Spotlight series – PAs in geriatrics
Geriatric medicine is a healthcare specialty focusing on providing medical care to the older generation. It covers both acute and chronic conditions and encompasses end-of-life care. It is also one of the 50 specialties that physician associates (PAs) continue to enter.
In this spotlight, we hear from Rowan Davies, a PA who has worked in geriatrics for 4 years. Rowan qualified as PA from the University of East Anglia (UEA) in 2018 and currently works at the Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust. He is also one of the first PAs in the UK to obtain a diploma in geriatric medicine from the Royal College of Physicians.
What made you decide to become a PA?
My initial interest dates back to being in school. I always wanted to do something beneficial but found studying quite difficult due to my dyslexia. I didn’t necessarily get the best grades but still went on to do an undergraduate degree in forensic science and neuroscience. There was an opportunity for me to move into medicine, but it didn’t feel like the right time for me at that point in my life due to the cost and length of time it would have taken. From there, I went on to do laboratory work. While I enjoyed it, it was very much a ‘behind the scenes’ role, and I always felt as though I wanted to be in a more patient-focused role and make a difference.
I then began working with Raleigh International on health projects in India. One of the GPs I worked with while out there mentioned the PA role. Having already been thinking about moving towards something that was more patient-focused and having explored becoming a paramedic or moving into therapy, the idea of the role really interested me. The team I was working with in India was really encouraging and gave me confidence that I would be a good fit for the PA role. When I came back from India, I had planned to research the role some more, but, by coincidence, I received a few emails advertising PA jobs. I was lucky to land a place at UEA on a funded course. Fast forward 5 years, and I am still very much enjoying working as a PA.
Can you tell us more about your experience working as a PA in geriatric medicine?
My first placement as a PA student was in geriatrics, and, straight away, I enjoyed working with the older generation. It was a very immersive experience, and the focus was always very much on the patient as well as on the disease. Being able to focus on both aspects was important to me, and I instantly felt a strong drive to do all I could for those patients during their time of need. When I qualified as a PA, the Queen Elizabeth (where I remain today) offered a PA rotation role between four main specialties: cardiology, respiratory medicine, gastroenterology and stroke medicine. Then, in my second year I was due to rotate between two specialties to help narrow down where my main interest was. My first 6 months were in the geriatric ward. From there, I decided not to rotate into any other specialties as I found myself in a very supportive team who were already beginning to think about my development as a clinician.
I was part of the first PA cohort to join the Trust, and it was very much a period of trial and error as not everyone knew exactly what our role was or what we could do. Despite that, the team of consultants and nurses were so welcoming and supportive, which made the transition much easier. I will always remember that in the early days my supervising consultant was committed to my progression and would continually focus on how to integrate me into the department and develop my skills.
I think it’s easy sometimes in medicine to focus solely on the scientific and medical elements, but geriatrics quickly teaches you to remember that there is a human behind it all. Communication becomes such an important element of our practice. I have had a lot of conversations with patients and families about end-of-life and palliative care. Those conversations must be approached in a respectful way, and, with the support of my supervising consultant and wider team, over time I have been able to develop my own personal style of having those important but difficult conversations. I’m pleased to have also had positive feedback from colleagues who have heard the conversations and have said that when the time comes they would like me to have these discussions with their family members.
What diagnostic/investigation/procedural skills have you gained?
Just over a year ago, the department began running a frailty in-reach programme for geriatric patients being admitted to the acute medical floor. I have built great working relationships with my supervising consultants, and they have a large amount of trust in my skills and ability. If the patient has been post-taken already, I’m able to assess and form their treatment plan and see them through to discharge. I’m also supported by and work with a nurse consultant who specialises in frailty medicine. This is a fantastic experience as I get to be part of the full patient journey.
Working in geriatrics means we see a lot of trips and falls. While I’m not able to request X-rays currently, I do interpret many of them, including hip, ankle and knee fracture X-rays, to help with the diagnosis and treatment plan. CT head scans are also common, and I’m confident in reviewing those, which I’m happy about.
A large part of working in geriatrics is about evaluating the outcome before you go ahead and decide to perform a procedure. Due to the frailty of geriatric patients, they are more at risk during invasive procedures. When a patient presents with a GI bleed, for example, I know what investigations and procedures need to be carried out, but it’s about evaluating if a patient in their 90s is going to survive the procedure, or if it would do more harm than good to the patient’s long-term health and outcome.
Similarly, I have thoroughly developed my understanding of medication use in geriatric patients, which is vital. There are a number of medications that are more problematic for geriatric patients than for younger patients. This can be due to physiological changes with age or due to the fact that they are more likely to be taking other medicines already. Polypharmacy can contribute to acute issues for these patients, which can have adverse outcomes for the person’s overall health. Understanding this fact is key to developing a patient’s treatment plan. Over time, my skills in this area have evolved along with my understanding of the types of scenario where certain medications will be more suitable than others.
How would you describe the impact your role as a PA has had?
As a PA, I’m a permanent fixture on the geriatric ward and able to provide continuity of care. I’m proud that I can deliver this as it’s such a beneficial factor in geriatric medicine. Many patients are physically unable to keep their families updated on their conditions, and I see them every day through the highs and the lows. Being so present means I’m able to interact with them and their families regularly. Being able to help a family understand what is happening and feel more at ease when their loved one is in our care is a priority.
I’ve recently become the senior PA within the Trust too. Part of my role involves mentoring PA students on placements. I’m in the process of creating a programme that will help to push them out of their comfort zones and give them a great experience while they are with us. We have had a lot of positive feedback so far, and I’m looking forward to slowly building up this programme. I’m also enjoying supporting and training our junior PAs. For example, I’m confident in my own ability to place long lines and ascitic drains, and I’m working on arranging teaching to allow our junior PAs to become confident. Both procedures are always in high demand and having a wider pool of PAs able to perform them will mean more timely care for patients.
I’ve also been involved in the management of ensuring all PAs within the Trust can order all investigations that sit within our remit. It was a long process and one that will now benefit us across multiple departments, aiding with speeding up patient discharges – ultimately positively impacting the Trust. Alongside this I am often involved in discussions with members of the management of the Trust to help promote the evolution of the PA role within the hospital, and I endeavour to champion PA interests for the future. I feel lucky to have been allowed to become senior PA, and it’s fantastic to see the growth of our role in the Trust.
What do you find most enjoyable and rewarding about being a PA?
Being able to be there and to help care for elderly patients at what could be the latter stages of their lives is difficult but an extremely rewarding process. I’ve witnessed occasions when families haven’t been given the right amount of information or the information they did receive was poorly communicated, which leaves them feeling anxious about what will happen to their loved ones. I touched on this earlier, but communication in geriatrics cannot be underestimated. I always ensure I take the time to speak with families and explain in detail the treatment plan and associated outcomes. Being able to help manage their anxieties during what is already a very difficult time for them is very gratifying.
I also enjoy the variety of my role. I’m able to be present on the wards to treat and support patients but also able to mentor PA students, medical students, junior PAs and doctors, which brings a whole new dynamic to my job. Being able to see the outcome of all the hard work and commitment that I have put in over the years really keeps me going. I was delighted this year to also become one of the UK’s first PAs to obtain a diploma in geriatric medicine from the RCP. It enabled me to build on my knowledge and skillset while also being recgonised for what I had already achieved in the specialty. It was a good opportunity to focus on areas of geriatric medicine I knew surface information about but had never had the time to dive deeper into. This new understanding has allowed me to approach complex conditions with more confidence. The practical element of the diploma provided me with external reassurance that my communication style and approach to the conversations that we often come across within geriatric medicine were well structured and deemed suitable for one who works within this field of medicine.
What challenges do you face as a PA working in geriatric medicine?
One of the biggest, most obvious challenges is being unable to request non-ionising imaging. I can interpret X-rays but personally can’t request them. Being able to would help increase the timeliness of the care I can give to patients and allow me to complete the entire process. Similarly, I’m really looking forward to being able to prescribe when we become a regulated profession. It’s frustrating when I know what medication my patients require, but can’t prescribe it myself. I’m pleased that I have already built up a great bank of knowledge and trained junior PAs and doctors so that when the time comes, I can put my knowledge into practice.
What does the future look like for you as a PA?
The beauty of being a PA is that we can create our future, and there are so many opportunities available to us, which I find exciting. I have an interest in movement disorders, and one of my registrar colleagues, who is training to become a consultant, is considering returning to our Trust and running his own clinics. I hope that if that happens, I will be able to support and get involved in those. I also have an interest in frailty clinics and would like to continue expanding my experience and understanding in that side of medicine, as treating a patient as an outpatient requires a different way of thinking.
From a non-clinical point of view, I thoroughly enjoy PA education and managing the PA student programme at the Trust. Supporting the future of the profession during their time with us is an important task to ensure they have a positive experience and get as much out of their placement as possible. With the nurse educator colleagues at the Trust, we are keen to set up MDT-focused simulation training for nurses, student doctors and student PAs, which will be a fantastic project to be involved with.
I also teach at UEA on the PA course. I’m keen to continue that role and develop more sessions in the future, and I’m often found at Liverpool helping as an examiner for the national PA OSCES. I’m also getting involved in the question writing groups supporting the PA National Examination.
What advice would you give to a PA looking to work in geriatric medicine?
Geriatrics offers high level of interaction with a wide range of professions, such as therapists and community-based teams, which allows you to see a lot of different elements in a patient’s journey. Personally, I have found the specialty of geriatrics to have the most supportive supervising and consultant teams. I always remember a student on placement with us who said that prior to joining the ward, she had never thought about entering geriatrics. After experiencing the level of support and guidance from the entire team that we were able to give her, she is now planning to enter geriatrics upon qualification.
Overall, it is a very rewarding specialty to be a part of. There is a great breadth of clinical medicine, human interaction when you care for patients and support their families, and time to explore other interests as a PA. We are all going to grow old and having the privilege of helping those already there is very rewarding. I would recommend any PA to consider working in geriatric medicine as it provides a supportive environment to learn and develop your skills.
We’re always looking for qualified PAs who are FPA members to share their stories. If you’re interested in sharing yours, get in touch using the contact details below. If you’re thinking of a career as a PA, you can learn more about how to begin your journey here.
Get in touch to share your PA story:
Jenna Donaldson – FPA communications officer