Medical associates: the introduction of PAs, ANPs, and ACPs is creating new challenges for doctors on rotational training

Instructive approach

The introduction of permanent ward clinicians has also created new “natural” hierarchies that present themselves in the day-to-day running of wards. These softer power imbalances will vary significantly, but they typically develop off the back of experience of working in the department, age differences, and strong professional relationships with consultants. Younger and more junior doctors, as a result, increasingly find themselves at the bottom of the stack and subject to delegation and instruction from people in overlapping roles. In a job where professional autonomy is already limited, this can make the work not only unrewarding but frustrating.

During our foundation training my colleagues and I often found ourselves instructed by those in non-traditional clinical roles, rather than working in collaboration on account of our age and newness in the role. We were told which wards to cover, which patients to prioritise, and how to divide up work. This instructive approach not only created a degree of resentment and limited professional trust but also denied us the opportunity to gain skills in sharing clinical responsibility and deciding priorities. Colleagues felt wary of challenging advanced nurse practitioners who decided rotas and controlled the ability to take holiday or swap shifts.

Permanent clinical staff also often had access to easy mechanisms of communication with ward consultants. While this was a useful route to consultant advice, it regularly created a gatekeeping step for us to escalate or raise queries with consultants, leaving us uncertain as to whether concerns had reached the right ears and whether the information coming back was reliable. In an increasingly litigious medical environment this created considerable unease.

Establishing and supporting flat hierarchies is therefore essential. This means challenging the increasing grip of medical tribalism in secondary care, through open and blameless conversation. Overlapping responsibilities and ambiguity around backgrounds, training, and seniority of non-traditional clinical roles are contributing to this confusion, so clarification of roles is urgently needed. Staff occupying these newer roles will need to adapt to different, more collaborative ways of working and recognise that age and previous experience in other clinical roles aren’t necessarily tools for exercising authority.

Working openly

Recognition of these challenges by senior doctors is also important. Doctors who are new to wards should be offered accessible senior support, clear escalation pathways, and direct mechanisms of communication with relevant consultants, early into rotations. Not only will this provide a safe and productive clinical environment but it will improve the professional satisfaction of junior doctors, something currently in short supply. In turn, rotating doctors must be proactive in forming these key relationships and must work openly with staff in newer professional roles.

This undoubtedly works both ways, and early career doctors must recognise that longer training at university doesn’t equate to an entitlement to instruct or direct. Doctors would also be remiss not to recognise the expertise and experience of medical associates or take the opportunity to learn from their specialty and wider experience.

The onus is on all clinical professionals to generate and maintain this shared understanding and ensure that clinical teams remain safe and collaborative.