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Original research
Comparing physician associates and foundation year two doctors-in-training undertaking emergency medicine consultations in England: a mixed-methods study of processes and outcomes
  1. Mary Halter1,
  2. Vari Drennan1,
  3. Chao Wang1,
  4. Carly Wheeler2,
  5. Heather Gage3,
  6. Laura Nice4,
  7. Simon de Lusignan5,
  8. Jonathan Gabe6,
  9. Sally Brearley1,
  10. James Ennis7,
  11. Phil Begg8,
  12. Jim Parle4
  1. 1Faculty of Health, Social Care and Education, Kingston University and St George's, University of London, London, UK
  2. 2Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK
  3. 3School of Economics, University of Surrey, Guildford, UK
  4. 4Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
  5. 5Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  6. 6School of Law and Social Science, Royal Holloway University of London, Egham, UK
  7. 7Chester Medical School, University of Chester, Chester, UK
  8. 8Royal Orthopaedic Hospital, Birmingham, UK
  1. Correspondence to Mary Halter; m.halter{at}


Objectives To compare the contribution of physician associates to the processes and outcomes of emergency medicine consultations with that of foundation year two doctors-in-training.

Design Mixed-methods study: retrospective chart review using 4 months’ anonymised clinical record data of all patients seen by physician associates or foundation year two doctors-in-training in 2016; review of a subsample of 40 records for clinical adequacy; semi-structured interviews with staff and patients; observations of physician associates.

Setting Three emergency departments in England.

Participants The records of 8816 patients attended by 6 physician associates and 40 foundation year two doctors-in-training; of these n=3197 had the primary outcome recorded (n=1129 physician associates, n=2068 doctor); 14 clinicians and managers and 6 patients or relatives for interview; 5 physician associates for observation.

Primary and secondary outcome measures The primary outcome was unplanned re-attendance at the same emergency department within 7 days. Secondary outcomes: consultation processes, clinical adequacy of care, and staff and patient experience.

Results Re-attendances within 7 days (n=194 (6.1%)) showed no difference between physician associates and foundation year two doctors-in-training (OR 0.87, 95% CI 0.61 to 1.24, p=0.437). If seen by a physician associate, patients were more likely receive an X-ray investigation (OR 2.10, 95% CI 1.72 to 4.24), p<0.001), after adjustment for patient characteristics, triage severity of condition and statistically significant clinician intraclass correlation. Clinical reviewers found almost all patients’ charts clinically adequate. Physician associates were evaluated as assessing patients in a similar way to foundation year two doctors-in-training and providing continuity in the team. Patients were positive about the care they had received from a physician associate, but had poor understanding of the role.

Conclusions Physician associates in emergency departments in England treated patients with a range of conditions safely, and at a similar level to foundation year two doctors-in-training, providing clinical operational efficiencies.

  • accident & emergency medicine
  • organisation of health services
  • quality in health care

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Twitter @varidrennan, @excel_wang, @Lusignan_S

  • Contributors VD (PhD, health policy and service delivery research), MH (PhD, health services research), JP (MD, general practice and clinical education), HG (PhD, health economics), SdeL (MD(Res), general practice and information science), JG (PhD, medical sociology), SB (BSc, patient and public engagement) and PB (PhD, audiology and strategic management) conceived and designed the study and obtained research funding. VD, MH and JP supervised the conduct of the study and data collection. VD, MH and JP undertook recruitment of participating centres and managed the data, including quality. CWa (PhD, statistics) undertook the statistical analysis; CWh (PhD, health services research), LN (PhD, health services research), MH, JE (MSc, physician associate and education) and VD undertook qualitative data collection and thematic analysis and HG considered the economic aspects. MH drafted the manuscript, and all authors contributed substantially to its revision. VD takes responsibility for the paper as a whole. All authors attest to meeting the four authorship criteria: (1) substantial contributions to the conception or design of the work; or the acquisition, analysis or interpretation of data for the work; (2) drafting the work or revising it critically for important intellectual content; (3) final approval of the version to be published and (4) agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding This project was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 14/19/26). This paper presents independent research commissioned by the National Institute for Health Research (NIHR). The protocol for the study is available at the website

  • Disclaimer The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, the Health Service and Delivery Research Programme or the Department of Health.

  • Competing interests SdeL was head of the Department of Clinical and Experimental Medicine until June 2019 at the University of Surrey, which launched a physician associate course in 2016. JP is the immediate past chair of the UK and Ireland Board for Physician Associate Education and immediate past director of the physician associate programme at the University of Birmingham. PB is honorary faculty at the University of Birmingham and has taught on the physician associate programme since 2008. JE taught part time on the University of Birmingham physician associate programme until 2020. VMD was a HS&DR Board Member in 2015.

  • Patient and public involvement Patients and/or the public were involved in the design, conduct, reporting or dissemination plans of this research. Refer to the 'Methods' section for further details.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the NHS Health Research Authority London-Central Research Ethics Committee (15/LO/1339).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No additional data are available for sharing.

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