Here, an assessment of competence at consulting is made from an analysis, based on real videotaped consultations, using a validated rating scale.
Sample numbers: physician assistants and general practitioners who volunteered to be video recorded
A further 62 consultations were video recorded: 21 (33.9%) with four PAs and 41 withfive GPs. The
number of consultations varied between 3 and 13 for the GPs and their patients who consented to be video recorded, and between two and seven for PAs (Table 44). These consultations were then reviewed by at least two reviewers.
TABLE 43 Comparison of reconsultation rates with judgements of appropriateness for cases reconsulting with the
same problem at the practice only
Practice type
Number of practice reconsultations for exactly the same condition
Total
0 1 2 3 4 9
PA practice
Was the index consultation appropriate?
Inappropriate 7 (17.1) 30 (73.2) 4 (9.8) 0 (0) 0 (0) 0 (0) 41 (100.0)
Appropriate 46 (25.3) 113 (62.1) 17 (9.3) 4 (2.2) 1 (0.5) 1 (0.5) 182 (100.0)
Total 53 (23.8) 143 (64.1) 21 (9.4) 4 (1.8) 1 (0.4) 1 (0.4) 223 (100.0) Non-PA practice
Was the index consultation appropriate?
Inappropriate 47 (37.9) 64 (51.6) 11 (8.9) 1 (0.8) 1 (0.8) 124 (100.0)
Appropriate 42 (32.8) 73 (57.0) 10 (7.8) 3 (2.3) 0 (0) 128 (100.0) Total 89 (35.3) 137 (54.4) 21 (8.3) 4 (1.6) 1 (0.4) 252 (100.0) Total
Was the index consultation appropriate?
Inappropriate 54 (32.7) 94 (57.0) 15 (9.1) 1 (0.6) 1 (0.6) 0 (0) 165 (100.0) Appropriate 88 (28.4) 186 (60.0) 27 (8.7) 7 (2.3) 1 (0.3) 1 (0.3) 310 (100.0)
Total 142 (29.9) 280 (58.9) 42 (8.8) 8 (1.7) 2 (0.4) 1 (0.2) 475 (100.0)
TABLE 44 Number of consultations for each HCP
HCP PA GP Total GP1 0 8 8 GP2 0 12 12 GP3 0 3 3 GP4 0 5 5 GP5 0 13 13 PA1 6 0 6 PA2 7 0 7 PA3 2 0 2 PA4 6 0 6 Total 21 41 62
Leicester Assessment Package scores: how the physician assistant consultations compared with the general practitioner consultations
Grades were given by four raters using six of the seven main categories of the assessment package.
These data were not normally distributed: median, interquartile range (IQR) and Mann–Whitney U-test to
compare GPs and PAs are presented in Table 45. Higher median scores were found for GPs than for PAs across all the dimensions of competence in the LAP. GPs were generally rated above 50% for each
element of the LAP; PAs’ median scores were mainly 60%, with some at 40%, although the lower range
score was the same for GPs and PAs on all competence dimensions bar problem solving. It was noted by the assessors that the PAs gave the computer more attention and may be writing better medical records. The weighted scores showed similar differences; GPs scored higher across all competencies (Figure 5). The median overall percentage for the practising GPs was 58.6% (25th centile 50.7%; 75th centile 69.7%). For PAs, the median percentage was 47% (25th centile 30.6%; 75th centile 60.0%). These data
were not normally distributed; the differences were statistically significant [Mann–Whitney U-test
(two-tailed) p = 0.012]. GP 0 20 40 60 T
otal weighted score (%)
80 100
PA
FIGURE 5 Range of results with the LAP: a box plot comparing PAs and GPs.
TABLE 45 Median score and IQR, out of 5, for each element of the LAP
Competence Weight
PAs, median (IQR) (n = 45)
GPs, median (IQR) (n = 85)
p-value, Mann–Whitney U-test Interview/history taking 20% 3.0 (2.0–3.5) 3.5 (2.0–4.0) 0.011 Physical examination 10% 3.0 (2.0–3.0) 3.5 (3.0–4.0) 0.003 Patient management 20% 2.0 (2.0–3.0) 3.0 (2.0–3.5) < 0.001 Problem solving 20% 3.0 (1.5–3.5) 3.5 (3.0–4.0) < 0.001 Behaviour/relationship with patients 10% 3.0 (2.0–4.0) 3.5 (2.0–4.0) 0.009 Anticipatory care 10% 2.0 (2.0–3.0) 3.0 (2.0–3.0) 0.024 Record keeping 10% Not assessed Not assessed Not assessed
The raters did not consider any of the health-care professionals to be unsafe to practise.
Inter-rater reliability
The Cohen and Fleiss kappa,103also referred to as‘Cohen’s kappa’, was used to measure inter-rater
reliability. Across all the ratings, kappa just fell into the poor agreement category104(к = 0.193);
there was fair agreement104for the GP assessments (к = 0.225), but poor agreement104for the PA
assessments (к = 0.121).
Workshop with raters
At the workshop, the GP raters, no longer blinded, felt that the following themes should be taken into account when comparing records:
l PAs were much more systematic in their approach to record writing, and GPs were much more likely
to make global assessments in their records. Possibly there were differences in training with regard to records and what to record when assessing patients.
l Raters felt that there was a difference in caseload between GPs and PAs, with the GPs having a more
complex caseload. However, the PAs were effective in managing a core part of the primary care caseload, and the nature of emergent histories was such that many of the cases were complex.
l Raters felt that the longer PA consultations may allow the creation of better medical records.
l The only aspect of PA consultations that raters would criticise was that some PAs did not correct the
patient calling them doctor. Clearly, the patient was comfortable with this misapprehension; however, this appeared undesirable and reminiscent of when medical students were introduced as
‘young doctors’.
l The need to get prescriptions signed appeared tofit into the workflow in the consultation, much as in
the way that GPs support nurse prescribing.
l Raters reiterated their view that they did not identify any patient safety problems, and that PAs
demonstrated expertise across a range of consultations.
Chapter summary
This chapter has describedfindings of the clinical review of, first of all, medical records where there was a
repeat consultation for the same problem within 2 weeks and, secondly, direct (video) observation of the consultation to assess competence at consulting. In summary, this chapter has reported that:
l The PAs were judged competent at consulting across a wide range of presentations, and appeared to
fit well into the primary health-care team.
l PAs produced more appropriate and systematic medical records than GPs in this sample (80% vs.
50% appropriate).
l Raters did not correctly identify PA records.
l GPs scored higher on the LAP for consultation competence; the raters did not consider any of the
Chapter 7 Case studies: evidence from interviews
with patients consulting a physician assistant
T
he patient experience with PAs and GPs was explored through the patient surveys (reported inChapter 5). The patient experience and understanding of the PA, a role which was new to the UK, was also explored through semi-structured interviews by telephone with a sample of those consulting PAs, as described in Chapter 5 (see The patient survey). This chapter reports on thefindings from the interviews.
Participants
All of those invited to participate in a survey and consulting a PA (n = 430) were invited to participate in an interview. The response to the invitation to participate in an interview is shown in Figure 6, resulting in 34 interviews with patients (described in this chapter as participants) who had consulted a PA. Participants were purposively recruited from each of the six PA employing practices. One interview was face to face in a practice setting and 33 were conducted by telephone, lasting between 10 and 20 minutes. Four interviews were subsequently excluded from the analysis.
Eighteen (60%) participants were male and 12 (40%) were female. Participants' age spanned 63 years (from 27 to 90 years) with a mean age of 58 years. The majority of participants were of white British ethnicity (Table 46).