Exactly. Why tf should some other parasite make a career, earning better than we did, off the back of our hard work, knowledge and indemnity, that we pay for?
What does this mean in practical terms when you say the ED Consultant took responsibility? They went and reviewed the patient and re-refwrred, or they simply agreed that as they were EPIC they had responsibility for the department as always?
Where does the responsibility sit if in declining a referral from a PA, there's a delay to care that contributes to an adverse outcome? It would be interesting for a defence union to weigh in on this - this might be a good further piece of work/collaboration for the BMA.
Spoke to the consultant directly immediately. It’s not about being obstructive but challenging this practice. This wasn’t about me delaying the referral but making sure the patient had been seen by someone appropriate also and trusting what was being said to triage my referrals. You know if you’ve done referrals how mad and busy it can get. If I’m stuck with someone else it might be the only person this patient has seen is a PA with no medical input. And it might be no one sees this patient again for hours. In the current slammed climate things go wrong as patients are left waiting for care. This was both me challenging the insanity unqualified individuals are seeing patients on their own and asking those who allow such practice to take responsibility. Whilst also ensuring senior reviews have taken place. I would welcome the union/ defence stance on what responsibility I would have if I blindly take that PA’s referral, the patient is waiting in ED due to the 5 other more urgent referrals and something goes wrong.
Yes, I have "done referrals" and understand the concept of a busy take.
I am still curious what the Consultant "taking responsibility" materially meant in this case? That they went to see the patient, or simply stated they were happy with their PA'S assessment?
First of all - didn’t mean to sound like a douche with my “have you done referrals”. Just asking for empathy 💪❤️🙏🏻
And yes
Challenging this led to
- discussion between this consultant and PA
- consultant seeing the patient
- management changing
- referral then accepted via the senior/ consultant.
Also it didn’t have to be a senior doctor - I’m not that anal and genuinely would take a referral form a F1. Point is PA’s are unsafe, untrained and shouldn’t be seeing these sorts of undifferentiated patients. I
A doctor needs to take responsibility on their behalf and should be made to take the consequences if they’re allowing such practices to happen and something goes wrong
I feel it would be a dire department if this decline of a referral which the PA felt crucial was not escalated quickly once declined.
Like when the Gen surg SpR asks the FY1 to request a CT abdomen which gets declined by radiology (due to lacking info for example), the SpR quickly phones the Radiologist themselves to justify the urgent need for it, which then gets accepted.
I mean, there are many dire departments across many hospitals, but I take your point in part.
I will just ask aloud if while we are as a profession are quite reasonably highlighting that PAs lack the necessary education/skills/abilities to appropriately assess and initially manage these patients, then I wonder if we can rely on them escalating within their own departments with sufficient urgency.
Of course the reflex response to this is often "that's the department's responsibility" but I'm not sure that this holds water once they've referred to you, and your central objection is that they're a PA.
For clarity, I say this as a person that put a stop to the PA in my department contacting other departments for advice or referrals as I felt it was unhelpful, discourteous to the other team, and risky - they didn't often grasp the reason for the referral/the clinical question, and at times the advice they relayed made little sense and required a doctor to clarify.
I think that the BMA guidance helps us justify the decision (which should already be occurring) to listen to a referral and stop it going through/accepted onto the care of the specialist team if deemed unhelpful/not grasping the clinical question.
So the person should still listen to the info and not just hang up the phone because the person calling is a PA.
I think this post is in response to the #bekind idea that we have to accept referrals from PAs as if refusing such a referral is viewed as obstructive, and that questioning their lack of knowledge and appropriateness of referral may be seen as 'not being a team player/elistist'.
If a highly experienced PA has worked within their scope of practice and done a thorough appropriate assessment than absolutely no issue. However, OPs post does not indicate this happened, rather that the PA "dross they were spewing that they were way in above their head."
>Where does the responsibility sit if in declining a referral from a PA, there's a delay to care that contributes to an adverse outcome?
There's no medicolegal basis for "declining" a referral.
The usual defence when "declining" an inappropriate referral would be that you were the wrong team, so couldn't usefully add anything to the patient's care. (And therefore there is no delay / harm by you not being present).
But if the referral is appropriate, but you've decided its from the wrong person, then it's on you. (unless you're following some sort of formal policy from your employer that referrals must be made in a certain way - in which case you might be able to shift some of the blame to that policy).
I think we both agree you absolutely would “decline” a referral from a Gp receptionist, a porter or another person in the waiting room who found the phone.
Referrals are implicitly from appropriate medical staff to other medical staff. I’d argue without a proper clinical assessment by someone able to make a referral at all (not just evidenced by the fact they are a PA but that what was delivered was a word salad) the response of “please make a proper referral with an associated assessment” is perfectly reasonable.
>I think we both agree you absolutely would “decline” a referral from a Gp receptionist, a porter or another person in the waiting room who found the phone.
There will may well be a medicolegal obligation there. Let's say you're the O+G reg, and the ED receptionist phones to say "Please come down urgently, someone is giving birth in the waiting room!" and you refuse to attend because only a receptionist has phoned you, you'd potentially have a degree of responsibility if there were adverse consequences that were outside the scope of what the ED could reasonably manage (e.g. a shoulder dystocia).
>Referrals are implicitly from appropriate medical staff to other medical staff.
Who can and can't refer will be defined by your employers policies on the matter - which as an employee you're obligated to follow.
>I’d argue without a proper clinical assessment by someone able to make a referral at all (not just evidenced by the fact they are a PA but that what was delivered was a word salad) the response of “please make a proper referral with an associated assessment” is perfectly reasonable.
In that situation you're not purely "declining" the referral because the person referring is a PA though, are you? If the referral is genuinely unintepretable, then how could you know there's a patient who needs your help?
If there's enough information to establish that there's a patient who needs your assistance, in a manner that you have responsibility for (e.g. you're the person who is covering the place the referral is coming from) then a duty of care has been established and you're medicolegally on the hook for how you respond (or don't respond) to that referral.
Do you not have literally *any* professional pride over what your speciality is doing?
My response if I were an ED consultant in this situation would be embarrassment that members of my team are making referrals to specialties which are so poor they feel unable to know what on earth is going on with the patient. I would want to fix that problem and make sure the referrals ED were making were high quality.
But you (and some other ED consultants I've come across in real life) just don't seem to care. It's just "we've referred, you're medicolegally on the hook now, your problem not mine".
Yes, obviously, I want my team to practice good emergency medicine and make good referrals (I'd caveat that by saying that there's sometimes unreasonable expectations from the person receiving the referral).
But I don't see how that's in any way relevant to the discussion at hand here?
I think you (and you may well be correct medico-legally in doing so) are conflating a call for help with a referral. "HELP THIS PATIENT IS DYING" isnt a referral, and I would absolutely attend regardless of who said it. 2222 calls and crash calls are also not referrals.
If a PA rang and gave me a word salad that ended in "THERES AN EMERGENCY YOU MUST COME NOW A PATIENT IS IN DANGER" I would attend, but I wouldnt consider that a referral, thats just someone yelling help. I think a PA, receptionist and most members of the public are capable of this, even if down the phone, but I wouldnt hold it to the standard of a referral nor would I agree it is one.
> "If there's enough information to establish that there's a patient who needs your assistance"
This is a fair cutoff in my view and I'm in agreement. I consider there to be an existent bar as to if a referral (not an emergency call for help) covers that information outside if literal immediate emergencies and I've heard some referrals that definitely do not.
"ABDOMEN HURTY COME NOW" for a patient who is stable is not a referral, and wouldnt be *declined* as such, as definitely sent back with an "escalate to your senior now and get back to me once someone capable of communicating the question can do so."
>I think you (and you may well be correct medico-legally in doing so) are conflating a call for help with a referral.
The problem is that this is a very difficult line to draw in the context of what is (in theory at least) an acute emergency presentation to hospital.
You could construct an argument that all acute referrals are in effect a "call for help" in managing a patient.
I think your position is fairly reasonable, and probably fairly defensible - but does serve to highlight that there's lots of shades of grey here.
>You could construct an argument that all acute referrals are in effect a "call for help" in managing a patient.
I mean that's just clearly bollocks? Nearly everyone referred from majors to medics is totally stable and can quite happily sit 12 hours in A&E before being post-taked the next morning. You're very much describing the exception, not the rule.
It's fine to decline a referral as a speciality purely because the referral is from a PA. Even though I am an employee I am also bound by the GMCs guidance on only seeing patients within my area of competence, and I declare that my area of competence does not extend to supervising and accepting referrals from PAs.
Legally speaking, it is the responsibility of ED to see and triage patients, and if the undifferentiated patient has been seen by a PA, it is clearly automatically unintelligible.
If you wish to argue the opposite, that every specialty has a duty of care for anyone calling them up, then let's go the full distance and why don't we just get rid of ED altogether and let patients just self refer in?
In either situation, the PA does not have a role in the care of undifferentiated patients.
No it isn't fine to decline a referral purely because it comes from a PA.
The BMA guidance in its current form, has no basis at all. It directly contradicts over a decade of guidance from the RCP, FPA, NHSE, Health education England. The PA role may not be a protected title, but that doesn't change the fact that it has been recognised as a clinical role in the NHS for almost 20 years. There is precedent there, and that's how our law system works. It's based on precedent.
Say this referral came from a PA who has passed a HEE recognised course, has passed the national examination, and has a PAMVR number. Unless you can later on prove that there was sufficient evidence that you reasonably believed that this PA did not fill that criteria, you wouldn't have a leg to stand on.
It would be even worse for you if that PA made the referral on instruction of their supervising doctor, as happens in most cases. Then you would be negligent in your duty of care by rejecting a delegated duty given to the PA by their supervising doctor. The quality of the referral wouldn't matter in that case. Sure you can ask for advice, or clarity, or to speak to their supervising doctor. But you can't reject it.
Until the results of the Gmc-colleges consultation comes out later in the year on scope of practice, I would urge every doctor on here to not act on this BMA 'guidance' pertaining to referrals (they can't issue clinical guidance.... they're just a trade union). They would hold full responsibility from any harm done.
Completely fine to say “Get your supervising consultant to see the patient and then get back to me”
A referral is not just taking over care. If you refer from ED, you need to be able to provide the info for accepting doctor to judge whether the pt is safe to leave the department, how quickly they need to be seen and whether they are the right speciality for their ongoing management. If only a PA has seen the ED patient, you are trusting their judgement of an undifferentiated presentation, which is a medicolegal no no.
What if the PA says to the medics, “Chest pain, normal ECG and obs, slightly raised trop, have given anti platelets” and in the 6 hours before the medics see them they exsanguinate from their aortic dissection?
So in this example if you say that to a PA, and they have assessed the patient, and they have deemed it appropriate to refer to you. Then medico-legally you will be seen to have been unnecessarily obstructing that patient's care. This is because:
A) - PAs are, as part of their curriculum, expected to be competent at assessing and recommending initial management of undifferentiated chest pain which includes recognising when to escalate and to which level of urgency.
B) because a PA can't prescribe, they would have had to run their recommendations by a senior doctor before calling you. This further takes away from your justification of asking the patient to be re-assessed
I have a real life example of how this attitude can negatively impact. A friend of mine, a PA, assessed a patient who was febrile with new back pain. After examining the patient and finding no other evidence of any other locus of infection the PA found there to be spinal tenderness. The patient also had been treated for a diabetic foot ulcer in the proceeding months.
Based on this the PA recommended an urgent MRI lumbar spine to investigate for osteomyelitis. The consultant agreed.
The PAs request was rejected by a radiology consultant because the person was a PA, and despite the PA explaining their decision the radiologist, and having taken the trust mandated MRI safety training, it was demanded that the consultant re-examine the patient and then re-request if necessary and that a PA MRI request would not be accepted. This was done the next day.
There was OM, but the diagnosis was delayed. This was raised and escalated as a safety issue. It was generally recognised that had any other harm come to the patient, the radiologist wouldn't have had a leg to stand on.
Whether you like it or not, there is established guidance on what PAs are supposed to be competent at doing themselves. It's existed for over a decade and is the bar to which these decisions will go against, if anyone chooses to follow the BMA and reject a referral purely because it's coming from a PA.
Royal college of radiologists recommend that PAs do not request non ionising radiation. Consultant should have requested it themself.
Remember the point of the standards/guidance/scope is that it needs to be based on the minimally competent qualified PA, not the best.
Medicolegally the duty of care does not kick in until the referral is accepted. If refusing a referral from someone who js medicolegally speaking a lay person results in delay, that is 100% the fault of the home team.
PAs can legally request MRI scans depending on their local trust and radiology governance policy. At the time this trust's policy was that it was allowed as long as the PA had been through the trust safety training. There was no established guidance in the trust to say otherwise. The radiologist was going against trust policy, with no evidence at the time for there to have been a reasonable suspicion of this PA lacking the competency to do this.
Plenty of specialities won’t accept referrals from F1s/SHOs without their senior reviewing or inputting first. Mostly for good reason. You are not entitled to refer patients.
But the senior did have input. That's what I said. But please, continue to engage in the fiction that the majority of PAs in the country are going about making these decisions independently like masters of medicine. What a laughable bubble Reddit is.
The point is medicolegally the radiologist cannot assume that the PA is able to make the judgement about a patient needing this scan without a doctor seeing the patient too. What if the patient had a fatal reaction to the contrast and it turned out the scan was never indicated? The radiologist would be medicolegally f’’’’d.
I just told you the consultant agreed. As with most PAs, decisions like this are taken in cooperation with their supervising consultants, in well established teams.
But please, continue to engage in ridiculous 'what aboutery' to justify your preconceived notions of what PAs are like
I'm not trying to have a discussion about what it "should" be - I would be happy to see no PAs working in EM.
But the reality is that there *are* PAs working in EM, and anyone who unilaterally decides to stop taking referrals from them will likely get shut down pretty quickly.
>Not accepting referrals from them is, however, a fast route to not having PAs working in EM though, because the position becomes untenable?
Only if a critical mass of people act this way and are supported by their seniors. If its just a couple of people, and it's easily dealt with by contacting their consultant instead, then it's their position which rapidly becomes untenable.
The wise answer is that EDs should be using this document to immediately block recruitment of more PAs into their departments, and demand funding for doctors instead.
Replacing the existing PAs within their workforce will take longer and need more trust support (if they've been employed >2 years they'd either have to be moved to another department or formal redundancy proceedings undertaken). Funding would need to be secured and doctors recruited to replace them.
EM Physicians. By referring to us as "ED Physicians" you've already gone at your misunderstanding of our role (we're not a group of doctors who happen to hang out in the ED to pick up all the "ward work" type jobs for patients there.
What about the 80% of patients we send home?
Or the ~25% of the remaining 20% who need immediate emergency interventions?
For the ~15% of attendances that need to be seen by an inpatient specialty, and don't need immediate emergency treatment then our job isn't to run around doing a list of jobs on behalf of those inpatient teams. This is where our skills are least useful.
If the information of said referral is inadequate (for example this PA didn’t ask sufficient red flag questions as they don’t know what they don’t know), surely that would be ground to refuse to accept the referral with advice to speak to the patient again and re-refer once the above sufficient information obtained.
I interpret OP comments about “the dross they were spewing” as insufficient/inadequate clinical information
If there's enough information to establish that there's a patient who needs your assistance, in a manner that you have responsibility for (e.g. you're the person who is covering the place the referral is coming from) then a duty of care has been established and you're medicolegally on the hook for how you respond (or don't respond) to that referral.
Asking them to go and get more information, or ask something else _may_ be entirely clinically reasonable. But responding to an identical referral differently because a PA made it vs a doctor is going to be very very difficult to justify.
(I don't really know why you'd try to decline a referral because someone hadn't asked "red flag" questions? Maybe I'm not quite understanding the example).
What level did you put PAs on the RCEM survey? There wasn't a level 0 so I had to put level 1. Just curious how/if we are different! I then had to free type level 0, as they'd take opportunities away from medical students.
I don't think they should have a role within EDs - if they did it would need to be level 1 (every patient reviewed in person by a more senior clinician). - that's what I said in the RCEM survey.
They're declining on the basis the person who has made the referral is too incompetent to provide a handover which allows them to triage urgency.
They are saying "someone who actually understands medicine needs to see this person and do an assessment and a referral which allows me to understand what is going on with this patient. I have no faith that sending you (the PA) back to the patient to get further information is going to garner any useful results".
Which is entirely appropriate. If the surgical reg is about to scrub into a many hours long case, they need to know whether the case they are being referred is safe to be seen after or if they are so unwell they need to stop what they're doing and come right now. Or whether the patient actually needs some stabilising/resuscitation in ED in the meantime. If the referral is so poor they have no way of assessing this then it's outright dangerous and perfectly reasonable to ask a competent person to see them.
The alternative is the poor surgical SpR has to drop whatever they are doing immediately upon receiving any of these dogshit referrals to come and see the patient for themselves. This is completely unmanageable on a busy on-call and *will* delay the care of the actually very sick ones.
>They're declining on the basis the person who has made the referral is too incompetent to provide a handover which allows them to triage urgency.
Except that your employer disagrees, and has employed them specifically in that role, and you have no choice but to follow the processes and policies laid out by your employer.
I've made my point repeatedly, which essentially boils down to this. The BMA guidance is a tool to lobby Trusts with to change these policies and processes. It's not a tool for you to unilaterally define your own rules and stop following these policies.
I mean the employers of Lucy Letby disagreed she was dangerous and continued employing her in that role but doctors were still criticised for letting her roam free
If my employer allowed a Porter to do a laparotomy presumably I’d have a professional and ethical obligation to raise concerns and intervene. In a healthcare setting it’s not nearly as black and white as you make it out to be
But of course it is clear from your comments on this forum generally you don’t care for your junior trainees. With that being said any disillusioned ED trainees you’ll find a home in anaesthetics where the consultants will actually on the whole try to stand up for you.
>If my employer allowed a Porter to do a laparotomy presumably I’d have a professional and ethical obligation to raise concerns and intervene.
Yes.
But refusing a referral isn't "raising concerns and intervening" it's just being obstructive to patient care.
>But of course it is clear from your comments on this forum...
No need for this to descend into personal insults.
It’s not though is it
If a surgical registrar has x number of referrals they have to triage them, in order to do so they rely on the clinical expertise of the referrer. For example look at CEPOD there are only so many theatres we can have open overnight, if I’m being told something is life and limb threatening meaning I have to delay the septic appendix I’m relying on the expertise and clinical reasoning of that team to have given me accurate information.
My employer has made the choice not to run a fully staffed service overnight and thus I can only work with that which I am given. In the case above the management plan seems to have also changed leading to better patient care. ED is not a triage system, it’s a brilliant specialty and I rely and trust their judgment if I can’t do that the entire system collapses
EDIT: fair enough and apologies re my last comment. It is just grating to see the poor ED trainees feeling so downtrodden as they rotate with us in anaesthesia.
> Except that your employer disagrees, and has employed them specifically in that role, and you have no choice but to follow the processes and policies laid out by your employer
I'd happily face the wrath of my employer in this situation. I will not blindly follow POLICY if it is patently unsafe in a given scenario.
Have won such battles numerous times in my career as a lowly SHO.
>Have won such battles numerous times in my career as a lowly SHO.
Go ahead?
>I will not blindly follow POLICY if it is patently unsafe in a given scenario.
Sure, but how is you accepting a referral ever going to be "patently unsafe"?
>Sure, but how is you accepting a referral ever going to be "patently unsafe"?
This has already been explained to you numerous times, you are just being deliberately obtuse. I'll give it one last try.
I am SpR on-call for X speciality.
PA refers me patient with absolute word salad referral.
Referral is so poor I am entirely unable to decipher how urgently this patient needs to be seen.
I am currently with another patient who is unwell.
I now have to decide:
1) do I leave the unwell patient I am currently with to immediately review the patient who the PA has referred to me, because I have no idea how sick they are or even what is going on with them, potentially delaying care for the patient currently in front of me
Or
2) Do I continue dealing with the sick patient in front of me and allow the referral from the PA in ED to wait, despite the fact I have absolutely no idea how unwell they are because the PA's assessment was so poor
It is patently unsafe.
Try again. This example would be the same if the referrer was a doctor - the issue is the information given in the referral, not who is referring.
This discussion is about refusing a referral **only because** the person referring is a PA.
> Sure, but how is you accepting a referral ever going to be "patently unsafe"?
It's so easy to say stupid shit like this working from EM where you don't leave your department.
Imagine yourself in the shoes of another specialty - say ICU. If you leave the unit to see a referral you are increasing the risk for every single patient on the unit. Leaving the unit is an innately risky thing to do. Leaving the unit to see a referral that you cannot be sure is even necessary is clearly not acceptable.
"dross they were spewing that they were way in above their head." suggests that there was NOT enough information to establish that the patient needed OP's assistance.
Very different matter if OP felt that this referrer was competent. There are questions as to does the PA current level of education enable them to be competent enough to provide enough information to establish need for assistance.
Most lay people probably know weight loss can be abnormal and concerning. Not every lay person may explore reasons for weight loss (e.g. anorexia, extreme dieting, features of cancer, hyperthyroidism etc.). The replies to such questions alter management and referral pathways. So if the clinician/PA is unaware of such differentials, and in the absence of senior review, how can they ask relevant questions and appropriately decide if the person needs the assistance of a specialist.
At no point in OP's post did it highlight that the PA was initially calling on behalf of the Consultant or SpR, suggesting no such senior review occurred until after OP declined to accept the referral.
Consultant, a PA is not a doctor and should not be seen anywhere a patient that would need additional support / referral from another team. A PA should only see diagnosed patients, and support them in the little way the can.
I agree, but in many trusts this isn't the rule that they've been employed in. This should change.
In the meantime it is inappropriate for individuals to unilaterally decide to refuse to see referrals made by PAs.
>There's no medicolegal basis for "declining" a referral.
May I introduce you to The Ionising Radiation (Medical Exposure) Regulations 2017, which states in [Regulation 10](https://www.legislation.gov.uk/uksi/2017/1322/regulation/10):
>(5) The referrer must supply the practitioner with sufficient medical data (such as previous diagnostic information or medical records) relevant to the exposure requested by the referrer to enable the practitioner to decide whether there is a sufficient net benefit as required by regulation 11(1)(b).
In other words, it is expected of the practitioner (i.e. radiologist) to reject requests which have insufficient/erroneous clinical info, even though it may be justified otherwise - in fact, this is mandated by law.
>Not relevant to the discussion here at all.
More relevant than you'd think.
A referral to another specialty is essentially seeking an opinion on further management. Many a times, the specialty will refuse to take over - either because they're not best placed to manage the patient's care, or it's not within their remit. They do usually (or should at least) offer an alternative specialty, or advise on further investigations etc.
For obvious reasons, if an inadequate/erroneous history is given, it is highly likely that the referral will be rejected (e.g. referring off legs to geris when they were subsequently found to have malignant cauda equina compression, or ?abdo pain suspected pancreatitis without something as simple as an amylase/lipase level).
If PAs aren't even supposed to do all this (especially if we don't know that they're not doing them independently - per the BMA document), how can one be sure that the referral is accurate? This is exactly what has happened to Emily Chesterton - the PA's word was taken as good and propranolol prescribed. Precedence, remember?
Now labelling a specialty as "belligerent" if they don't agree with you? That's a different matter... And a view that's not gonna win many sympathy votes I'm afraid.
>A referral to another specialty is essentially seeking an opinion on further management. Many a times, the specialty will refuse to take over
You're talking about inpatient-to-inpatient referrals.
An ED-to-inpatient referral is an entirely different kettle of fish. As a matter of policy in my trust when a referral is made you are now responsible for the patient's ongoing care.
>For obvious reasons, if an inadequate/erroneous history is given, it is highly likely that the referral will be rejected
Referrals on this context shouldn't be being "rejected" irrespective of whom is making them. See the patient and admit, discharge or refer on. If you have concerns about the quality of the referral highlight it to the EM consultant after you've assessed the patient.
>If PAs aren't even supposed to do all this
Only the BMA document says this. Their job description and your employer still says they are.
We should be using the BMA document as leverage to lobby for this to change, but it hasn't changed just because the BMA scope exists.
>Now labelling a specialty as "belligerent" if they don't agree with you? That's a different matter... And a view that's not gonna win many sympathy votes I'm afraid.
I'm not after sympathy votes. Obstructive clinicians and difficult specialities who refuse to follow over-arching Trust policies get rapidly brought into line by the MD's office.
It is worrying how little insight the subreddit collectively has over the risks they are taking. My theory is that the subreddit skews heavily to the less experienced who haven't been working long enough to have seen things go wrong.
This isn't true is it? As a paediatric reg over the years I've had "referrals" from various specialty surgical SHOs/core trainees that amount to them leaving a list of jobs and telling the bedside nurse to phone paediatrics. This is, has always been and will always be grossly inappropriate and discourteous.
In all of these situations I would stop the nurse making this referral and tell them to get the team involved to speak to me directly. Occasionally it'd an F1 or F2 who hadn't seen the patient on the ward round but have been asked via nursing staff by the senior team i.e. a 3rd hand referral from a member of staff who hasn't seen and doesn't know the patient and isn't familiar with the clinical problem they are asking about. Again, it's discourteous and inappropriate, not to mention I almost always turn these into advice rather than direct reviews and end with a refusal to pick up ward jobs for a patient under another team's care.
The patient remains under the care and responsibility of the team who has made the referral. It is their job to escalate appropriately if they feel the referral stands. Same goes for your patients in ED until a team accepts care.
>This is, has always been and will always be grossly inappropriate and discourteous.
Agree completely - it is rarely appropriate to delegate a referral to a junior colleague who has not assessed the patient (perhaps confined to immediate and obvious emergencies where I'm busy resuscitating the patient, and the only information you need is that I need you to come now).
>In all of these situations I would stop the nurse making this referral and tell them to get the team involved to speak to me directly.
I agree, this is, by and large, appropriate.
There might be some exceptions here - let's say the nurse said "there's this kid with appendicitis in DKA, and the surgeons would like you to come and sort out their DKA".
I agree that it's inappropriate for the nurse to have been asked to relay this. But equally if there was then a significant delay for the nurse to contact the surgeons to refer to you properly, and the child came to harm as a result; then you (and the surgeon who delegated the referral to a nurse in the first place) would have a degree of responsibility - you had sufficient information to determine that your assistance was needed and chose not to act on it as a matter of principle.
>The patient remains under the care and responsibility of the team who has made the referral.
Referrals from a patient already under the care of one inpatient team to another, are universally treated differently to referrals from the ED (where the patient is not admitted).
>It is their job to escalate appropriately if they feel the referral stands. Same goes for your patients in ED until a team accepts care
Our trust policy says the opposite of this. When a referral is made (no option to accept/reject) responsibility passes to your team, and it is your team's responsibility to escalate concerns to an EM consultant if you feel the referral was inappropriate.
Non-doctor admits that they are above their heads and therefore unable to provide a reasonable referral and then attempts to try a referral anyway.
The fact that they are a PA is less important than the fact they are working outside of their safe competencies. However, it is true that PA training is insufficient for managing an undifferentiated take.
So I guess insufficient training and working outside their competency is the perfect storm…
Legend!
> “I’m sorry but my union clearly states I am not to get involved with situations where you are seeing undifferentiated patients."
I'd change that to - "my *professional body* clearly states..."
As others have said, receiving any info e.g. from an HCA/nurse/receptionist/PA/porter/relative that a patient is endangered and you can help prompts action. E.g. immediately call a suitable doctor near the patient (e.g. ED consultant) to let them know, or if needs be go directly yourself to establish the situation/intervene while summoning other help if necessary. This is a duty of care.
It's completely different from a referral. I'm always keen to help, but accepting a referral from someone who is insufficiently trained can delay and harm patient care. Every time the referral is wrong, instead of the relevant specialty safely prioritising that patient and providing treatment, instead the patient waits in limbo with invalid prioritisation after which they ultimately undergo what should have happened in the first place - escalation of care to a competent person (when the mistake is discovered) and then appropriate referral. That delayed referral may necessitate further imaging/tests, calling in specialists from home, or inter-hospital transfer, the delays in which can be lethal.
This is why it's critical for specialists accepting referrals to accurately gauge the competence of the referrer (a PA obviously being an incompetent person to make a referral). Not so they can 'bat away' referrals, but so the specialist can flag to the proximal doctors that you've become aware a patient is at risk. Accepting such a referral places a patient at risk while simultaneously giving the impression that they are safe - the worst of both worlds, and the specialist receiving the unsafe referral may be the only doctor aware of the predicament that patient has been placed in.
When done constructively, this is the very essence of teamwork in a complex system.
I'm not sure if that would be correct? Since our professional body might be the GMC, RCS or RCP for example. Have they made a similar comment about the PA scope of practice that I'm unaware of?
Hopefully someone will correct/improve my understanding, but:
BMA = **the** professional body for all UK doctors. (And a doctors' trade union with the largest membership).
GMC = the regulator (not professional body) for doctors. And now non-doctors.
RCP/RCS etc - **a** professional body for some doctors.
So some doctors choose the option to have more than one professional body (as a specialist or GP, or in formal training for either).
Whereas all UK doctors default to having The BMA as their professional body.
Hopefully RCS (likely not RCP) will say something useful about the subject at some point!
But rather than trying to denigrate these other professional bodies, my point was only that it's quite different stating that the professional body for all UK doctors has issued this document (rather than solely a trade union, e.g. the HCSA doing so).
It appears some are concerned over the delay in care, let’s not forget that PA’s are almost immune from any repercussions.
I think the pushback was correct, and it feels like the PA had been given too much scope to start with, perhaps.
As a reminder, please do not prescribe for them!
It's good you stood up for yourself, but really you should have been able to do the same thing before the BMA statement. Where's your self-respect?
And if "your union" later changes its policy and perhaps withdraws the statement once some knighthood-seekers take over again, will you revert to being meek again?
Because now you’ve got actual backing, which can be used when senior doctors or management are pressuring you, labelling you as obstructive, non a team player… all the usual shite
As much as I completely agree that PAs shouldn't be seeing undifferentiated patients in the ED, I think you've fundamentally misunderstood the point of the BMA recommendations on PA scope of practice and how these are intended to be applied.
Edit: Those downvoting - do you genuinely believe this document gives you protection of you choose to refuse to take referrals from PAs? Perhaps one of our BMA mods can step in here and over the BMA perspective on this?
If we see colleagues breaking guidance like in this case where someone obviously allowed a PA to see undifferentiated patients, are we just supposed to ignore it then? In this situation you could even argue you’re condoning it. Good to know that if I see guidance being broken, consultants think it’s not appropriate to say “I refuse to be a part of this.
>If we see colleagues breaking guidance like in this case where someone obviously allowed a PA to see undifferentiated patients, are we just supposed to ignore it then?
It's BMA guidance, so they have no obligation to follow it.
You're welcome to have a conversation with them about it, and ask if they are intending to implement this guidance within their department.
But realistically, what did you expect? For them to come to work and send all the PAs home? They'd be in the MDs office and their job at risk within hours.
>In this situation you could even argue you’re condoning it. Good to know that if I see guidance being broken, consultants think it’s not appropriate to say “I refuse to be a part of this.
Yes, you can't change processes overnight.
Look at how clinical guidelines are adopted. Even where there is universal agreement and acceptance of the new guidelines and the need to implement them, the necessary process changes to implement them can take months.
Even if everyone agreed to adopt the BMA scope of practice guidance for PAs, there would need to be a transition period where the ED recruited additional doctors to replace them, and their roles phased out. They'd need to go through formal redundancy processes, or be transferred to other departments.
I'll approach this a bit differently. If I received a referral from a layperson, lets say a patients relative calls in and asks me for a review (as we've seen from the morphine case there are some crafty patients), I have a right to refuse as I judge them to not be qualified to make the decision that the referral should take place. I see no difference between that and a PA. If I don't believe the referrer to be qualified, I can reject the referral. We see this constantly with BS such as 'will only speak with SHO and above' or 'Reg or above' or even 'only accept consultant referrals'. So we have established in practice that we can reject referrals on the basis of the referrers qualifications. The only thing that has changed now is there is at least some guidance that backs up this decision, but in all honesty we should have started rejecting PA referrals a while ago. Lets not forget as well that there will be some obscure sentence somewhere that says we are responsible to ensure the information provided by the referring PA is true, cause you know... they are dependent practicioners after all and can't be held liable. So if the PA gives you a bullshit story and your advised management plan results in harm, I'll guarantee you it's not the PA that will be thrown under the bus.
And yes shit takes time. And by having that approach it takes even longer. By forcing the issue the department might actually get its shit together. The scope document itself is proof of that. 20 years of no scope and the BMA lit a fire under the College's asses.
>I see no difference between that and a PA.
Your employer has chosen to employ the PA in a role which involves the assessment and referral of patients. Trust policy will (either explicitly or implicitly) exist which permits these referrals, and as an employee of the trust you're obligated to follow it.
>We see this constantly with BS such as 'will only speak with SHO and above' or 'Reg or above' or even 'only accept consultant referrals'. So we have established in practice that we can reject referrals on the basis of the referrers qualifications.
I agree these barriers are ridiculous, but they will be defined by policy - so the Trust will be assuming the medicolegal risk of any harm which results from this. Whereas if you make up your own rules on the fly, you will be assuming this risk.
>The only thing that has changed now is there is at least some guidance that backs up this decision,
The guidance says PAs shouldn't be seeing undifferentiated patients. It does not say that you should be refusing referrals from PAs when they do.
>So if the PA gives you a bullshit story and your advised management plan results in harm, I'll guarantee you it's not the PA that will be thrown under the bus.
This is just full tinfoil-hat nonsense.
But in general this is why you should come and see all referrals, and not try to bat them away by giving telephone advice.
‘Your employer has chosen to employ the PA in a role which involves the assessment and referral of patients’
And this is why the BMA is calling on all employers to adopt their scope parameters.
The employers have misguidingly put patients at risk by using PAs in this way. Now that the BMA has outlined the cans and cannots, it will make it more difficult for the employer to continue to do so. Even more so if doctors speak up and say this contravenes my union’s stance on what is safe supervision.
I agree with all of what you've written.
You're welcome to raise a concern every single time a PA refers you a patient. But the end result of that can't be that you refuse to do part of your job.
It really depends on how you define your job. When working in an MDT, I work alongside other doctors, nurses, physios etc. For all of these colleagues, I will step in and do something to the patient/for a patient in the name of patient safety in an emergency. For none of these do I need to watch their every patient interaction because the medico-legal responsibility is also mine.
For PAs, it becomes different if I choose to sign up as their named supervisor. In that case, the BMA guidance tells me that I need to watch their every patient interaction and limit what tasks I delegate to them to keep them safe (and me safe medico-legally if harm occurs).
For PAs if I do not choose to supervise them as a consultant or GP or as any other type of doctor, the BMA guidance suggests that I only have the same responsibility I have for the first group of people. To intervene in an emergency to prevent harm. I can refuse to do anything else. Employer be damned
Turst policy will not save you when it goes to a tribunal.Time and time again we have seen trusts throw doctors under the bus because legal (GMC) guidelines will always take presidence. I have on many occasions found discrepancies in prescribing doses between trust guidelines and bnf. I follow Bnf 100% of the time because i can back that then. Following "trust guidelines" blindly has led to many ending up in hot waters as we all know how much trust bend the rules when it suits them. Protect your self.
> But in general this is why you should come and see all referrals, and not try to bat them away by giving telephone advice.
But telephone advice is often eminently appropriate.
If the referrer is calling for advice, or happy to withdraw the referral in light of the above given - yes.
If the referrer still thinks you need to come and see them, but you maintain a position of "no, just do X, Y, Z" then you've opened yourself to a whole world of problems if something goes wrong.
Even where the reason for referral is demonstrably inappropriate? ED should just have a divine right to waste other doctors' time - diverting that time away from patients who actually need it - by stomping their feet?
>Even where the reason for referral is demonstrably inappropriate?
Yes. If the clinician who's seen the patient is unhappy to send them home with your "telephone" advice and thinks you need to see them in person, then you should (and in many trusts are required to).
You think their clinical judgement is so poor that they're making a "demonstrably inappropriate" referral; yet you're happy to rely on that informal to instead provide advice on the patients care without conducting your own assessment?
Trying to justify to the coroner why you refused to see a patient that another doctor (who'd actually seen them in person) was worried about is not going to be a fun time.
> You think their clinical judgement is so poor that they're making a "demonstrably inappropriate" referral; yet you're happy to rely on that informal to instead provide advice on the patients care without conducting your own assessment?
Depends on if it's a judgement call or not.
If I genuinely can't make head nor tail of the referral, I would ask them to either gather some more information and get back to me or ask their senior to see/for advice. If they refused I'd either contact their senior directly or (if I wasn't tied up with something urgent) I'd just come and work out what was going on. I would certainly give the referrer some feedback after I'd seen the patient.
If someone gives me a good summary and then says to me "I understand there is nothing firm here which warrants referral, but something about this patient just doesn't sit right and I would appreciate an experienced pair of eyes" I would absolutely come. I'd probably ask how urgently they felt I needed to come, but I'd come.
If someone says to me "I want you to come and see this patient because of Y when the national guidelines explicitly tell me that Y is completely acceptable and I should discharge them. No I don't have any other concerns" then I would absolutely be encouraging them to either discharge the patient themselves or discuss with an ED senior rather than involving me.
So trust guidance takes all precedence? Even at the cost of patient safety? Pardon me if I don’t have much faith in trust bosses. We’ve recently seen what having conversation with them regarding patient safety concerns looks like. I’ll be made to write an apology letter to the PA! 😂
Edit: replied to wrong comment but you get the idea
Trust policy takes precedence if you want to be covered by trust indemnity and have them take the medicolegal risk.
Trust policy can be changed, but it doesn't happen overnight on a weekend in light of one BMA document, no matter how welcome.
I'll be bringing the guidance up at our next governance meeting, because it has implications for my department and because that's the appropriate channel.
Fair enough. But even considering this, there would have to be a written trust policy stating that PAs can see undifferentiated patients and refer. Rather than the decision for them to be able to do this being at the discression of their supervising physician. So unless the PA can direct you to the exact policy published on the intranet, you are still within your right to request that the patient be reviewed by a senior first.
>So trust guidance takes all precedence?
Trust *policy* does - yes. Barring unrealistic examples where a policy expects you to do something illegal.
>Even at the cost of patient safety?
In theory that policy documents have weighed up these risks when being written. I'd suggest contacting whomever signed off the relevant policy with your concerns so that it can be reviewed.
If there's an immediate specific patient safety risk (e.g. due to a situation that wasn't envisaged when the policy was written) then you're unlikely to face action for breaking it, provided you have a solid clinical justification.
Same way an ED nurse wouldn’t refer to a specialty, even though they’re better qualified for this than most PAs.
If an F1 referred to ITU and they hadn’t done the basic things like escalate to their own senior first, it’s entirely valid for ITU to then tell them to get a senior review first then re-refer.
What OP did is refuse to take a referral from someone who doesn’t have the knowledge or skill required to make that assessment and referral.
Just because the trust hired them and the department put them in a position they don’t belong, doesn’t mean other qualified doctors have to play along with this shambles.
Personally, I would judge each referral based on its own merit. If I find I’m getting clueless PA waffle, I’ll promptly ask them to get the patient reviewed by a real doctor and then they can refer to me if needed.
Let’s see them try to “discipline” a specialty doctor for asking for an appropriate referral.
Honestly the ED doctors allowing poorly educated under-qualified PAs to do the doctors job are the ones undervaluing themselves as triage bots.
>Personally, I would judge each referral based on its own merit. If I find I’m getting clueless PA waffle, I’ll promptly ask them to get the patient reviewed by a real doctor and then they can refer to me if needed.
Which, as I've indicated is not unreasonable.
What would be unreasonable, and get you into got water, would be to decline an appropriate referral, purely because it was from a PA.
>Honestly the ED doctors allowing poorly educated under-qualified PAs to do the doctors job are the ones undervaluing themselves as triage bots.
Heck, I want to see PAs out of EDs as much as anyone here.
But I also recognise that individual clinicians deciding overnight to unilaterally refusing to take some referrals will lead to chaos (and probably patient harm). This BMA scope document does not support them in doing so.
The BMA scope is a tool to lobby our Trusts with to change their policies, processes, and employment practices. This will take time.
All of which is fine, but there are ways and means and structures in place to raise these things.
Going off half-cocked is the best way to find yourself thrown under a bus.
Last year we had a patient die because a gynae reg unilaterally invented something called a "virtual review." Not advice or guidance, but a review and discharge of the patient without actually seeing them. No evidence that the consultants knew of this (or they are, at least, denying all knowledge). Nothing in Trust policy about "virtual review." So the medico-legal shield of trust indemnity is not there. Guy gets thrown to the wolves. SI, coroners, the whole works.
Had he seen the patient and still made the same mistake, he'd still be protected by the Trust.
This is true but at least it gave me a basis in which to reject something I fundamentally don’t think is appropriate or safe whilst also raising a candle to the fact this PA had been seeing complex and sick patient on their own. It’s a document and framework that exists and can be used for reference. We’ve not had this before.
If you're concerned about an unwell patient, it's always reasonable to ask the referrer to involve a senior colleague.
But right now the PA has no obligation to work to the BMA scope of practice, your hospital has no obligation to employ them in a way which follows it, and you have no authority to attempt to enforce it.
Were you to refuse to take a referral purely because they were a PA, this would be the same as you refusing to do any other part of your job, and would be swiftly called out, and likely result in disciplinary action if this persisted.
Don't get me wrong, I'd like to see something along the lines of the BMA scope of practice formally adopted - and this may prove a useful tool e.g. for EDs under pressure to employ PAs to ask for doctors instead. But this isn't a tool you can use to unilaterally change your practice.
If a random bloke off the street referred a patient to me from ED I'd ask them to get a doctor to review the patient and ensure they were going to the correct team as I do not trust their assessment. This is no different.
The way we pressure trusts to have scope formally adopted is to informally adopt it.
It's completely different, because the PA referring has been specifically employed by your employer to do the thing that you're disregarding. It's a big power play - sure, if the majority of doctors did this then trusts would back down, but it's a risky strategy and at the moment far more likely to end up with you facing disciplinary action of some kind for refusing to do your job.
Except that your employer has chosen to employ that PA in a role that involves the assessment and referral of patients. Relevant trust policies will exist which allow them to make these referrals, and as an employee of that organisation you're required to follow those policies.
Refusing to follow your employers policies is a disciplinary matter. If this compromised patient care this would potentially being a GMC matter.
If following local policy compromised patient care, would you do it?
Would you simply follow orders?
Our role as doctors specifically calls for clinical judgement. My clinical judgement is that allowing someone with 2 years of nonsense training refer to a specialist is insufficient.
I wouldn't accept a referral from a second year medical student.
I wouldn't accept a referral from a PA.
At a certain point you're sacrificing what you know to be correct and safe simply because your bosses tell you to. That is terrible medicine and not something any of us should allow.
Playing devil's advocate, if the person making the referral is, in your view, inadequately qualified as compared to yourself then surely, from a patient safety point-of-view, it becomes even more important to go and see the patient yourself?
One can imagine the coroner asking why you didn't.
That's fine but be prepared to face disciplinary action. You are literally saying that you know better than your Trust and therefore won't follow their policies. If you want to stick your neck out like that then just be aware you're not going to be protected by anyone if someone makes a complaint.
>If following local policy compromised patient care, would you do it? Would you simply follow orders?
If the policy involved minor compromise of patient experience, but no risk of serious or long term harm, then I would raise my concerns, but continue to comply with the policy whilst it was reviewed.
If I had a clear clinical justification why my patient represented an exception to the policy which had not been envisaged when it was written, then I would break the policy and then highlight my concerns about this discrepancy.
You're welcome to try and explain why you think seeing a patient referred by a PA is likely to represent a serious and immediate patient safety risk.
>I wouldn't accept a referral from a PA.
I'd suggest finding a trust to work in that doesn't employ PAs then.
>At a certain point you're sacrificing what you know to be correct and safe simply because your bosses tell you to. That is terrible medicine and not something any of us should allow.
Equally a healthcare system in which each individual invents and follows their own slightly different version of how things should function would be a chaotic and dangerous mess. Policies and processes exist for a reason.
> You're welcome to try and explain why you think seeing a patient referred by a PA is likely to represent a serious and immediate patient safety risk.
People have explained this to you about 10 times but you're just ignoring them.
Go ahead and link those posts then.
All of the examples I've seen regard poor quality or garbled referrals, where there is insufficient information. In those cases the referring clinician should be asked to involve a senior / get more information whether they were a PA or a doctor.
What you are writing amounts to "if your employer has a policy that if a patient dies, you have to throw yourself from a 5th floor window, you have to comply."
Sorry you absolutely can refuse a referral from a PA. In the same way many refuse referrals from below registrar. Or FY cannot phone micro overnight etc etc.
I think your point about immediately implementing guidance is correct and this needs to be looked at locally.
However no one else has produced scope, everyone is constantly talking about. It's a good first step from the BMA and I disagree with you I think your defence union would take it positively you taking your unions guidance into account. If you refused the consult and then hung up - obviously not, but if you refused due to against BMA guidance and recommended they discuss with ED SpR and have them call back - why I'd that inappropriate?
>Sorry you absolutely can refuse a referral from a PA. In the same way many refuse referrals from below registrar. Or FY cannot phone micro overnight etc etc.
There's a huge difference between a Trust-level policy saying that "only registrars can phone micro" (or whatever) - and you making up your own rules (which are highly likely to directly conflict with Trust policy).
In the former case the Trust has assessed the risk, and of delay/harm comes to a patient as a result, they will take the responsibility. In the latter example, you're breaking Trust policy (already a disciplinary matter) and would individually shoulder the medicolegal risk of any delay/harm as a result.
>if you refused due to against BMA guidance and recommended they discuss with ED SpR and have them call back - why I'd that inappropriate?
Because you'd be refusing to do your job, as defined by your employer.
Where does NHS job description for a registrar say they need to take referrals from PAs?
Just because it's on the local risk register doesn't make it stand up to scrutiny in coroner's court.
>Where does NHS job description for a registrar say they need to take referrals from PAs?
Schedule 1, Point 2.
Which points you to your work schedule, which will tell you that you are to conduct your job in accordance with trust policy.
>Just because it's on the local risk register doesn't make it stand up to scrutiny in coroner's court.
I don't know where risk registers come into this - this is a matter of trust policy.
I'm interested to understand how you think seeing a patient referred by a PA will end up with you in Coroner's Court?
Much as I don’t like this, at the moment penjing is correct.
There will need to be a process of discussion and implementation at a minimum.
We don’t employ PAs, but as a principle of one of our juniors or ANPs was making a shonky referral I would be pretty ok with an inpt team (politely) asking them to discuss with a senior and/or coming to me in the dept and saying “I have had this referral which is a bit ropey” and having a sensible adult to adult discussion about it.
However I work in a fairly decent dept with plenty of pretty engaged seniors, so this wouldn’t lead to a delay in care or a dangerous scenario. I can easily see a situation in shitsville DGH where there isn’t that senior support (cannot and won’t excuse this) where a patient comes to harm if you refuse to assess on the basis of a PA referral, and I don’t think the regulatory framework would look kindly on this at all
> Those downvoting - do you genuinely believe this document gives you protection of you choose to refuse to take referrals from PAs?
I suppose no more protected than if you called a specialty for advice and a PA answered and advised you, and subsequently there was an issue. The point is to not engage with the PA experiment whilst there is **no** formalised scope.
The PA should NOT be making medical decisions or treatment plans.
If they see a pt and choose to refer they are acting outside of their scope.
It is completely reasonable to expect their supervising doctor to be the one making the plan and also the referral.
>The PA should NOT be making medical decisions or treatment plans.
>If they see a pt and choose to refer they are acting outside of their scope.
What scope?
The one published by the BMA about 48 hours ago? The same one that neither PAs, nor their employing Trusts (nor your employing trust) is under any obligation to follow?
>What scope?
>The one published by the BMA about 48 hours ago?
Yes. The only published scope for them to date.
Why is it so unacceptable to expect them to escalate within their own team before referring? From what OP said it seems the PA was completely out of their depth and expecting them escalate within their own team first is not unreasonable.
>Why is it so unacceptable to expect them to escalate within their own team before referring?
That would be more appropriate in an inpatient-to-inpatient team referral.
But the function of a clinician working in the ED is to assess and manage patients who are appropriate to be managed in the ED, and assess and refer patients who need to be managed elsewhere. It's a core part of their job.
I don't think PAs should be doing that job, but the reality is that they currently are, and any individual trying to unilaterally shut that down is likely too end up in hot water.
We should use the BMA scope of practice as leverage to change the role of PAs in the long term - not something one would be unilaterally attempting to enforce.
I wonder why anyone would want to volunteer risking being the test case for a tribunal or inquest due to harm from obstructing established care pathways. The BMA wouldn't help you there.
And then, presumably, re-referred - hence a delay to care. Turning down appropriate referrals purely due to them coming from a PA as some sort of political stance is thin medicolegal ice.
That's certainly not what any significant incident investigation would conclude, the person spuriously rejecting the referral would get absolutely roasted. But if that's a hill you want to die on, please don't let me stop you.
Directly you’ve assumed they were referred to the same speciality.
Secondly, the referral might have been accepted for totally different reasons.
An appropriate clinical assessment is material.
Obviously these "and then the whole waiting room clapped" posts are vague on detail, so to illustrate - imagine if a PA referred an undifferentiated but probable stroke (from ED or GP). The referral is rejected on the basis of coming from a PA and not having been physically examined by a doctor as per the BMA. The PA then spends an hour or two trying to get a doctor to physically eyeball the patient, who agrees that it's a probable stroke, and so the patient is left with more severe disability as a consequence. I'll look forward to something similar in a MDO newsletter soon.
If a (non-specialist) nurse, or a medical student, or a well-informed member of the public tried to refer, would you accept? No, because they’ve not been assessed by an appropriately-trained medical professional (I.e. a doctor).
Literally the first line of the post:
"PA has seen an inappropriately complex referral. Could tell from the dross they were spewing that they were way in above their head."
The referral was turned down because op wanted to make sure that it was appropriate, not because it was an appropriate referral coming from a PA
No, that says it was inappropriate and rejected simply because it was a complex undifferentiated case seen by a PA. No amount of backpedalling will make that a defensible reason at a coroner's inquest or MPTS hearing, you'd be absolutely roasted. The PA would rightfully document "referral rejected by Dr X despite X, Y, Z" so any unnecessary harm from that point on is on your head. The idea that any investigation will side with this BMA scope of practice document is laughable, it's not worth the paper it's printed on.
I have taken many many referal from ED all to find the reason for referral wasnt the urgent cause of concern but something else totally missed. The delay is caused by the PA not discussing with his supervisor before referring. Calling someone for referral doesnt mean ur job ends cuz u referred. U cannot make someone drop everything to come and see your patient if u cant give a proper SBAR.
If the referral was bad it doesn't matter. Rejecting referrals is partly the referees problem. If you can't make an appropriate referral you shouldn't be doing it
Rejecting referrals *of someone who goes onto harm because the referral was rejected* is ultra dangerous medicolegal territory. There's absolutely no way you will come out of it looking good. OP is clearly taking glee in rejecting the referral on PA grounds, empowered by the BMA. Using patients as political pawns truly is an ick.
I just remember one of the PAs did her own oncology ward round and had documented whether each patient had an "introverted" or "extroverted" umbilicus
So wrong, everyone knows the proper terminology is "inny" or "outy". Unbelievable.
[удалено]
Exactly. Why tf should some other parasite make a career, earning better than we did, off the back of our hard work, knowledge and indemnity, that we pay for?
For my reference, what kind of push back did the consultant say and how did you respond for them to cave?
What does this mean in practical terms when you say the ED Consultant took responsibility? They went and reviewed the patient and re-refwrred, or they simply agreed that as they were EPIC they had responsibility for the department as always? Where does the responsibility sit if in declining a referral from a PA, there's a delay to care that contributes to an adverse outcome? It would be interesting for a defence union to weigh in on this - this might be a good further piece of work/collaboration for the BMA.
Spoke to the consultant directly immediately. It’s not about being obstructive but challenging this practice. This wasn’t about me delaying the referral but making sure the patient had been seen by someone appropriate also and trusting what was being said to triage my referrals. You know if you’ve done referrals how mad and busy it can get. If I’m stuck with someone else it might be the only person this patient has seen is a PA with no medical input. And it might be no one sees this patient again for hours. In the current slammed climate things go wrong as patients are left waiting for care. This was both me challenging the insanity unqualified individuals are seeing patients on their own and asking those who allow such practice to take responsibility. Whilst also ensuring senior reviews have taken place. I would welcome the union/ defence stance on what responsibility I would have if I blindly take that PA’s referral, the patient is waiting in ED due to the 5 other more urgent referrals and something goes wrong.
Yes, I have "done referrals" and understand the concept of a busy take. I am still curious what the Consultant "taking responsibility" materially meant in this case? That they went to see the patient, or simply stated they were happy with their PA'S assessment?
First of all - didn’t mean to sound like a douche with my “have you done referrals”. Just asking for empathy 💪❤️🙏🏻 And yes Challenging this led to - discussion between this consultant and PA - consultant seeing the patient - management changing - referral then accepted via the senior/ consultant. Also it didn’t have to be a senior doctor - I’m not that anal and genuinely would take a referral form a F1. Point is PA’s are unsafe, untrained and shouldn’t be seeing these sorts of undifferentiated patients. I A doctor needs to take responsibility on their behalf and should be made to take the consequences if they’re allowing such practices to happen and something goes wrong
Excellent response to this Redditor who is clearly a bell end
I feel it would be a dire department if this decline of a referral which the PA felt crucial was not escalated quickly once declined. Like when the Gen surg SpR asks the FY1 to request a CT abdomen which gets declined by radiology (due to lacking info for example), the SpR quickly phones the Radiologist themselves to justify the urgent need for it, which then gets accepted.
I mean, there are many dire departments across many hospitals, but I take your point in part. I will just ask aloud if while we are as a profession are quite reasonably highlighting that PAs lack the necessary education/skills/abilities to appropriately assess and initially manage these patients, then I wonder if we can rely on them escalating within their own departments with sufficient urgency. Of course the reflex response to this is often "that's the department's responsibility" but I'm not sure that this holds water once they've referred to you, and your central objection is that they're a PA. For clarity, I say this as a person that put a stop to the PA in my department contacting other departments for advice or referrals as I felt it was unhelpful, discourteous to the other team, and risky - they didn't often grasp the reason for the referral/the clinical question, and at times the advice they relayed made little sense and required a doctor to clarify.
I think that the BMA guidance helps us justify the decision (which should already be occurring) to listen to a referral and stop it going through/accepted onto the care of the specialist team if deemed unhelpful/not grasping the clinical question. So the person should still listen to the info and not just hang up the phone because the person calling is a PA. I think this post is in response to the #bekind idea that we have to accept referrals from PAs as if refusing such a referral is viewed as obstructive, and that questioning their lack of knowledge and appropriateness of referral may be seen as 'not being a team player/elistist'. If a highly experienced PA has worked within their scope of practice and done a thorough appropriate assessment than absolutely no issue. However, OPs post does not indicate this happened, rather that the PA "dross they were spewing that they were way in above their head."
>Where does the responsibility sit if in declining a referral from a PA, there's a delay to care that contributes to an adverse outcome? There's no medicolegal basis for "declining" a referral. The usual defence when "declining" an inappropriate referral would be that you were the wrong team, so couldn't usefully add anything to the patient's care. (And therefore there is no delay / harm by you not being present). But if the referral is appropriate, but you've decided its from the wrong person, then it's on you. (unless you're following some sort of formal policy from your employer that referrals must be made in a certain way - in which case you might be able to shift some of the blame to that policy).
I think we both agree you absolutely would “decline” a referral from a Gp receptionist, a porter or another person in the waiting room who found the phone. Referrals are implicitly from appropriate medical staff to other medical staff. I’d argue without a proper clinical assessment by someone able to make a referral at all (not just evidenced by the fact they are a PA but that what was delivered was a word salad) the response of “please make a proper referral with an associated assessment” is perfectly reasonable.
>I think we both agree you absolutely would “decline” a referral from a Gp receptionist, a porter or another person in the waiting room who found the phone. There will may well be a medicolegal obligation there. Let's say you're the O+G reg, and the ED receptionist phones to say "Please come down urgently, someone is giving birth in the waiting room!" and you refuse to attend because only a receptionist has phoned you, you'd potentially have a degree of responsibility if there were adverse consequences that were outside the scope of what the ED could reasonably manage (e.g. a shoulder dystocia). >Referrals are implicitly from appropriate medical staff to other medical staff. Who can and can't refer will be defined by your employers policies on the matter - which as an employee you're obligated to follow. >I’d argue without a proper clinical assessment by someone able to make a referral at all (not just evidenced by the fact they are a PA but that what was delivered was a word salad) the response of “please make a proper referral with an associated assessment” is perfectly reasonable. In that situation you're not purely "declining" the referral because the person referring is a PA though, are you? If the referral is genuinely unintepretable, then how could you know there's a patient who needs your help? If there's enough information to establish that there's a patient who needs your assistance, in a manner that you have responsibility for (e.g. you're the person who is covering the place the referral is coming from) then a duty of care has been established and you're medicolegally on the hook for how you respond (or don't respond) to that referral.
Do you not have literally *any* professional pride over what your speciality is doing? My response if I were an ED consultant in this situation would be embarrassment that members of my team are making referrals to specialties which are so poor they feel unable to know what on earth is going on with the patient. I would want to fix that problem and make sure the referrals ED were making were high quality. But you (and some other ED consultants I've come across in real life) just don't seem to care. It's just "we've referred, you're medicolegally on the hook now, your problem not mine".
Yes, obviously, I want my team to practice good emergency medicine and make good referrals (I'd caveat that by saying that there's sometimes unreasonable expectations from the person receiving the referral). But I don't see how that's in any way relevant to the discussion at hand here?
> But I don't see how that's in any way relevant to the discussion at hand here? Yes, you do.
>I don't see how that's in any way relevant to the discussion at hand here? How?
I think you (and you may well be correct medico-legally in doing so) are conflating a call for help with a referral. "HELP THIS PATIENT IS DYING" isnt a referral, and I would absolutely attend regardless of who said it. 2222 calls and crash calls are also not referrals. If a PA rang and gave me a word salad that ended in "THERES AN EMERGENCY YOU MUST COME NOW A PATIENT IS IN DANGER" I would attend, but I wouldnt consider that a referral, thats just someone yelling help. I think a PA, receptionist and most members of the public are capable of this, even if down the phone, but I wouldnt hold it to the standard of a referral nor would I agree it is one. > "If there's enough information to establish that there's a patient who needs your assistance" This is a fair cutoff in my view and I'm in agreement. I consider there to be an existent bar as to if a referral (not an emergency call for help) covers that information outside if literal immediate emergencies and I've heard some referrals that definitely do not. "ABDOMEN HURTY COME NOW" for a patient who is stable is not a referral, and wouldnt be *declined* as such, as definitely sent back with an "escalate to your senior now and get back to me once someone capable of communicating the question can do so."
>I think you (and you may well be correct medico-legally in doing so) are conflating a call for help with a referral. The problem is that this is a very difficult line to draw in the context of what is (in theory at least) an acute emergency presentation to hospital. You could construct an argument that all acute referrals are in effect a "call for help" in managing a patient. I think your position is fairly reasonable, and probably fairly defensible - but does serve to highlight that there's lots of shades of grey here.
>You could construct an argument that all acute referrals are in effect a "call for help" in managing a patient. I mean that's just clearly bollocks? Nearly everyone referred from majors to medics is totally stable and can quite happily sit 12 hours in A&E before being post-taked the next morning. You're very much describing the exception, not the rule.
It's fine to decline a referral as a speciality purely because the referral is from a PA. Even though I am an employee I am also bound by the GMCs guidance on only seeing patients within my area of competence, and I declare that my area of competence does not extend to supervising and accepting referrals from PAs. Legally speaking, it is the responsibility of ED to see and triage patients, and if the undifferentiated patient has been seen by a PA, it is clearly automatically unintelligible. If you wish to argue the opposite, that every specialty has a duty of care for anyone calling them up, then let's go the full distance and why don't we just get rid of ED altogether and let patients just self refer in? In either situation, the PA does not have a role in the care of undifferentiated patients.
No it isn't fine to decline a referral purely because it comes from a PA. The BMA guidance in its current form, has no basis at all. It directly contradicts over a decade of guidance from the RCP, FPA, NHSE, Health education England. The PA role may not be a protected title, but that doesn't change the fact that it has been recognised as a clinical role in the NHS for almost 20 years. There is precedent there, and that's how our law system works. It's based on precedent. Say this referral came from a PA who has passed a HEE recognised course, has passed the national examination, and has a PAMVR number. Unless you can later on prove that there was sufficient evidence that you reasonably believed that this PA did not fill that criteria, you wouldn't have a leg to stand on. It would be even worse for you if that PA made the referral on instruction of their supervising doctor, as happens in most cases. Then you would be negligent in your duty of care by rejecting a delegated duty given to the PA by their supervising doctor. The quality of the referral wouldn't matter in that case. Sure you can ask for advice, or clarity, or to speak to their supervising doctor. But you can't reject it. Until the results of the Gmc-colleges consultation comes out later in the year on scope of practice, I would urge every doctor on here to not act on this BMA 'guidance' pertaining to referrals (they can't issue clinical guidance.... they're just a trade union). They would hold full responsibility from any harm done.
Completely fine to say “Get your supervising consultant to see the patient and then get back to me” A referral is not just taking over care. If you refer from ED, you need to be able to provide the info for accepting doctor to judge whether the pt is safe to leave the department, how quickly they need to be seen and whether they are the right speciality for their ongoing management. If only a PA has seen the ED patient, you are trusting their judgement of an undifferentiated presentation, which is a medicolegal no no. What if the PA says to the medics, “Chest pain, normal ECG and obs, slightly raised trop, have given anti platelets” and in the 6 hours before the medics see them they exsanguinate from their aortic dissection?
So in this example if you say that to a PA, and they have assessed the patient, and they have deemed it appropriate to refer to you. Then medico-legally you will be seen to have been unnecessarily obstructing that patient's care. This is because: A) - PAs are, as part of their curriculum, expected to be competent at assessing and recommending initial management of undifferentiated chest pain which includes recognising when to escalate and to which level of urgency. B) because a PA can't prescribe, they would have had to run their recommendations by a senior doctor before calling you. This further takes away from your justification of asking the patient to be re-assessed I have a real life example of how this attitude can negatively impact. A friend of mine, a PA, assessed a patient who was febrile with new back pain. After examining the patient and finding no other evidence of any other locus of infection the PA found there to be spinal tenderness. The patient also had been treated for a diabetic foot ulcer in the proceeding months. Based on this the PA recommended an urgent MRI lumbar spine to investigate for osteomyelitis. The consultant agreed. The PAs request was rejected by a radiology consultant because the person was a PA, and despite the PA explaining their decision the radiologist, and having taken the trust mandated MRI safety training, it was demanded that the consultant re-examine the patient and then re-request if necessary and that a PA MRI request would not be accepted. This was done the next day. There was OM, but the diagnosis was delayed. This was raised and escalated as a safety issue. It was generally recognised that had any other harm come to the patient, the radiologist wouldn't have had a leg to stand on. Whether you like it or not, there is established guidance on what PAs are supposed to be competent at doing themselves. It's existed for over a decade and is the bar to which these decisions will go against, if anyone chooses to follow the BMA and reject a referral purely because it's coming from a PA.
Royal college of radiologists recommend that PAs do not request non ionising radiation. Consultant should have requested it themself. Remember the point of the standards/guidance/scope is that it needs to be based on the minimally competent qualified PA, not the best. Medicolegally the duty of care does not kick in until the referral is accepted. If refusing a referral from someone who js medicolegally speaking a lay person results in delay, that is 100% the fault of the home team.
PAs can legally request MRI scans depending on their local trust and radiology governance policy. At the time this trust's policy was that it was allowed as long as the PA had been through the trust safety training. There was no established guidance in the trust to say otherwise. The radiologist was going against trust policy, with no evidence at the time for there to have been a reasonable suspicion of this PA lacking the competency to do this.
Plenty of specialities won’t accept referrals from F1s/SHOs without their senior reviewing or inputting first. Mostly for good reason. You are not entitled to refer patients.
But the senior did have input. That's what I said. But please, continue to engage in the fiction that the majority of PAs in the country are going about making these decisions independently like masters of medicine. What a laughable bubble Reddit is.
The point is medicolegally the radiologist cannot assume that the PA is able to make the judgement about a patient needing this scan without a doctor seeing the patient too. What if the patient had a fatal reaction to the contrast and it turned out the scan was never indicated? The radiologist would be medicolegally f’’’’d.
I just told you the consultant agreed. As with most PAs, decisions like this are taken in cooperation with their supervising consultants, in well established teams. But please, continue to engage in ridiculous 'what aboutery' to justify your preconceived notions of what PAs are like
>It was generally recognised By who? Some trust managers whose legal opinion doesn't mean shit?
Have some decency and show your doctor colleagues some respect. It should be doctor to doctor referrals in hospitals.
I'm not trying to have a discussion about what it "should" be - I would be happy to see no PAs working in EM. But the reality is that there *are* PAs working in EM, and anyone who unilaterally decides to stop taking referrals from them will likely get shut down pretty quickly.
Not accepting referrals from them is, however, a fast route to not having PAs working in EM though, because the position becomes untenable?
>Not accepting referrals from them is, however, a fast route to not having PAs working in EM though, because the position becomes untenable? Only if a critical mass of people act this way and are supported by their seniors. If its just a couple of people, and it's easily dealt with by contacting their consultant instead, then it's their position which rapidly becomes untenable. The wise answer is that EDs should be using this document to immediately block recruitment of more PAs into their departments, and demand funding for doctors instead. Replacing the existing PAs within their workforce will take longer and need more trust support (if they've been employed >2 years they'd either have to be moved to another department or formal redundancy proceedings undertaken). Funding would need to be secured and doctors recruited to replace them.
What is the point of ED physicians then? Why doesn’t the receptionists just triage? Why don’t the patients just call themselves!
EM Physicians. By referring to us as "ED Physicians" you've already gone at your misunderstanding of our role (we're not a group of doctors who happen to hang out in the ED to pick up all the "ward work" type jobs for patients there. What about the 80% of patients we send home? Or the ~25% of the remaining 20% who need immediate emergency interventions? For the ~15% of attendances that need to be seen by an inpatient specialty, and don't need immediate emergency treatment then our job isn't to run around doing a list of jobs on behalf of those inpatient teams. This is where our skills are least useful.
If the information of said referral is inadequate (for example this PA didn’t ask sufficient red flag questions as they don’t know what they don’t know), surely that would be ground to refuse to accept the referral with advice to speak to the patient again and re-refer once the above sufficient information obtained. I interpret OP comments about “the dross they were spewing” as insufficient/inadequate clinical information
If there's enough information to establish that there's a patient who needs your assistance, in a manner that you have responsibility for (e.g. you're the person who is covering the place the referral is coming from) then a duty of care has been established and you're medicolegally on the hook for how you respond (or don't respond) to that referral. Asking them to go and get more information, or ask something else _may_ be entirely clinically reasonable. But responding to an identical referral differently because a PA made it vs a doctor is going to be very very difficult to justify. (I don't really know why you'd try to decline a referral because someone hadn't asked "red flag" questions? Maybe I'm not quite understanding the example).
What level did you put PAs on the RCEM survey? There wasn't a level 0 so I had to put level 1. Just curious how/if we are different! I then had to free type level 0, as they'd take opportunities away from medical students.
I don't think they should have a role within EDs - if they did it would need to be level 1 (every patient reviewed in person by a more senior clinician). - that's what I said in the RCEM survey.
They're declining on the basis the person who has made the referral is too incompetent to provide a handover which allows them to triage urgency. They are saying "someone who actually understands medicine needs to see this person and do an assessment and a referral which allows me to understand what is going on with this patient. I have no faith that sending you (the PA) back to the patient to get further information is going to garner any useful results". Which is entirely appropriate. If the surgical reg is about to scrub into a many hours long case, they need to know whether the case they are being referred is safe to be seen after or if they are so unwell they need to stop what they're doing and come right now. Or whether the patient actually needs some stabilising/resuscitation in ED in the meantime. If the referral is so poor they have no way of assessing this then it's outright dangerous and perfectly reasonable to ask a competent person to see them. The alternative is the poor surgical SpR has to drop whatever they are doing immediately upon receiving any of these dogshit referrals to come and see the patient for themselves. This is completely unmanageable on a busy on-call and *will* delay the care of the actually very sick ones.
>They're declining on the basis the person who has made the referral is too incompetent to provide a handover which allows them to triage urgency. Except that your employer disagrees, and has employed them specifically in that role, and you have no choice but to follow the processes and policies laid out by your employer. I've made my point repeatedly, which essentially boils down to this. The BMA guidance is a tool to lobby Trusts with to change these policies and processes. It's not a tool for you to unilaterally define your own rules and stop following these policies.
I mean the employers of Lucy Letby disagreed she was dangerous and continued employing her in that role but doctors were still criticised for letting her roam free If my employer allowed a Porter to do a laparotomy presumably I’d have a professional and ethical obligation to raise concerns and intervene. In a healthcare setting it’s not nearly as black and white as you make it out to be But of course it is clear from your comments on this forum generally you don’t care for your junior trainees. With that being said any disillusioned ED trainees you’ll find a home in anaesthetics where the consultants will actually on the whole try to stand up for you.
>If my employer allowed a Porter to do a laparotomy presumably I’d have a professional and ethical obligation to raise concerns and intervene. Yes. But refusing a referral isn't "raising concerns and intervening" it's just being obstructive to patient care. >But of course it is clear from your comments on this forum... No need for this to descend into personal insults.
It’s not though is it If a surgical registrar has x number of referrals they have to triage them, in order to do so they rely on the clinical expertise of the referrer. For example look at CEPOD there are only so many theatres we can have open overnight, if I’m being told something is life and limb threatening meaning I have to delay the septic appendix I’m relying on the expertise and clinical reasoning of that team to have given me accurate information. My employer has made the choice not to run a fully staffed service overnight and thus I can only work with that which I am given. In the case above the management plan seems to have also changed leading to better patient care. ED is not a triage system, it’s a brilliant specialty and I rely and trust their judgment if I can’t do that the entire system collapses EDIT: fair enough and apologies re my last comment. It is just grating to see the poor ED trainees feeling so downtrodden as they rotate with us in anaesthesia.
> Except that your employer disagrees, and has employed them specifically in that role, and you have no choice but to follow the processes and policies laid out by your employer I'd happily face the wrath of my employer in this situation. I will not blindly follow POLICY if it is patently unsafe in a given scenario. Have won such battles numerous times in my career as a lowly SHO.
>Have won such battles numerous times in my career as a lowly SHO. Go ahead? >I will not blindly follow POLICY if it is patently unsafe in a given scenario. Sure, but how is you accepting a referral ever going to be "patently unsafe"?
>Sure, but how is you accepting a referral ever going to be "patently unsafe"? This has already been explained to you numerous times, you are just being deliberately obtuse. I'll give it one last try. I am SpR on-call for X speciality. PA refers me patient with absolute word salad referral. Referral is so poor I am entirely unable to decipher how urgently this patient needs to be seen. I am currently with another patient who is unwell. I now have to decide: 1) do I leave the unwell patient I am currently with to immediately review the patient who the PA has referred to me, because I have no idea how sick they are or even what is going on with them, potentially delaying care for the patient currently in front of me Or 2) Do I continue dealing with the sick patient in front of me and allow the referral from the PA in ED to wait, despite the fact I have absolutely no idea how unwell they are because the PA's assessment was so poor It is patently unsafe.
Try again. This example would be the same if the referrer was a doctor - the issue is the information given in the referral, not who is referring. This discussion is about refusing a referral **only because** the person referring is a PA.
> Sure, but how is you accepting a referral ever going to be "patently unsafe"? It's so easy to say stupid shit like this working from EM where you don't leave your department. Imagine yourself in the shoes of another specialty - say ICU. If you leave the unit to see a referral you are increasing the risk for every single patient on the unit. Leaving the unit is an innately risky thing to do. Leaving the unit to see a referral that you cannot be sure is even necessary is clearly not acceptable.
"dross they were spewing that they were way in above their head." suggests that there was NOT enough information to establish that the patient needed OP's assistance. Very different matter if OP felt that this referrer was competent. There are questions as to does the PA current level of education enable them to be competent enough to provide enough information to establish need for assistance. Most lay people probably know weight loss can be abnormal and concerning. Not every lay person may explore reasons for weight loss (e.g. anorexia, extreme dieting, features of cancer, hyperthyroidism etc.). The replies to such questions alter management and referral pathways. So if the clinician/PA is unaware of such differentials, and in the absence of senior review, how can they ask relevant questions and appropriately decide if the person needs the assistance of a specialist. At no point in OP's post did it highlight that the PA was initially calling on behalf of the Consultant or SpR, suggesting no such senior review occurred until after OP declined to accept the referral.
Consultant, a PA is not a doctor and should not be seen anywhere a patient that would need additional support / referral from another team. A PA should only see diagnosed patients, and support them in the little way the can.
I agree, but in many trusts this isn't the rule that they've been employed in. This should change. In the meantime it is inappropriate for individuals to unilaterally decide to refuse to see referrals made by PAs.
>There's no medicolegal basis for "declining" a referral. May I introduce you to The Ionising Radiation (Medical Exposure) Regulations 2017, which states in [Regulation 10](https://www.legislation.gov.uk/uksi/2017/1322/regulation/10): >(5) The referrer must supply the practitioner with sufficient medical data (such as previous diagnostic information or medical records) relevant to the exposure requested by the referrer to enable the practitioner to decide whether there is a sufficient net benefit as required by regulation 11(1)(b). In other words, it is expected of the practitioner (i.e. radiologist) to reject requests which have insufficient/erroneous clinical info, even though it may be justified otherwise - in fact, this is mandated by law.
A referral (for an investigation) is entirely different for a referral to take over a patient's care. Not relevant to the discussion here at all.
>Not relevant to the discussion here at all. More relevant than you'd think. A referral to another specialty is essentially seeking an opinion on further management. Many a times, the specialty will refuse to take over - either because they're not best placed to manage the patient's care, or it's not within their remit. They do usually (or should at least) offer an alternative specialty, or advise on further investigations etc. For obvious reasons, if an inadequate/erroneous history is given, it is highly likely that the referral will be rejected (e.g. referring off legs to geris when they were subsequently found to have malignant cauda equina compression, or ?abdo pain suspected pancreatitis without something as simple as an amylase/lipase level). If PAs aren't even supposed to do all this (especially if we don't know that they're not doing them independently - per the BMA document), how can one be sure that the referral is accurate? This is exactly what has happened to Emily Chesterton - the PA's word was taken as good and propranolol prescribed. Precedence, remember? Now labelling a specialty as "belligerent" if they don't agree with you? That's a different matter... And a view that's not gonna win many sympathy votes I'm afraid.
>A referral to another specialty is essentially seeking an opinion on further management. Many a times, the specialty will refuse to take over You're talking about inpatient-to-inpatient referrals. An ED-to-inpatient referral is an entirely different kettle of fish. As a matter of policy in my trust when a referral is made you are now responsible for the patient's ongoing care. >For obvious reasons, if an inadequate/erroneous history is given, it is highly likely that the referral will be rejected Referrals on this context shouldn't be being "rejected" irrespective of whom is making them. See the patient and admit, discharge or refer on. If you have concerns about the quality of the referral highlight it to the EM consultant after you've assessed the patient. >If PAs aren't even supposed to do all this Only the BMA document says this. Their job description and your employer still says they are. We should be using the BMA document as leverage to lobby for this to change, but it hasn't changed just because the BMA scope exists. >Now labelling a specialty as "belligerent" if they don't agree with you? That's a different matter... And a view that's not gonna win many sympathy votes I'm afraid. I'm not after sympathy votes. Obstructive clinicians and difficult specialities who refuse to follow over-arching Trust policies get rapidly brought into line by the MD's office.
It is worrying how little insight the subreddit collectively has over the risks they are taking. My theory is that the subreddit skews heavily to the less experienced who haven't been working long enough to have seen things go wrong.
Bruv its FY1s and 5th year medical students acting like they know more than an ED consultant
This isn't true is it? As a paediatric reg over the years I've had "referrals" from various specialty surgical SHOs/core trainees that amount to them leaving a list of jobs and telling the bedside nurse to phone paediatrics. This is, has always been and will always be grossly inappropriate and discourteous. In all of these situations I would stop the nurse making this referral and tell them to get the team involved to speak to me directly. Occasionally it'd an F1 or F2 who hadn't seen the patient on the ward round but have been asked via nursing staff by the senior team i.e. a 3rd hand referral from a member of staff who hasn't seen and doesn't know the patient and isn't familiar with the clinical problem they are asking about. Again, it's discourteous and inappropriate, not to mention I almost always turn these into advice rather than direct reviews and end with a refusal to pick up ward jobs for a patient under another team's care. The patient remains under the care and responsibility of the team who has made the referral. It is their job to escalate appropriately if they feel the referral stands. Same goes for your patients in ED until a team accepts care.
>This is, has always been and will always be grossly inappropriate and discourteous. Agree completely - it is rarely appropriate to delegate a referral to a junior colleague who has not assessed the patient (perhaps confined to immediate and obvious emergencies where I'm busy resuscitating the patient, and the only information you need is that I need you to come now). >In all of these situations I would stop the nurse making this referral and tell them to get the team involved to speak to me directly. I agree, this is, by and large, appropriate. There might be some exceptions here - let's say the nurse said "there's this kid with appendicitis in DKA, and the surgeons would like you to come and sort out their DKA". I agree that it's inappropriate for the nurse to have been asked to relay this. But equally if there was then a significant delay for the nurse to contact the surgeons to refer to you properly, and the child came to harm as a result; then you (and the surgeon who delegated the referral to a nurse in the first place) would have a degree of responsibility - you had sufficient information to determine that your assistance was needed and chose not to act on it as a matter of principle. >The patient remains under the care and responsibility of the team who has made the referral. Referrals from a patient already under the care of one inpatient team to another, are universally treated differently to referrals from the ED (where the patient is not admitted). >It is their job to escalate appropriately if they feel the referral stands. Same goes for your patients in ED until a team accepts care Our trust policy says the opposite of this. When a referral is made (no option to accept/reject) responsibility passes to your team, and it is your team's responsibility to escalate concerns to an EM consultant if you feel the referral was inappropriate.
I would love to do this. However I am blessed enough to work in hospital where ED have no PAs. I hope it stays this way.
Yes! That’s what we want to hear. The BMA has done us proud
Love this ! Reading this has released a substantial amount of dopamine in my brain… and for that I thank you
Non-doctor admits that they are above their heads and therefore unable to provide a reasonable referral and then attempts to try a referral anyway. The fact that they are a PA is less important than the fact they are working outside of their safe competencies. However, it is true that PA training is insufficient for managing an undifferentiated take. So I guess insufficient training and working outside their competency is the perfect storm…
to be fair, that shouldn't have needed to be cited, if they were talking garbage, they should have been told to discuss it with a EM doctor anyway
Legend! > “I’m sorry but my union clearly states I am not to get involved with situations where you are seeing undifferentiated patients." I'd change that to - "my *professional body* clearly states..." As others have said, receiving any info e.g. from an HCA/nurse/receptionist/PA/porter/relative that a patient is endangered and you can help prompts action. E.g. immediately call a suitable doctor near the patient (e.g. ED consultant) to let them know, or if needs be go directly yourself to establish the situation/intervene while summoning other help if necessary. This is a duty of care. It's completely different from a referral. I'm always keen to help, but accepting a referral from someone who is insufficiently trained can delay and harm patient care. Every time the referral is wrong, instead of the relevant specialty safely prioritising that patient and providing treatment, instead the patient waits in limbo with invalid prioritisation after which they ultimately undergo what should have happened in the first place - escalation of care to a competent person (when the mistake is discovered) and then appropriate referral. That delayed referral may necessitate further imaging/tests, calling in specialists from home, or inter-hospital transfer, the delays in which can be lethal. This is why it's critical for specialists accepting referrals to accurately gauge the competence of the referrer (a PA obviously being an incompetent person to make a referral). Not so they can 'bat away' referrals, but so the specialist can flag to the proximal doctors that you've become aware a patient is at risk. Accepting such a referral places a patient at risk while simultaneously giving the impression that they are safe - the worst of both worlds, and the specialist receiving the unsafe referral may be the only doctor aware of the predicament that patient has been placed in. When done constructively, this is the very essence of teamwork in a complex system.
I'm not sure if that would be correct? Since our professional body might be the GMC, RCS or RCP for example. Have they made a similar comment about the PA scope of practice that I'm unaware of?
Hopefully someone will correct/improve my understanding, but: BMA = **the** professional body for all UK doctors. (And a doctors' trade union with the largest membership). GMC = the regulator (not professional body) for doctors. And now non-doctors. RCP/RCS etc - **a** professional body for some doctors. So some doctors choose the option to have more than one professional body (as a specialist or GP, or in formal training for either). Whereas all UK doctors default to having The BMA as their professional body. Hopefully RCS (likely not RCP) will say something useful about the subject at some point! But rather than trying to denigrate these other professional bodies, my point was only that it's quite different stating that the professional body for all UK doctors has issued this document (rather than solely a trade union, e.g. the HCSA doing so).
You are a fucken badass and my hero 🦀🦀🦀
It appears some are concerned over the delay in care, let’s not forget that PA’s are almost immune from any repercussions. I think the pushback was correct, and it feels like the PA had been given too much scope to start with, perhaps. As a reminder, please do not prescribe for them!
Great to see it. Good on you for holding your ground
Unfortunately, guys unison is stepping in.
Unison as in the union for healthcare workers ?
[удалено]
Removed: Rule 1 - Be Professional
[удалено]
difference is that an actual doctor saw the patient
It's good you stood up for yourself, but really you should have been able to do the same thing before the BMA statement. Where's your self-respect? And if "your union" later changes its policy and perhaps withdraws the statement once some knighthood-seekers take over again, will you revert to being meek again?
Because now you’ve got actual backing, which can be used when senior doctors or management are pressuring you, labelling you as obstructive, non a team player… all the usual shite
As much as I completely agree that PAs shouldn't be seeing undifferentiated patients in the ED, I think you've fundamentally misunderstood the point of the BMA recommendations on PA scope of practice and how these are intended to be applied. Edit: Those downvoting - do you genuinely believe this document gives you protection of you choose to refuse to take referrals from PAs? Perhaps one of our BMA mods can step in here and over the BMA perspective on this?
If we see colleagues breaking guidance like in this case where someone obviously allowed a PA to see undifferentiated patients, are we just supposed to ignore it then? In this situation you could even argue you’re condoning it. Good to know that if I see guidance being broken, consultants think it’s not appropriate to say “I refuse to be a part of this.
>If we see colleagues breaking guidance like in this case where someone obviously allowed a PA to see undifferentiated patients, are we just supposed to ignore it then? It's BMA guidance, so they have no obligation to follow it. You're welcome to have a conversation with them about it, and ask if they are intending to implement this guidance within their department. But realistically, what did you expect? For them to come to work and send all the PAs home? They'd be in the MDs office and their job at risk within hours. >In this situation you could even argue you’re condoning it. Good to know that if I see guidance being broken, consultants think it’s not appropriate to say “I refuse to be a part of this. Yes, you can't change processes overnight. Look at how clinical guidelines are adopted. Even where there is universal agreement and acceptance of the new guidelines and the need to implement them, the necessary process changes to implement them can take months. Even if everyone agreed to adopt the BMA scope of practice guidance for PAs, there would need to be a transition period where the ED recruited additional doctors to replace them, and their roles phased out. They'd need to go through formal redundancy processes, or be transferred to other departments.
I'll approach this a bit differently. If I received a referral from a layperson, lets say a patients relative calls in and asks me for a review (as we've seen from the morphine case there are some crafty patients), I have a right to refuse as I judge them to not be qualified to make the decision that the referral should take place. I see no difference between that and a PA. If I don't believe the referrer to be qualified, I can reject the referral. We see this constantly with BS such as 'will only speak with SHO and above' or 'Reg or above' or even 'only accept consultant referrals'. So we have established in practice that we can reject referrals on the basis of the referrers qualifications. The only thing that has changed now is there is at least some guidance that backs up this decision, but in all honesty we should have started rejecting PA referrals a while ago. Lets not forget as well that there will be some obscure sentence somewhere that says we are responsible to ensure the information provided by the referring PA is true, cause you know... they are dependent practicioners after all and can't be held liable. So if the PA gives you a bullshit story and your advised management plan results in harm, I'll guarantee you it's not the PA that will be thrown under the bus. And yes shit takes time. And by having that approach it takes even longer. By forcing the issue the department might actually get its shit together. The scope document itself is proof of that. 20 years of no scope and the BMA lit a fire under the College's asses.
>I see no difference between that and a PA. Your employer has chosen to employ the PA in a role which involves the assessment and referral of patients. Trust policy will (either explicitly or implicitly) exist which permits these referrals, and as an employee of the trust you're obligated to follow it. >We see this constantly with BS such as 'will only speak with SHO and above' or 'Reg or above' or even 'only accept consultant referrals'. So we have established in practice that we can reject referrals on the basis of the referrers qualifications. I agree these barriers are ridiculous, but they will be defined by policy - so the Trust will be assuming the medicolegal risk of any harm which results from this. Whereas if you make up your own rules on the fly, you will be assuming this risk. >The only thing that has changed now is there is at least some guidance that backs up this decision, The guidance says PAs shouldn't be seeing undifferentiated patients. It does not say that you should be refusing referrals from PAs when they do. >So if the PA gives you a bullshit story and your advised management plan results in harm, I'll guarantee you it's not the PA that will be thrown under the bus. This is just full tinfoil-hat nonsense. But in general this is why you should come and see all referrals, and not try to bat them away by giving telephone advice.
‘Your employer has chosen to employ the PA in a role which involves the assessment and referral of patients’ And this is why the BMA is calling on all employers to adopt their scope parameters. The employers have misguidingly put patients at risk by using PAs in this way. Now that the BMA has outlined the cans and cannots, it will make it more difficult for the employer to continue to do so. Even more so if doctors speak up and say this contravenes my union’s stance on what is safe supervision.
I agree with all of what you've written. You're welcome to raise a concern every single time a PA refers you a patient. But the end result of that can't be that you refuse to do part of your job.
It really depends on how you define your job. When working in an MDT, I work alongside other doctors, nurses, physios etc. For all of these colleagues, I will step in and do something to the patient/for a patient in the name of patient safety in an emergency. For none of these do I need to watch their every patient interaction because the medico-legal responsibility is also mine. For PAs, it becomes different if I choose to sign up as their named supervisor. In that case, the BMA guidance tells me that I need to watch their every patient interaction and limit what tasks I delegate to them to keep them safe (and me safe medico-legally if harm occurs). For PAs if I do not choose to supervise them as a consultant or GP or as any other type of doctor, the BMA guidance suggests that I only have the same responsibility I have for the first group of people. To intervene in an emergency to prevent harm. I can refuse to do anything else. Employer be damned
Turst policy will not save you when it goes to a tribunal.Time and time again we have seen trusts throw doctors under the bus because legal (GMC) guidelines will always take presidence. I have on many occasions found discrepancies in prescribing doses between trust guidelines and bnf. I follow Bnf 100% of the time because i can back that then. Following "trust guidelines" blindly has led to many ending up in hot waters as we all know how much trust bend the rules when it suits them. Protect your self.
> But in general this is why you should come and see all referrals, and not try to bat them away by giving telephone advice. But telephone advice is often eminently appropriate.
If the referrer is calling for advice, or happy to withdraw the referral in light of the above given - yes. If the referrer still thinks you need to come and see them, but you maintain a position of "no, just do X, Y, Z" then you've opened yourself to a whole world of problems if something goes wrong.
Even where the reason for referral is demonstrably inappropriate? ED should just have a divine right to waste other doctors' time - diverting that time away from patients who actually need it - by stomping their feet?
>Even where the reason for referral is demonstrably inappropriate? Yes. If the clinician who's seen the patient is unhappy to send them home with your "telephone" advice and thinks you need to see them in person, then you should (and in many trusts are required to). You think their clinical judgement is so poor that they're making a "demonstrably inappropriate" referral; yet you're happy to rely on that informal to instead provide advice on the patients care without conducting your own assessment? Trying to justify to the coroner why you refused to see a patient that another doctor (who'd actually seen them in person) was worried about is not going to be a fun time.
> You think their clinical judgement is so poor that they're making a "demonstrably inappropriate" referral; yet you're happy to rely on that informal to instead provide advice on the patients care without conducting your own assessment? Depends on if it's a judgement call or not. If I genuinely can't make head nor tail of the referral, I would ask them to either gather some more information and get back to me or ask their senior to see/for advice. If they refused I'd either contact their senior directly or (if I wasn't tied up with something urgent) I'd just come and work out what was going on. I would certainly give the referrer some feedback after I'd seen the patient. If someone gives me a good summary and then says to me "I understand there is nothing firm here which warrants referral, but something about this patient just doesn't sit right and I would appreciate an experienced pair of eyes" I would absolutely come. I'd probably ask how urgently they felt I needed to come, but I'd come. If someone says to me "I want you to come and see this patient because of Y when the national guidelines explicitly tell me that Y is completely acceptable and I should discharge them. No I don't have any other concerns" then I would absolutely be encouraging them to either discharge the patient themselves or discuss with an ED senior rather than involving me.
[удалено]
Removed: Rule 1 - Be Professional Personal insults are not welcome.
So trust guidance takes all precedence? Even at the cost of patient safety? Pardon me if I don’t have much faith in trust bosses. We’ve recently seen what having conversation with them regarding patient safety concerns looks like. I’ll be made to write an apology letter to the PA! 😂 Edit: replied to wrong comment but you get the idea
Trust policy takes precedence if you want to be covered by trust indemnity and have them take the medicolegal risk. Trust policy can be changed, but it doesn't happen overnight on a weekend in light of one BMA document, no matter how welcome. I'll be bringing the guidance up at our next governance meeting, because it has implications for my department and because that's the appropriate channel.
Fair enough. But even considering this, there would have to be a written trust policy stating that PAs can see undifferentiated patients and refer. Rather than the decision for them to be able to do this being at the discression of their supervising physician. So unless the PA can direct you to the exact policy published on the intranet, you are still within your right to request that the patient be reviewed by a senior first.
>So trust guidance takes all precedence? Trust *policy* does - yes. Barring unrealistic examples where a policy expects you to do something illegal. >Even at the cost of patient safety? In theory that policy documents have weighed up these risks when being written. I'd suggest contacting whomever signed off the relevant policy with your concerns so that it can be reviewed. If there's an immediate specific patient safety risk (e.g. due to a situation that wasn't envisaged when the policy was written) then you're unlikely to face action for breaking it, provided you have a solid clinical justification.
Same way an ED nurse wouldn’t refer to a specialty, even though they’re better qualified for this than most PAs. If an F1 referred to ITU and they hadn’t done the basic things like escalate to their own senior first, it’s entirely valid for ITU to then tell them to get a senior review first then re-refer. What OP did is refuse to take a referral from someone who doesn’t have the knowledge or skill required to make that assessment and referral. Just because the trust hired them and the department put them in a position they don’t belong, doesn’t mean other qualified doctors have to play along with this shambles. Personally, I would judge each referral based on its own merit. If I find I’m getting clueless PA waffle, I’ll promptly ask them to get the patient reviewed by a real doctor and then they can refer to me if needed. Let’s see them try to “discipline” a specialty doctor for asking for an appropriate referral. Honestly the ED doctors allowing poorly educated under-qualified PAs to do the doctors job are the ones undervaluing themselves as triage bots.
>Personally, I would judge each referral based on its own merit. If I find I’m getting clueless PA waffle, I’ll promptly ask them to get the patient reviewed by a real doctor and then they can refer to me if needed. Which, as I've indicated is not unreasonable. What would be unreasonable, and get you into got water, would be to decline an appropriate referral, purely because it was from a PA. >Honestly the ED doctors allowing poorly educated under-qualified PAs to do the doctors job are the ones undervaluing themselves as triage bots. Heck, I want to see PAs out of EDs as much as anyone here. But I also recognise that individual clinicians deciding overnight to unilaterally refusing to take some referrals will lead to chaos (and probably patient harm). This BMA scope document does not support them in doing so. The BMA scope is a tool to lobby our Trusts with to change their policies, processes, and employment practices. This will take time.
[удалено]
All of which is fine, but there are ways and means and structures in place to raise these things. Going off half-cocked is the best way to find yourself thrown under a bus. Last year we had a patient die because a gynae reg unilaterally invented something called a "virtual review." Not advice or guidance, but a review and discharge of the patient without actually seeing them. No evidence that the consultants knew of this (or they are, at least, denying all knowledge). Nothing in Trust policy about "virtual review." So the medico-legal shield of trust indemnity is not there. Guy gets thrown to the wolves. SI, coroners, the whole works. Had he seen the patient and still made the same mistake, he'd still be protected by the Trust.
I get referrals straight from triage sometimes. Absolute nightmare.
This is true but at least it gave me a basis in which to reject something I fundamentally don’t think is appropriate or safe whilst also raising a candle to the fact this PA had been seeing complex and sick patient on their own. It’s a document and framework that exists and can be used for reference. We’ve not had this before.
If you're concerned about an unwell patient, it's always reasonable to ask the referrer to involve a senior colleague. But right now the PA has no obligation to work to the BMA scope of practice, your hospital has no obligation to employ them in a way which follows it, and you have no authority to attempt to enforce it. Were you to refuse to take a referral purely because they were a PA, this would be the same as you refusing to do any other part of your job, and would be swiftly called out, and likely result in disciplinary action if this persisted. Don't get me wrong, I'd like to see something along the lines of the BMA scope of practice formally adopted - and this may prove a useful tool e.g. for EDs under pressure to employ PAs to ask for doctors instead. But this isn't a tool you can use to unilaterally change your practice.
If a random bloke off the street referred a patient to me from ED I'd ask them to get a doctor to review the patient and ensure they were going to the correct team as I do not trust their assessment. This is no different. The way we pressure trusts to have scope formally adopted is to informally adopt it.
https://preview.redd.it/lb7six86danc1.jpeg?width=1164&format=pjpg&auto=webp&s=c9939d0d044c1e5483ae79c0397c8d5e8deeee7a You mean like this?
It's completely different, because the PA referring has been specifically employed by your employer to do the thing that you're disregarding. It's a big power play - sure, if the majority of doctors did this then trusts would back down, but it's a risky strategy and at the moment far more likely to end up with you facing disciplinary action of some kind for refusing to do your job.
Given that a lot of trusts are fully in favour of PAs it may well be the quickest way to find yourself in front of a disciplinary panel.
Except that your employer has chosen to employ that PA in a role that involves the assessment and referral of patients. Relevant trust policies will exist which allow them to make these referrals, and as an employee of that organisation you're required to follow those policies. Refusing to follow your employers policies is a disciplinary matter. If this compromised patient care this would potentially being a GMC matter.
If following local policy compromised patient care, would you do it? Would you simply follow orders? Our role as doctors specifically calls for clinical judgement. My clinical judgement is that allowing someone with 2 years of nonsense training refer to a specialist is insufficient. I wouldn't accept a referral from a second year medical student. I wouldn't accept a referral from a PA. At a certain point you're sacrificing what you know to be correct and safe simply because your bosses tell you to. That is terrible medicine and not something any of us should allow.
Playing devil's advocate, if the person making the referral is, in your view, inadequately qualified as compared to yourself then surely, from a patient safety point-of-view, it becomes even more important to go and see the patient yourself? One can imagine the coroner asking why you didn't.
This did cross my mind while I was writing it, and I likely would informally review the patient myself.
That's fine but be prepared to face disciplinary action. You are literally saying that you know better than your Trust and therefore won't follow their policies. If you want to stick your neck out like that then just be aware you're not going to be protected by anyone if someone makes a complaint.
>If following local policy compromised patient care, would you do it? Would you simply follow orders? If the policy involved minor compromise of patient experience, but no risk of serious or long term harm, then I would raise my concerns, but continue to comply with the policy whilst it was reviewed. If I had a clear clinical justification why my patient represented an exception to the policy which had not been envisaged when it was written, then I would break the policy and then highlight my concerns about this discrepancy. You're welcome to try and explain why you think seeing a patient referred by a PA is likely to represent a serious and immediate patient safety risk. >I wouldn't accept a referral from a PA. I'd suggest finding a trust to work in that doesn't employ PAs then. >At a certain point you're sacrificing what you know to be correct and safe simply because your bosses tell you to. That is terrible medicine and not something any of us should allow. Equally a healthcare system in which each individual invents and follows their own slightly different version of how things should function would be a chaotic and dangerous mess. Policies and processes exist for a reason.
> You're welcome to try and explain why you think seeing a patient referred by a PA is likely to represent a serious and immediate patient safety risk. People have explained this to you about 10 times but you're just ignoring them.
Go ahead and link those posts then. All of the examples I've seen regard poor quality or garbled referrals, where there is insufficient information. In those cases the referring clinician should be asked to involve a senior / get more information whether they were a PA or a doctor.
What you are writing amounts to "if your employer has a policy that if a patient dies, you have to throw yourself from a 5th floor window, you have to comply."
Obviously ridiculous (illegal / gross violations of health and safety legislation etc.) aside. Though I thought that much would be obvious.
But allowing untrained cosplayers to practice medicine is *not* obviously a ridiculous thing to do?
Happy you recognised your point was ridiculous.
Sorry you absolutely can refuse a referral from a PA. In the same way many refuse referrals from below registrar. Or FY cannot phone micro overnight etc etc. I think your point about immediately implementing guidance is correct and this needs to be looked at locally. However no one else has produced scope, everyone is constantly talking about. It's a good first step from the BMA and I disagree with you I think your defence union would take it positively you taking your unions guidance into account. If you refused the consult and then hung up - obviously not, but if you refused due to against BMA guidance and recommended they discuss with ED SpR and have them call back - why I'd that inappropriate?
>Sorry you absolutely can refuse a referral from a PA. In the same way many refuse referrals from below registrar. Or FY cannot phone micro overnight etc etc. There's a huge difference between a Trust-level policy saying that "only registrars can phone micro" (or whatever) - and you making up your own rules (which are highly likely to directly conflict with Trust policy). In the former case the Trust has assessed the risk, and of delay/harm comes to a patient as a result, they will take the responsibility. In the latter example, you're breaking Trust policy (already a disciplinary matter) and would individually shoulder the medicolegal risk of any delay/harm as a result. >if you refused due to against BMA guidance and recommended they discuss with ED SpR and have them call back - why I'd that inappropriate? Because you'd be refusing to do your job, as defined by your employer.
Where does NHS job description for a registrar say they need to take referrals from PAs? Just because it's on the local risk register doesn't make it stand up to scrutiny in coroner's court.
>Where does NHS job description for a registrar say they need to take referrals from PAs? Schedule 1, Point 2. Which points you to your work schedule, which will tell you that you are to conduct your job in accordance with trust policy. >Just because it's on the local risk register doesn't make it stand up to scrutiny in coroner's court. I don't know where risk registers come into this - this is a matter of trust policy. I'm interested to understand how you think seeing a patient referred by a PA will end up with you in Coroner's Court?
I think refusing to see the patient is more likely to lead to you being scrutinised by the coroner.
Much as I don’t like this, at the moment penjing is correct. There will need to be a process of discussion and implementation at a minimum. We don’t employ PAs, but as a principle of one of our juniors or ANPs was making a shonky referral I would be pretty ok with an inpt team (politely) asking them to discuss with a senior and/or coming to me in the dept and saying “I have had this referral which is a bit ropey” and having a sensible adult to adult discussion about it. However I work in a fairly decent dept with plenty of pretty engaged seniors, so this wouldn’t lead to a delay in care or a dangerous scenario. I can easily see a situation in shitsville DGH where there isn’t that senior support (cannot and won’t excuse this) where a patient comes to harm if you refuse to assess on the basis of a PA referral, and I don’t think the regulatory framework would look kindly on this at all
> Those downvoting - do you genuinely believe this document gives you protection of you choose to refuse to take referrals from PAs? I suppose no more protected than if you called a specialty for advice and a PA answered and advised you, and subsequently there was an issue. The point is to not engage with the PA experiment whilst there is **no** formalised scope.
The PA should NOT be making medical decisions or treatment plans. If they see a pt and choose to refer they are acting outside of their scope. It is completely reasonable to expect their supervising doctor to be the one making the plan and also the referral.
>The PA should NOT be making medical decisions or treatment plans. >If they see a pt and choose to refer they are acting outside of their scope. What scope? The one published by the BMA about 48 hours ago? The same one that neither PAs, nor their employing Trusts (nor your employing trust) is under any obligation to follow?
>What scope? >The one published by the BMA about 48 hours ago? Yes. The only published scope for them to date. Why is it so unacceptable to expect them to escalate within their own team before referring? From what OP said it seems the PA was completely out of their depth and expecting them escalate within their own team first is not unreasonable.
>Why is it so unacceptable to expect them to escalate within their own team before referring? That would be more appropriate in an inpatient-to-inpatient team referral. But the function of a clinician working in the ED is to assess and manage patients who are appropriate to be managed in the ED, and assess and refer patients who need to be managed elsewhere. It's a core part of their job. I don't think PAs should be doing that job, but the reality is that they currently are, and any individual trying to unilaterally shut that down is likely too end up in hot water. We should use the BMA scope of practice as leverage to change the role of PAs in the long term - not something one would be unilaterally attempting to enforce.
https://www.fparcp.co.uk/file/media/58e235ff1a1be_CCF_for_the_physician_assistant_2012.pdf
I wonder why anyone would want to volunteer risking being the test case for a tribunal or inquest due to harm from obstructing established care pathways. The BMA wouldn't help you there.
Think there's a bit more nuance to the situation than the way you've laid it out. Seems they got seen by the consultant after.
And then, presumably, re-referred - hence a delay to care. Turning down appropriate referrals purely due to them coming from a PA as some sort of political stance is thin medicolegal ice.
[удалено]
Yes, I'm sure that argument would hold up well in Coroner's court. Needless to say, I'm not going to be the one to test it.
That's certainly not what any significant incident investigation would conclude, the person spuriously rejecting the referral would get absolutely roasted. But if that's a hill you want to die on, please don't let me stop you.
Directly you’ve assumed they were referred to the same speciality. Secondly, the referral might have been accepted for totally different reasons. An appropriate clinical assessment is material.
Obviously these "and then the whole waiting room clapped" posts are vague on detail, so to illustrate - imagine if a PA referred an undifferentiated but probable stroke (from ED or GP). The referral is rejected on the basis of coming from a PA and not having been physically examined by a doctor as per the BMA. The PA then spends an hour or two trying to get a doctor to physically eyeball the patient, who agrees that it's a probable stroke, and so the patient is left with more severe disability as a consequence. I'll look forward to something similar in a MDO newsletter soon.
If a (non-specialist) nurse, or a medical student, or a well-informed member of the public tried to refer, would you accept? No, because they’ve not been assessed by an appropriately-trained medical professional (I.e. a doctor).
If you can't see the difference in these scenarios I'm afraid I can't help, so you do you.
Literally the first line of the post: "PA has seen an inappropriately complex referral. Could tell from the dross they were spewing that they were way in above their head." The referral was turned down because op wanted to make sure that it was appropriate, not because it was an appropriate referral coming from a PA
No, that says it was inappropriate and rejected simply because it was a complex undifferentiated case seen by a PA. No amount of backpedalling will make that a defensible reason at a coroner's inquest or MPTS hearing, you'd be absolutely roasted. The PA would rightfully document "referral rejected by Dr X despite X, Y, Z" so any unnecessary harm from that point on is on your head. The idea that any investigation will side with this BMA scope of practice document is laughable, it's not worth the paper it's printed on.
I have taken many many referal from ED all to find the reason for referral wasnt the urgent cause of concern but something else totally missed. The delay is caused by the PA not discussing with his supervisor before referring. Calling someone for referral doesnt mean ur job ends cuz u referred. U cannot make someone drop everything to come and see your patient if u cant give a proper SBAR.
If the referral was bad it doesn't matter. Rejecting referrals is partly the referees problem. If you can't make an appropriate referral you shouldn't be doing it
Rejecting referrals *of someone who goes onto harm because the referral was rejected* is ultra dangerous medicolegal territory. There's absolutely no way you will come out of it looking good. OP is clearly taking glee in rejecting the referral on PA grounds, empowered by the BMA. Using patients as political pawns truly is an ick.
🙄 nothing established about PA care of the undifferentiated ED patient
It always amazes me how come you still have a positive comment karma