
Summary
Most participants were not clear about the PA role but were very positive about the involvement of the PA and about the quality of the care they received. Not all patients or relatives knew that they had been treated by a PA, but despite this lack of understanding/awareness about the role, all patients said that they would be happy to be treated by a PA in the future.