PI Brief Update

The Problem with Poor Quality Professionals - Dr Mark Burgin

12/02/25. Dr Mark Burgin asks if allied health professionals such as PAs are the solution to falling standards or the sign that doctors have no place in the future of medicine.

Professionals can provide poor quality service for a number of reasons many professionals are unwell, burned out and have low motivation. Another problem is that because professions are broad the professional may have a knowledge gap. Missing important steps such as recording the consultation can lead to missed diagnoses.

Historically there was a large gap between the knowledge of the professional and the ordinary person however with availability of access on the internet this is narrowing. Although professionals have access to the new technologies in practice they use old fashioned approaches. Studies have shown that doctor’s performance does not improve with use of AI even if the AI has the right answer.

In medicine much of the work of the doctor is being taken by other professional groups such as nurses, pharmacists, physiotherapists and significantly physician associates PA. The quality of their work is rarely of the highest quality but usually indistinguishable from that of the doctors. This has created an existential crisis in the medical profession as they have lost their uniqueness.

Bolam

The basis of the professional person’s test is that however poorly a professional performs as long as there are other professionals of the same standard they have not breached their duty of care. The test is based upon the expectation of a small part of the professional group not the profession as a whole and certainly not the expectation of the patients.

It is possible now for a group of physician associates PA to have higher standards than the doctors they are replacing. Whilst this problem has always been present for instance a specialist who knows less about their subject than a GP the PA is not even a doctor. Patients may prefer to see PAs if there is an expectation that the standard of care is higher than a doctors.

It would not help the doctors to argue that generally care from doctors is better if when tested in a clinical negligence court they argue that poor quality care was acceptable. PAs are a special threat to doctors because the area of practice overlaps. Whereas a pharmacist can only deal with medication, physio with MSK problems the PA can deal with any medical problems.

Only 1% of medical errors reach a clinical negligence claim and less than half of those succeed. Examples of failures were a patient with 20 times increased risk of heart attack who was given no preventative treatment, patients with cancer symptoms that were not investigated and supervisors who did not notice red flags. In each of these cases Bolam was successfully employed to argue that a reasonable body of doctors would do the same.

Professional standards

The GMC in 2024 has rewritten good medical practice and it is clearer that professional standards are a decreasing focus. The four areas have equal weight and only one ‘Knowledge, skills and development’ is about standard of practice. The others are focus on relationships and behaviour which whilst important cannot replace good quality medicine.

The GMC argues that many of the problems occur because professionals behave badly and fight with each other. This ignores the fact that a doctor who is no good at their job is a liability that no amount of teamwork can fix. The GMC occasionally tests the professional knowledge and finds about 30% of doctor have inadequate knowledge (compare this with 15% in USA which arguably has higher standards).

Several professional leaders have argued that knowledge is not important for a senior doctor apparently scared that they might face routine knowledge testing. Clinical skills are important but cannot replace knowledge when making diagnoses. If there is no system for ensuring that professional standards remain high then some doctors will not keep up to date.

Exceptional PAs

The physician associate training is different to that of a doctor, they study to degree level then spend 2 years learning medicine. What they lose in breadth they gain in relevance to their future job role. Many highly skilled people choose not to become doctors because they consider the medical training to be archaic and irrelevant. When they study as a PA their progress is rapid and impressive.

Not all PAs (or doctors) are of high standard and there are many in both professions who are below average. Doctors are concerned that there appears to be little to distinguish the best of the PAs and the best of doctors. It has been suggested that PAs become apprentice doctors to assimilate PA’s distinctiveness into the medical profession.

This suggestion has two important implications for doctors, first that PAs expertise should be respected and second that PAs will need to be allowed to become leaders.

Conclusions

The leaders of medical professional bodies continue to state that there is not a problem with professional standards and resist testing. They explain the enquiry findings into scandals as one-off events or ‘lessons learned’ rather than accepting that problems are endemic. They accept that shortages of GPs exist but deny that they are having impacts on the rest of the health service. Professional standards are increasingly out of step with expectations of everybody but doctors.

PAs have become the bête noire blamed because the doctors are trapped between arguing that low standards are acceptable and that their standards are higher than PAs. The public is told that doctors are better than PAs however this does not align with their experience. A highly skilled PA may appear to have advantages over a burned-out doctor for many people.

Lawyers face the same issues with both paralegals doing much of their work often to a high standard and AI. Part 35 questions that fail to address the material issues, do not comply with CPR35 and are hostile in tone reflects worse on the solicitor than the paralegal. A doctor who cannot diagnose a patient or a solicitor who cannot write a document have no value in the coming world.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is a Disability Analyst and is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 websites drmarkburgin.co.uk and gecko-alligator-babx.squarespace.com

Disability Analysis: A Practical Guide by Mark Burgin | 18 Oct 2024

This is part of a series of articles by Dr. Mark Burgin. The opinions expressed in this article are the author's own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand.

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