Avoid hospital stays in August You’ve probably heard this ‘warning’ before, as this is the month when junior doctors start their careers in the NHS and there are fears that it’s a dangerous time for hospital stays.
And this assumption was not unfounded. For example, a 2009 study by Imperial College London showed that the death rate of patients admitted as emergency patients on the first Wednesday in August (the day the new doctors started their service and which was dubbed “Black Wednesday” in the media) was 6 percent higher than that of patients admitted on the last Wednesday in July.
In fact, it is much safer these days. The greater risk, in my opinion, lies with another group of healthcare professionals: physician assistants.
Despite NHS plans to give them more care, a survey published in yesterday’s Mail found that more than half of patients do not know what a ‘Physician Assistant’ is.
Dr Rob Galloway says some newly qualified doctors are overconfident
But first, back to the new doctors. When they arrive at the station, they have already completed years of training and passed numerous difficult exams.
At the beginning, they are closely supervised by more experienced doctors and – crucially – have a ‘provisional’ professional licence with precisely defined powers and prohibitions.
Is the system perfect? Of course not. But having spent the last 13 years training final-year medical students, including their Pre-Practice course, and then mentoring them as they enter the workforce, I know what it takes to make that transition as safe as possible.
One of the reasons for improving safety is the way we teach our medical students and new physicians to make clinical decisions and know the limits of their abilities.
Decision-making in medicine is complex, but can be broadly divided into quick and intuitive decisions (“this patient needs CPR now”) or slow and deliberate decisions (“this patient needs blood tests, tests, scans, and a review of his medical history”).
But doctors, especially young doctors, do not know the answer to all questions.
That’s fine, as long as they know that and don’t try to pretend they know, which we call “conscious incompetence.”
As an emergency room physician, I see many patients with complex problems that are outside my area of expertise, but I am trained to recognize this and feel comfortable asking for help from experts in the field.
The real risk is that doctors treat their patients without realizing that they don’t know all the answers, and they make decisions with a confidence that is at odds with their level of knowledge and expertise – also known as unconscious incompetence.
He says hospitals should have a culture where young doctors feel able to ask for help
This is not deliberate arrogance, but overconfidence due to a lack of experience. As Shakespeare put it, “The fool thinks he is wise, but the wise man knows he is a fool.”
We reduce unconscious incompetence in medicine through training and by creating a culture where young doctors feel able to ask for help so they are not forced to make decisions that are beyond their competence. And we need supportive structures around them.
When I was a resident 22 years ago, I was on my own on the night shift and made mistakes due to a lack of supervision. I still live with some of those mistakes today, including the case of a man in his 50s with poorly controlled diabetes.
He had an infection in his lungs that had led to diabetic ketoacidosis, which meant he was severely dehydrated. I thought I knew best how to treat him.
But despite six years of medical study and two years as a doctor, I had neither the experience to treat him properly nor to realize that I was overwhelmed by my situation.
I gave him fluids and when he didn’t get better as quickly as I thought, I gave him more and then more.
I gave him too much fluid and he went into cardiac arrest. He died a few days later in intensive care. His death certificate said sepsis, diabetes and cardiac arrest. But I know that all of these causes were due to my unconscious incompetence.
In my department, in addition to four junior doctors, a mid-level doctor and an emergency room specialist work at night to provide support and direct supervision.
The main reason I believe new doctors are safer is because of the rules and regulations introduced by the General Medical Council (GMC) in 2005.
For example, newly trained doctors are only provisionally licensed and cannot be required to make specific decisions as nursing professionals, such as whether a patient needs to be resuscitated in an emergency.
This is why treatment errors today occur much more frequently among doctors who have already been working in practice for several years than among young assistant doctors.
But as we improve patient safety for new doctors, there is another group of staff that I am increasingly concerned about: Physician Associates (PAs), who have worked in the NHS for over 20 years. They were hired to take on some of the administrative and routine tasks that doctors need.
However, over the years their role has changed and they are now used to fill the gaps created by the shortage of general practitioners and junior doctors by conducting entire consultations independently.
This is unfair to PAs and puts patients at risk.
In 2022, 30-year-old actress Emily Chesterton died after being diagnosed with anxiety at the doctor’s office: she had a blood clot in her lungs.
A blood clot is not unusual, but it is not easy to detect. That is why training to become a general practitioner includes at least five years of training in addition to medical school.
The aim of this comprehensive training is to uncover unconscious incompetence and recognize when to ask for help.
Those who have financial control use physician assistants as a more cost-effective way to provide medical care.
But Emily was not examined by a general practitioner as she thought, but by a physician’s assistant.
After completing a non-medical degree, they only complete two years of further training and can then start treating patients in a general practice without any additional training.
This new model of medical care has crept into the NHS more by accident than by design. The medical leadership (some of the Royal Colleges, GMC and NHS England) promoted this role without regulating what PAs can and cannot do, or what level of oversight is required.
The primary care practice where the physician assistant in the Emily Chesterton case worked did not violate any regulations – because there were no regulations.
Without realizing the risks, those with the financial means, such as primary care practice owners and hospital managers, are using PAs as a more cost-effective way to provide care and fill gaps in care.
They have even been encouraged to do so thanks to the Additional Roles Reimbursement Scheme (which ended on 2 August). These funds could be used to employ PAs, but not GPs (the professionals that patients actually want to see!).
While I have nothing against the idea of physician assistants, they must be able to work for the original intent – which is to be registered with a non-medical regulatory body, have a defined set of skills, and perform specific treatments according to protocol under the supervision of a senior physician.
However, from December they will be regulated by the GMC, adding to the confusion as to whether they are actually a type of doctor.
It is not the young physicians and the “Black Wednesdays” that cause the real concern, but the influx of unregulated physician assistants to take care of you.
And if we don’t urgently rethink things, the seemingly good idea to improve care will ultimately have the exact opposite effect.
@drrobgallowaj
