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• Without matching of patient acuity, comparison of outcomes is meaningless
  Daniel J Chivers
  Published on: 6 June 2024
• Drawing comparisons between doctors and PAs
  Patrick D Warren
  Published on: 19 March 2024
• RE: Comparing physician associates and foundation year 1 doctors-in-training undertaking emergency medicine consultations in England: a quantitative study of outcomes
  Gregory Yates
  Published on: 19 March 2024
• Concerns with Design, Methodology, Interpretation, and Conclusions
  Tomas Ferreira
  Published on: 19 March 2024

• Published on: 6 June 2024

  Without matching of patient acuity, comparison of outcomes is meaningless

  • Daniel J Chivers, Junior Doctor Sheffield Teaching Hospitals NHS Foundation Trust

  I began to read this paper with interest, but it quickly became clear the methodology is significantly flawed, with a seemingly significant misunderstanding of the factors that contribute to any collected data.
  The authors acknowledge that the PAs sampled were mostly working in Resus and Majors; how can there therefore be a reliable comparison between any outcome measure? A measure of the degree of sickness and co-morbidity would be the most important variables to match in any comparison. Furthermore, sampling 11 PAs and 7 FY1s cannot possibly be considered well-powered quantitative data.

  These issues should have been highlighted during peer review.

  Conflict of Interest:
  None declared.

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• Published on: 19 March 2024

  Drawing comparisons between doctors and PAs

  • Patrick D Warren, Anaesthetic Trainee Hampshire Hospitals Foundation Trust

  Dear Editor,

  There are several aspects of this study which I find puzzling. Firstly, this study compares PAs to FY1 doctors; it is not clear why this comparison was chosen, as the core purpose of an FY1 placement in Emergency Medicine is the educational benefit to the FY1 doctor, rather than service provision. Indeed, there is not an established non-training FY1-level ED Dr role in the UK; FY1 doctors sit at Tier 1 on RCEM’s capability tier system, and ‘should not be considered part of the workforce when considering capacity’ (1). PAs sit at Tier 2 on this scale, alongside FY2 and CT1-2 doctors. I suggest that it would be much more logical to compare outcomes between PAs and another Tier 2 clinician group rather than FY1 doctors (a role which is arguably incomparable). Furthermore, this study does not control for the extra experience a PA will accrue beyond the four months that an FY1 will spend working in the ED before rotating; nor does it detail how much experience the 11 PAs in this study had, which is surely relevant.

  Secondly, two of the four outcome measures chosen seem to be of limited to no relevance to patient outcomes or assessment of clinical roles. Wait time to consultation as a dependent variable occurs prior to independent variable (FY1 or PA) allocation, so cannot be affected by this - rather it is dependent on the overall staffing and attendance levels of the department. Patients who leave without being seen (LWBS) again will not have met th...

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  Dear Editor,

  There are several aspects of this study which I find puzzling. Firstly, this study compares PAs to FY1 doctors; it is not clear why this comparison was chosen, as the core purpose of an FY1 placement in Emergency Medicine is the educational benefit to the FY1 doctor, rather than service provision. Indeed, there is not an established non-training FY1-level ED Dr role in the UK; FY1 doctors sit at Tier 1 on RCEM’s capability tier system, and ‘should not be considered part of the workforce when considering capacity’ (1). PAs sit at Tier 2 on this scale, alongside FY2 and CT1-2 doctors. I suggest that it would be much more logical to compare outcomes between PAs and another Tier 2 clinician group rather than FY1 doctors (a role which is arguably incomparable). Furthermore, this study does not control for the extra experience a PA will accrue beyond the four months that an FY1 will spend working in the ED before rotating; nor does it detail how much experience the 11 PAs in this study had, which is surely relevant.

  Secondly, two of the four outcome measures chosen seem to be of limited to no relevance to patient outcomes or assessment of clinical roles. Wait time to consultation as a dependent variable occurs prior to independent variable (FY1 or PA) allocation, so cannot be affected by this - rather it is dependent on the overall staffing and attendance levels of the department. Patients who leave without being seen (LWBS) again will not have met their clinician at the point of self-discharge, so this cannot be dependent on whether they would have been seen by an FY1 or PA. These two tenuous outcome measures contribute to the statement: “PAs… managed patients… with a similar level of impact on three emergency medicine outcomes measures as FY1s”. Moreover, the claim that “no significant difference of patients LWBS… suggest similar quality and efficiency of care between the two clinicians” seems an unsubstantiated conclusion to arrive at.

  Overall, I wish to share what I believe are reasonable doubts about the conclusions drawn from this study, and any potential inferences of these for informing staffing choices in Emergency Departments. Two very distinct roles, the FY1 and PA, were compared, with two of the four metrics arguably independent from the clinician assigned. The lack of a previous FY1-PA comparison study is not a compelling reason for one to have been done; if comparisons must be drawn, this should be against other Tier 2 clinicians, as Tier 1 capability is not meant to be a benchmark of effective service provision. That being said, I would congratulate the FY1 doctors in this study - as noted by the author, they were ‘very efficient in all areas’. In light of It would certainly be of interest to compare the relevant metrics (LOS and return within 72h) between PAs and an appropriately selected grade of doctor. Finally, I must comment on the prevalence of unsubstantiated generic claims about the capabilities of PAs in this paper, e.g: “PAs are particularly able to see large volumes of patients in higher acuity areas”; “[after GMC regulation] their efficiencies are highly likely to improve…”. These are bold claims to make, especially without evidence or explanation; especially in the context of ongoing Royal College discussions regarding ensuring MAPs work to an appropriate scope of practice, it may be best to stick to the facts.

  (1) Royal College of Emergency Medicine. Medical and Practitioner Staffing in Emergency Departments. Available: https://rcem.ac.uk/wp-content/uploads/2021/11/RCEM_Medical_and_Practitio...

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  Conflict of Interest:
  None declared.

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• Published on: 19 March 2024

  RE: Comparing physician associates and foundation year 1 doctors-in-training undertaking emergency medicine consultations in England: a quantitative study of outcomes

  • Gregory Yates, ST1 Doctor Manchester Royal Infirmary

  Dear Editor,

  As an emergency medicine trainee, I read this paper with interest. The timing is important. A few days ago, the British Medical Association released a report outlining how PAs should work safely within the NHS [1]. The death of Emily Chesterton, whose pulmonary embolism was mis-diagnosed as anxiety by a PA in 2022, is referenced in this report.

  I was surprised to read the following in the authors' discussion:

  "The findings of no statistical difference in those reattending within 72 hours or LWBS demonstrate similar safety and appropriateness practices between the two clinicians."

  Although re-attendance and self-dicsharges are important outcomes, they do not demonstrate safety. The only safety outcome investigated by the authors was death in the ED. This is an uncommon event. I am not surprised that it was not encountered in a sample consisting of eighteen clinicians.

  In order for the authors to make claims about safety, it would be necessary to see data on in-hospital and 30-day mortality, in addition to the "adverse events, near misses, and errors" they suggest for future research.

  With that said: the authors did compare admission rates between FY1 doctors and PAs. In vulnerable patient groups, this can be interpreted as a safety outcome. One such group is the elderly, who were seen in greater numbers by the PAs in this study. Admission to hospital carries multiple risks for elderly patient...

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  Dear Editor,

  As an emergency medicine trainee, I read this paper with interest. The timing is important. A few days ago, the British Medical Association released a report outlining how PAs should work safely within the NHS [1]. The death of Emily Chesterton, whose pulmonary embolism was mis-diagnosed as anxiety by a PA in 2022, is referenced in this report.

  I was surprised to read the following in the authors' discussion:

  "The findings of no statistical difference in those reattending within 72 hours or LWBS demonstrate similar safety and appropriateness practices between the two clinicians."

  Although re-attendance and self-dicsharges are important outcomes, they do not demonstrate safety. The only safety outcome investigated by the authors was death in the ED. This is an uncommon event. I am not surprised that it was not encountered in a sample consisting of eighteen clinicians.

  In order for the authors to make claims about safety, it would be necessary to see data on in-hospital and 30-day mortality, in addition to the "adverse events, near misses, and errors" they suggest for future research.

  With that said: the authors did compare admission rates between FY1 doctors and PAs. In vulnerable patient groups, this can be interpreted as a safety outcome. One such group is the elderly, who were seen in greater numbers by the PAs in this study. Admission to hospital carries multiple risks for elderly patients, including infections, venous thrombo-embolism, and de-conditioning. It is concerning that PAs admitted, on average, 25% more patients.

  The increased admission rate may, of course, reflect working environment. For reasons that were not clear to me as a reader, the PAs in this study assessed significantly more patients in Majors and Resus. Admission is a likely event in these higher-acuity areas. Unfortunately, patient outcome was the only variable for which no adjusted analysis was disclosed. I have contacted the authors for a break-down of their admission statistics by patient age and area of department.

  I would urge the British Medical Journal to issue a correction to this article removing the use of the word "safety" until the authors are able to support their claim. If possible, in a revised version, the authors should also disclose the additional information on admissions described above.

  [1] British Medical Association (2024) Safe scope of practice for Medical Associate Professionals. Available at: https://www.bma.org.uk/media/tkcosjt1/maps-scope-of-practice2024-web.pdf (Accessed: 10 March 2024).

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  Conflict of Interest:
  None declared.

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• Published on: 19 March 2024

  Concerns with Design, Methodology, Interpretation, and Conclusions

  • Tomas Ferreira, Medical Student Bristol Medical School, University of Bristol

  I read this article with great interest. Understanding the role of physician associates (PAs) in emergency departments (ED) is of significant relevance to current healthcare delivery challenges. While the study’s objectives are clear, it is difficult to understand the premise for this study. Further, there are several areas of concern regarding the study's design, interpretation, and conclusions that I believe merit further discussion.

  The selected outcomes, particularly wait times and length of stay (LOS), might not fully reflect the complexity of patient care quality or satisfaction. These metrics, while important, may reflect broader departmental workload challenges rather than the individual performance of PAs or FY1s. Moreover, patients leaving without being seen (LWBS) could similarly be influenced by systemic factors beyond the control of individual clinicians.

  The study's retrospective design introduces a high risk of bias, compounded by the lack of a pre-specified plan for data collection and analysis. The declared conflict of interest by the authors in promoting PAs, despite acknowledged, does not negate the potential for bias in data collection, analysis, and interpretation. The control of the regression model by the lead author, given this COI, could further exacerbate these concerns.

  Furthermore, the selection of FY1s as a comparator raises questions. FY1s, being the most junior doctors, typically require more supervision and may...

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  I read this article with great interest. Understanding the role of physician associates (PAs) in emergency departments (ED) is of significant relevance to current healthcare delivery challenges. While the study’s objectives are clear, it is difficult to understand the premise for this study. Further, there are several areas of concern regarding the study's design, interpretation, and conclusions that I believe merit further discussion.

  The selected outcomes, particularly wait times and length of stay (LOS), might not fully reflect the complexity of patient care quality or satisfaction. These metrics, while important, may reflect broader departmental workload challenges rather than the individual performance of PAs or FY1s. Moreover, patients leaving without being seen (LWBS) could similarly be influenced by systemic factors beyond the control of individual clinicians.

  The study's retrospective design introduces a high risk of bias, compounded by the lack of a pre-specified plan for data collection and analysis. The declared conflict of interest by the authors in promoting PAs, despite acknowledged, does not negate the potential for bias in data collection, analysis, and interpretation. The control of the regression model by the lead author, given this COI, could further exacerbate these concerns.

  Furthermore, the selection of FY1s as a comparator raises questions. FY1s, being the most junior doctors, typically require more supervision and may not routinely work in EDs. There are fundamental differences in training, experience, and scope of practice between PAs and FY1s which are likely to confound the outcomes measured and have not been adequately justified or addressed within the study. There are also significant differences in baseline characteristics between the patient groups seen by PAs and FY1s suggest a high risk of confounding, which are not adequately addressed by the study’s analytical approach. Considering the complex nature of ED consultations, techniques such as propensity score matching, or more advanced multivariate analyses could offer a more nuanced understanding of the impact of clinician type on patient outcomes.

  The interpretation of the results, particularly the assertion that there is no statistical difference in reattendance or LWBS rates, suggesting similar safety and appropriateness practices between PAs and FY1s, is not fully supported by the data presented. The conclusions drawn from the study, especially regarding the safety and utility of PAs in the ED over doctors, seem disconnected from the results. The study's design limitations call for a more cautious interpretation of the findings, with a thorough consideration of alternative explanations such as differences in case complexity or departmental practices.

  The conclusions drawn about the implications for policy and practice may be overly optimistic given the study's limitations. The discussion should critically evaluate the strength of the evidence for recommending PAs as a solution to workforce shortages and consider the broader context of ED functioning and healthcare provision. The study does not convincingly demonstrate the safety of PAs or provide a strong rationale for their use in the ED over doctors. It is also concerning that the study's conclusion points towards an agenda advocating for the expansion of PAs' scope of practice, particularly concerning prescribing rights and the authority to order investigations using ionising radiation. Additionally, FY1s, despite being on a lower salary than PAs, are reported by the authors to be more efficient, which raises economic considerations regarding the cost-effectiveness of employing PAs in ED.

  In conclusion, the intention is commendable in seeking to evaluate the role of PAs in the ED. However, the execution and the interpretation of the findings raise significant concerns. Addressing these issues in future research is crucial for accurately assessing the potential of PAs to alleviate workforce shortages and improve care delivery in emergency settings.

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  Conflict of Interest:
  TF is a medical student.

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