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Comparing physician associates and foundation year two doctors-in-training undertaking emergency medicine consultations in England: a mixed-methods study of processes and outcomes.

ABSTRACT: 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.

SUBMITTER: Halter M

PROVIDER: S-EPMC7467515 | biostudies-literature | 2020 Sep

REPOSITORIES: biostudies-literature

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Comparing physician associates and foundation year two doctors-in-training undertaking emergency medicine consultations in England: a mixed-methods study of processes and outcomes.

Halter Mary M Drennan Vari V Wang Chao C Wheeler Carly C Gage Heather H Nice Laura L de Lusignan Simon S de Lusignan Simon S Gabe Jonathan J Brearley Sally S Ennis James J Begg Phil P Parle Jim J

BMJ open 20200901 9

<h4>Objectives</h4>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.<h4>Design</h4>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 p ...[more]

PMID: 32873677

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Project description:BackgroundTemporary doctors, known as locums, are a key component of the medical workforce in the NHS but evidence on differences in quality and safety between locum and permanent doctors is limited. We aimed to examine differences in the clinical practice, and prescribing safety for locum and permanent doctors working in primary care in England.MethodsWe accessed electronic health care records (EHRs) for 3.5 million patients from the CPRD GOLD database with linkage to Hospital Episode Statistics from 1st April 2010 to 31st March 2022. We used multi-level mixed effects logistic regression to compare consultations with locum and permanent GPs for several patient outcomes including general practice revisits; prescribing of antibiotics; strong opioids; hypnotics; A&E visits; emergency hospital admissions; admissions for ambulatory care sensitive conditions; test ordering; referrals; and prescribing safety indicators while controlling for patient and practice characteristics.ResultsConsultations with locum GPs were 22% more likely to involve a prescription for an antibiotic (OR = 1.22 (1.21 to 1.22)), 8% more likely to involve a prescription for a strong opioid (OR = 1.08 (1.06 to 1.09)), 4% more likely to be followed by an A&E visit on the same day (OR = 1.04 (1.01 to 1.08)) and 5% more likely to be followed by an A&E visit within 1 to 7 days (OR = 1.05 (1.02 to 1.08)). Consultations with a locum were 12% less likely to lead to a practice revisit within 7 days (OR = 0.88 (0.87 to 0.88)), 4% less likely to involve a prescription for a hypnotic (OR = 0.96 (0.94 to 0.98)), 15% less likely to involve a referral (OR = 0.85 (0.84 to 0.86)) and 19% less likely to involve a test (OR = 0.81 (0.80 to 0.82)). We found no evidence that emergency admissions, ACSC admissions and eight out of the eleven prescribing safety indicators were different if patients were seen by a locum or a permanent GP.ConclusionsDespite existing concerns, the clinical practice and performance of locum GPs did not appear to be systematically different from that of permanent GPs. The practice and performance of both locum and permanent GPs is likely shaped by the organisational setting and systems within which they work.

Project description:BackgroundEffective communication is vital for optimal medical consultation, but there is little current information about physician preferences for effective consultation.MethodsWe invited physicians with at least one post-graduate year of experience at four Minnesota teaching hospitals to complete a 16-question Internet questionnaire about inpatient consultations.ResultsE-mail requests were received by an estimated 651 physicians. Questionnaires were completed by 323 (50%). Of these, 54% had completed training >5 years before, 17% had completed training <5 years before, and 30% were residents or fellows. Three elements were considered essential in consultation requests by most respondents: the specific question to be addressed (94%), whom to call with the response (68%), and consultation urgency (66%). In the consultation note, 71% of subjects placed high importance on simple, concise recommendations and 64% on the rationale behind them, while only 7% placed high importance on citing references. Most (69%) preferred that assessments and recommendations be written in bulleted or numbered format. A plurality (48%) preferred that assessments and recommendations be separated. Most placed high value on recommendations regarding drug therapy that specify dose (80%), duration (80%), and generic medication name (62%). Requesters placed greater importance than consultants (87% vs. 65%, respectively, P = 0.004) on recommendations that included duration of therapy. The majority (63%) stated that telephone requests were needed for emergent or urgent consultations. Those who usually requested consultations were more likely than those who usually responded to consultation requests to prefer telephone requests for routine consultations (43% vs. 20%, P < 0.001).ConclusionsPhysicians agreed on many essential elements for effective consultations. These results should guide efforts to improve communication in the consultation process and design electronic medical record systems.

Project description:ObjectivesTo investigate the deployment of physician associates (PAs); the factors supporting and inhibiting their employment and their contribution and impact on patients' experience and outcomes and the organisation of services.DesignMixed methods within a case study design, using interviews, observations, work diaries and documentary analysis.SettingSix acute care hospitals in three regions of England in 2016-2017.Participants43 PAs, 77 other health professionals, 28 managers, 28 patients and relatives.ResultsA key influencing factor supporting the employment of PAs in all settings was a shortage of doctors. PAs were found to be acceptable, appropriate and safe members of the medical/surgical teams by the majority of doctors, managers and nurses. They were mainly deployed to undertake inpatient ward work in the medical/surgical team during core weekday hours. They were reported to positively contribute to: continuity within their medical/surgical team, patient experience and flow, inducting new junior doctors, supporting the medical/surgical teams' workload, which released doctors for more complex patients and their training. The lack of regulation and attendant lack of authority to prescribe was seen as a problem in many but not all specialties. The contribution of PAs to productivity and patient outcomes was not quantifiable separately from other members of the team and wider service organisation. Patients and relatives described PAs positively but most did not understand who and what a PA was, often mistaking them for doctors.ConclusionsThis study offers new insights concerning the deployment and contribution of PAs in medical and surgical specialties in English hospitals. PAs provided a flexible addition to the secondary care workforce without drawing from existing professions. Their utility in the hospital setting is unlikely to be completely realised without the appropriate level of regulation and authority to prescribe medicines and order ionising radiation within their scope of practice.

Project description:ObjectivesTo examine what activities constitute the work of Foundation doctors and understand the factors that determine how that work is constructed.DesignCross-sectional mixed methods study. Questionnaire survey of the frequency with which activities specified in curricular documents are performed. Semistructured interviews and focus groups.SettingPostgraduate medical training in the UK.ParticipantsDoctors in their first 2 years of postgraduate practice (Foundation Programme). Staff who work with Foundation doctors-supervisors, nurses and employers (clinical; non-clinical).ResultsSurvey data from 3697 Foundation doctors identified curricular activities (41/103, 42%) that are carried out routinely (performed at least once or twice per week by >75% of respondents). However, another 30 activities (29%) were carried out rarely (at least once or twice per week by <25% respondents), largely because they are routinely part of nurses', and not doctors', work. Junior doctors indicated their work constituted three roles: 'support' of ward and team, 'independent practitioner' and 'learner'. The support function dominated work, but conflicted with stereotyped expectations of what 'being a doctor' would be. It was, however, valued by the other staff groups. The learner role was felt to be incidental to practice, but was couched in a limited definition of learning that related to new skills, rather than consolidation and practice. Activities and perceived role were shaped by the organisational context, medical hierarchies and through relationships with nurses, which could change unpredictably and cause tension. Training progression did not affect what activities were done, but supported greater autonomy in how they were carried out.ConclusionsNew doctors must be fit for multiple roles. Strategies for transition should manage graduates' expectations of real-world work, and encourage teams and organisations to better accommodate graduates. These strategies may help ensure that new doctors can adapt to the variable demands of the evolving multiprofessional workforce.

Project description:BackgroundIncreasingly, consultations in health care settings are conducted remotely using a range of communication technologies. Email allows for 2-way text-based communication, occurring asynchronously. Studies have explored the content and nature of email consultations to understand the use, structure, and function of email consultations. Most previous content analyses of email consultations in primary care settings have been conducted in North America, and these have shown that concerns and assumptions about how email consultations work have not been realized. There has not been a UK-based content analysis of email consultations.ObjectiveThis study aims to explore and delineate the content of consultations conducted via email in English general practice by conducting a content analysis of email consultations between general practitioners (GPs) and patients.MethodsWe conducted a content analysis of anonymized email consultations between GPs and patients in 2 general practices in the United Kingdom. We examined the descriptive elements of the correspondence to ascertain when the emails were sent, the number of emails in an email consultation, and the nature of the content. We used a normative approach to analyze the content of the email consultations to explore the use and function of email consultation.ResultsWe obtained 100 email consultations from 85 patients, which totaled 262 individual emails. Most email users were older than 40 years, and over half of the users were male. The email consultations were mostly short and completed in a few days. Emails were mostly sent and received during the day. The emails were mostly clinical in content rather than administrative and covered a wide range of clinical presentations. There were 3 key themes to the use and function of the email consultations: the role of the GP and email consultation, the transactional nature of an email consultation, and the operationalization of an email consultation.ConclusionsMost cases where emails are used to have a consultation with a patient in general practice have a shorter consultation, are clinical in nature, and are resolved quickly. GPs approach email consultations using key elements similar to that of the face-to-face consultation; however, using email consultations has the potential to alter the role of the GP, leading them to engage in more administrative tasks than usual. Email consultations were not a replacement for face-to-face consultations.

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Comparing physician associates and foundation year two doctors-in-training undertaking emergency medicine consultations in England: a mixed-methods study of processes and outcomes.

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Comparing physician associates and foundation year two doctors-in-training undertaking emergency medicine consultations in England: a mixed-methods study of processes and outcomes.

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