Shakespeare, Macbeth, Act 5, Scene 5; ‘The fool doth think he is wise, but the wise man knows himself to be a fool.’ Medically in the past, I have been a fool; I was overconfident and didn’t realise when I was out of my depth. Worse than being a fool, I was a fool who thought himself to be wise. In the last few years I have reflected on this and have come to realise realising that I went through a stage of my career when I was unconsciously incompetent (I didn’t know what I didn’t know) and patients came to harm because of this. They deserved better and I have spent a number of years running courses on how we need to make medical decision making safer. Its about education, supervision and appropriate regulation so that those with the insight needed to be consciously incompetent (know what they don’t know) are the ones who make clinical decisions. That’s why doctors who have been working for 2-3 years are at much higher risk of making mistakes than brand new F1s. Its also why I have concerns about Physician Associates working in roles where they are making complex decisions with limited training and without adequate regulation and supervision. Im not against the concept of physician associates. But it needs to be in defined roles following protocolised medical care to improve overall care rather than what is often happening of plugging gaps in medical rotas and covering for a lack of fully qualified GPs. Unless there’s an urgent rethink, what seemed like a good idea to improve care, could end up doing the exact opposite. In today’s health section of the mail I explain my thinking behind this and what is needed to ensure patients are treated as safely as possible. dailymail.co.uk/health/article… For those who cant access the article, the words are below: Avoid going to hospital in August – chances are you’ve heard this ‘warning’ before, because this is the month when junior doctors start their NHS career, and it’s led to a fear that it’s a dangerous time to be in hospital. And this was not without basis. For instance, a study published in 2009 by Imperial College showed that the death rate for patients admitted as an emergency on the first Wednesday in August (when the new doctors started, dubbed ‘Black Wednesday’ in the media) was 6 per cent higher than those admitted on the last Wednesday in July. In fact these days it is genuinely much safer and the greater risk, in my view, is another group of medical professionals: physician associates. But first back to the new doctors; by the time they reach the hospital floor they’ve already had years of training and passed multiple difficult exams. And when they start, they have close supervision by more senior doctors and, crucially, they have a ‘provisional’ licence to practise, with a defined scope of what they can and can’t do. For example, only a more senior doctor can decide to discharge a patient. Is the system perfect? – of course not. But having spent the last 13 years involved in the final year of training medical students, including their ‘preparation for practice’ course and then supervising them when they start working with us, I know what’s gone into making this transition as safe as possible. And one of the reasons safety has improved is because of how we teach our final-year medical students and new doctors to make clinical decisions and crucially to know the limitations of their skills. Medical decision making is incredibly complex but can basically be split into fast and intuitive decisions (this patient needs CPR now) to slow and thoughtful (this patient needs blood tests, full examination, scans and review of their complex medical history). But doctors, especially newly qualified ones, don’t know the answers to all the things they’re asked about. This is fine - as long as they know that and don’t try to pretend they do, which we call ‘conscious incompetence’. As an A&E consultant, I see lots of patients with complex problems that my expertise doesn’t cover. But I am trained to recognise that, and to feel comfortable asking for help from experts in their field. The real risk is clinicians who treat patients without realising that they don’t have all the answers: they make decisions with a confidence that belies their level of knowledge and expertise, or unconscious incompetence. It’s not a deliberate arrogance, but an overconfidence from lack of experience. As Shakespeare put it: ‘The fool doth think he is wise, but the wise man knows himself to be a fool.’ We reduce unconscious incompetence in medicine by training, and establishing a culture where every junior doctors feels able to ask for help so they’re not forced into making decisions above their level of competence. And we need support structures around them - when I was a very junior doctor 22 years ago, I was on my own on night shifts and my lack of supervision meant I made mistakes. I live with some of these to this day, including a man in his 50s with poorly controlled diabetes. He had a chest infection, which had led to diabetic ketoacidosis - which meant he was incredibly dehydrated. I thought I knew best how to treat him. But despite six years at medical school and two as a doctor, I didn’t have the experience either to treat him correctly - or to realise I was out of my depth. I gave him fluids and then, as he didn’t get better as quickly as I thought he would, I gave him more, then more. I gave him too much fluid and sent him into heart failure; he died a few days later in intensive care. His death certificate stated sepsis, diabetes and heart failure. But I know underlying all those causes was my unconscious incompetence. Now at night in my department, as well as four junior doctors, working alongside them is a middle grade doctor and a consultant A&E doctor for support and direct supervision. But the main reason I believe the new doctors are safer is because of the rules and regulations introduced by the General Medical Council (GMC) in 2005. For example, newly-qualified doctors are now only provisionally registered, which means nurses know that they can’t ask them to make specific decisions, such as if a patient is to be resuscitated in an emergency. This is why medical mistakes are now much more common with doctors who’ve been working for a couple of years rather than new junior doctors. Yet while we’ve been improving patient safety when it comes to new doctors, there’s another group of staff I’m increasingly anxious about. Physician associates have been working in the NHS for over 20 years, brought in to help relieve some of the administrative and routine tasks from doctors. Over the years though, their role has morphed and they’re now being used to plug the gaps left by the lack of GPs and junior doctors - conducting entire appointments on their own. This is unfair on the physician associates themselves and is putting patients at risk. In October 2022, Emily Chesterton, a 30-year-old actress, died after being misdiagnosed at a GP surgery with anxiety: she had a blood clot on her lung. A blood clot is not uncommon but spotting it isn’t easy and that’s why, as well as medical school training, there is a minimum of five years training to become a GP – extensive training designed to train out unconscious incompetence and to know when to ask for help. But the clinician who saw Emily was not a GP, as she thought, but a physician associate. They have just two years training after a non-medical degree and can start working in a GP surgery seeing patients with no additional training. This new model of medical care has crept into the NHS more by accident than design, with medical leadership (some of the Royal Colleges, the GMC and NHS England) promoting the role without regulations for what the physician associates can and can’t do and the levels of supervision needed. The GP surgery that employed the physician associate in Emily Chesterton’s case didn’t break any rules – because there were no rules in place. Without fully understanding the risks, those who hold the financial purse strings such as GP practice owners and hospital managers, have been using physician associates as a cheaper way of providing medical care and to plug gaps. They’ve even been incentivised to do this, thanks to the additional roles reimbursement scheme (it ended on August 2nd): this funding could be used to employ physician associates but not GPs (the professionals patients actually want to see)! I’m not against the idea of physician associates but we need them to work as originally intended - registered with a non-medical regulatory body, with a defined set of skills and undertaking specific care with protocols, under the supervision of a senior doctor (eg, managing routine diabetic or asthma clinics at a GP surgery.) Yet from next December they will be regulated by the GMC, adding to the confusion that they are in fact a type of doctor. It’s not newbie medics and Black Wednesdays that’s the real anxiety for all of us, it’s the march of unregulated physician associates looking after you. And unless there’s an urgent rethink, what seemed like a good idea to improve care will end up doing the exact opposite.
