Spotlight series – physician associate in leadership
Physician associate (PA) Mathilde Richou, qualified from St George’s University of London in 2018. Immediately after qualifying, Mathilde began working in the emergency department (ED) at St George’s University Hospitals NHS Foundation Trust. Four years on, she is the department’s lead PA managing a team of six PAs, and is the PA representative on the Royal College of Physicians Patient Safety Committee. This is her story so far.
What made you decide to become a PA?
Initially, during school I was good at sports, and I was focused on a career in musculoskeletal health rehabilitation. I completed an undergraduate and master’s degree in osteopathic medicine. Following qualification, I opened my own practice in India and I worked there for 3 years. During the process, I began to realise that I had a much stronger interest in the broader spectrum of healthcare – not just musculoskeletal health. The desire to want more remained with me, and in 2010, I met an American physician assistant in Haiti while I was on a global health mission following the earthquake. She explained her role in the USA to me, and I felt it could be a good fit. The thought of being able to practise with generalist knowledge, and the diversity of the role, really appealed to me.
After I did some research and found the role was active in the UK, I went for it and secured my place at St George’s. I can get bored easily, but the PA role stood out to me as I knew I would be able to switch between specialties. At the time, the role was still very new in the UK, and I did have some concerns about how challenging it would be to integrate it into the NHS system. On the flip side, being able to step up and contribute to such a new profession in the UK seemed like a pioneering and interesting challenge.
Can you tell us more about your experience of working as a PA in emergency care leadership?
When I qualified as a PA, I initially wanted to work in intensive care (ITU). While I was researching, I came across my role at St George’s in the emergency department. It appealed to me greatly that St George’s is a trauma centre, and I knew I would learn a lot. When I joined, I was part of a three-PA cohort, and we were there as part of a pilot PA programme. Looking back, I thought I would spend a couple of years building up my skills and then move into ITU, but I quickly realised that emergency care as a specialty suited me. The department is fast paced, challenging, and enables us to initiate the first diagnosis for a patient. Every day we treat and care for a wide variety of patients. The PA role is well suited to the specialty, providing us with a lot of autonomy once we’re skilled up, and making the most of our generalist training.
Over time our PA team has grown, and currently, we’re a team of seven. Gradually, as the team expanded, I was foreseeing potential issues such as structure for PAs, service provision and career progression. There were some concerns within the PA team, and I understood that we required leadership. Our role as PAs is different from doctors, and our senior management team needed to understand that.
Over time, I advocated for this, and after approaching our clinical director, the leadership vacancy became open. I’ve been in my role as lead PA in the emergency department for a year now. I work 70% clinical and 30% non-clinical. In the beginning it was challenging, leading my peers and instigating a new role. However, I thrive on new experiences and using my creative thinking to help support and progress my team. Overall, I bridge the gap between the PA team and our seniors, and the role has forced me to think outside the box and see the bigger picture of our NHS.
What diagnostic/investigation/procedural skills have you gained?
Before I moved into my leadership role, I had worked in the ED for over 3 years. Here, I had spent time developing my clinical skills and gaining additional expertise by passing the advanced life support course and the paediatric advanced life support course. Before becoming the lead PA, I concentrated on learning new procedural skills such as arterial lines, chest drains, fascia iliaca blocks, fracture manipulation and improving my ultrasound skills. This enables me to feel confident when assisting doctors, but also when demonstrating such procedures to my PA colleagues or students. One of my aims as lead PA is to ensure that my team is proficient in all ED procedures. It is important to me that they can develop and gain confidence. When an opportunity arises for a PA colleague to perform such procedures, I wish for them to take the lead, and I’m here to offer full support if I can. We have PAs who have been qualified for 4 years and some who have been qualified for 2 years. Therefore, if there is an opportunity for a colleague to perform a procedure, but they aren’t present, I will actively find them and offer them the chance to do so.
That is one of the key areas where my personal leadership skills have developed. I’m focused on developing my team so that we have equal opportunities to extend our skills but, in turn, that everyone in my team continues to progress in their careers in the way they wish. My lead PA role has also enabled me to become a better listener. I think there is a perception that when entering this form of role, you are expected to know the needs and wants of everyone. It isn’t until you’re actively managing the process that you come to understand what will motivate them, what they personally want to learn and how they want to progress. All of which are vital components when ensuring your team is happy.
How would you describe the impact your role as a PA has had?
When I approach this, I speak on behalf of my entire team of PAs, who are amazing at what they do. Overall, the impact of the introduction of PAs into the ED has been hugely positive. Due to the generalist nature of our role and within our team, we can regularly rotate throughout the department. For us, this covers the resuscitation room, adult majors, adult minor injuries and the paediatric ED. Having PAs consistently available within the department and on rotation in these areas proves highly beneficial for our seniors and patients. On average, our PA team treats around 8,000 patients per year within the ED. We also get to know patients who have complex care and tend to re-attend the department, which benefits them given we understand their care plans. For many patients, being in the ED is one of the scariest moments of their lives; if they can see a familiar face and hear a familiar voice, it really helps them to feel that little bit more at ease.
We’re there as support for junior doctors too, and during the rotational period to maintain the level of care. We’re able to support and guide juniors thanks to our institutional memory and knowledge of trust protocols and pathways. We can also support them in the learning of procedures in which they may not be confident. From a leadership point of view, currently, I’m working towards advocating for my team and making this ED a sustainable working environment for PAs. This means looking into their work-life balance so that they don’t burn out and enabling them to maintain other clinical activities and interests to keep them engaged and fulfilled. As part of my commitment to ensuring my team is up-skilled, I also arrange weekly mandatory training sessions for them. Everyone has different scopes of practice coming from varied backgrounds, and the teaching is tailored to their needs, which benefits the wider team and department. Recently I have also managed to start self-rostering for the team and increase their non-clinical time and study leave by 50%.
What do you find most enjoyable and rewarding about being a PA?
Ultimately, I entered the medical field because I wanted to help people. Working in the ED allows me to be on a patient's journey from the beginning. I see them when they are admitted and support them during the initial diagnostic and investigation stages, through to the acute management of their care. I enjoy feeling like a detective, figuring out what the problem is and how I can better it. I also find it rewarding when you can quickly treat an acute problem, especially coming from a background in musculoskeletal health, where the process of bettering a patient can be slow. For some patients, it is a matter of a couple of hours, and they will be walking out the door thanks to your treatment, while others will need further definitive treatment. The choices I make in those initial hours can make a big difference in the prognosis of some patients.
You don’t know who is going to come through the door and need to be prepared for anything. The communication and human aspect can be challenging and fulfilling too. We’re there sharing intense moments with strangers from all walks of life who are likely very stressed. For some patients, their trust is present in you the moment they walk through the door, but for others, you will need to gain their trust or even de-escalate a heated situation. Finally, the other aspect I enjoy is the opportunity to continue learning. There is never a time as a PA that you think ‘I’ve maxed out in terms of my knowledge’ – there are always ways to continue learning and improving your skills.
What challenges do you face as a PA working in leadership?
Currently, there aren’t many PAs working in leadership roles. Although it is great to see more of us stepping into this area, it is still a new role, and it can be challenging to step into such a novel place in a well-established structure. Again, there aren’t many governance policies in place for PAs currently, which means it can be challenging to change things for the better. Thankfully, I’m lucky to be helped by a team of seniors who support me and my PA team, who are amazing clinicians. This helps make my role enjoyable even within a high-stress environment. I also worry about the PA role becoming used for service provision. Within the ED, you need large teams to help it function smoothly, and I worry that PAs will get lost within such a large group of clinicians. We must remain on our path, and have career progression opportunities available to us. I would hope that once we become a regulated profession, this will change for the better.
The lack of prescribing rights does prove difficult. As a specialty, emergency care relies on timely treatment, and this can be delayed at times due to prescribing having to be relayed to our seniors. I am hopeful that once regulation is confirmed, this will also change for the better.
What does the future look like for you as a PA?
I thoroughly enjoy procedures, and it is my ambition to build on my scope of practice and gain independence in my clinical decision making process and in performing multiple procedures. I will become fully confident in my ability and only call on my seniors when I need them in all areas of the department. This would also help me to maintain and grow my leadership skills when training potential new PAs entering the team. My long-term aim would be to combine my main three interests: emergency medicine, leadership and global health. Once I have become a competent clinician, I would like to move into studying with a focus on global health. From there, I would like to be one of the pioneering PAs working for a non-profit organisation as a medical project manager in response to an acute health crisis. Currently, I am working with a team on a project whereby we’re creating a training programme for Zambian doctors, nurses and midwives, which aims to reduce neonatal and maternal deaths over the next 3 years. It’s a main personal interest of mine, and my role in PA leadership has enabled me to have access to this form of opportunity.
What advice would you give to a PA looking to work in emergency care or leadership?
Working in the ED is fast paced, and it’s important to know what to expect before you commit. The PA course offers a 6-week placement, and I would advise maximising the time you have there and the people you meet. Ask as many questions as possible – you must understand if the role and what it entails is for you. Ask about shift patterns and see the department at different times of the day so you understand how it feels when it’s busy and what you can expect. Understand your internal physical clock and reflect on whether working shifts is going to work for you. You have a full multidisciplinary team at your disposal – ask doctors, nurses and PAs what their experiences are like so you can build a solid knowledge of what to expect. When entering a leadership role, I would advise you to be curious and make yourself as aware as possible. Maintain knowledge of what is happening within the profession. Stay up to date with the FPA, the General Medical Council and other policies from NHS trusts. Being aware of what is happening in the profession can give you a lot to think about. Once you have the knowledge base to build upon, don’t be afraid to try new ways of doing things, or to approach your seniors with ideas. Be bold – if you don’t try, you don’t get.
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