Avoid going to hospital in August. You’ve probably heard this ‘warning’ before, because this is the month when junior doctors start their careers in the NHS and it has raised fears that it’s a dangerous time to be in hospital.
And this was not without foundation. For example, a study carried out in 2009 by Imperial College London showed that the mortality rate of patients admitted to emergency care on the first Wednesday in August (when the new doctors started, and which the media called “Black Wednesday”) was 6% higher than that of those admitted on the last Wednesday in July.
In fact, it is much safer today. The biggest risk, in my opinion, is posed by another group of medical professionals: junior doctors.
Despite NHS plans to make them more aware, a survey published in the Mail yesterday found that more than half of patients do not know what a “medical assistant” is.
Dr Rob Galloway says some newly qualified doctors are overconfident
But first let’s get back to the new doctors. By the time they arrive at the hospital, they have already undergone 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” license to practice, with a defined scope of what they can and cannot do.
Is the system perfect? Of course not. But having spent the last 13 years training final-year medical students, including their “preparation for practice” course (and then supervising them when they start work), I know what has been done to make this transition as safe as possible.
And one of the reasons that safety has improved is because of how we teach our medical students and new physicians to make clinical decisions and to know the limitations of their skills.
Medical decision-making is complex, but can basically be divided into quick, intuitive decisions (‘this patient needs CPR now’) and slow, thoughtful decisions (‘this patient needs blood tests, exams, scans, and a review of their medical history’).
But doctors, especially new graduates, do not know the answers to all the questions they are asked.
This is fine, as long as they know it and don’t try to pretend that they know it, which we call “conscious incompetence.”
As an emergency consultant, I see many patients with complex problems that are not covered by my expertise, but I am trained to recognise them and feel comfortable seeking help from experts in the relevant field.
The real risk is doctors who treat patients without realizing that they don’t have all the answers: they make decisions with a confidence that belies their level of knowledge and experience, known as unconscious incompetence.
He says hospitals should foster a culture where young doctors feel empowered to ask for help.
This is not deliberate arrogance, but overconfidence due to lack of experience. As Shakespeare said: “A fool thinks he is wise, but a wise man knows he is a fool.”
We reduce unconscious incompetence in medicine through education and by establishing a culture in which young doctors feel empowered to ask for help so they are not forced to make decisions that are beyond their level of competence. And we need support structures around them.
When I was a resident physician 22 years ago, I worked only night shifts and my lack of supervision led me to make mistakes. I live with some of them to this day, including the case of a 50-year-old man with poorly controlled diabetes.
He had a chest infection that had caused diabetic ketoacidosis, which meant he was very dehydrated. I thought I knew best how to treat him.
But despite having studied medicine for six years and working as a doctor for two, I didn’t have the experience to treat him properly or to realize that he was beyond my reach.
I gave him fluids and then when he didn’t get better as fast as I thought he would, I gave him more, and then more.
I gave him too many fluids and it caused him to go into heart failure; he died a few days later in intensive care. His death certificate listed sepsis, diabetes and heart failure, but I know that behind all of those causes was my unconscious incompetence.
Now, at night, in my department, in addition to four junior doctors, a mid-level doctor and an emergency consultant work alongside them to provide support and direct supervision.
But the main reason I think 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, meaning nurses know they cannot be asked to make specific decisions, such as whether a patient should be resuscitated in an emergency.
This is why medical errors are now much more common among doctors who have been working for a couple of years than among new, young doctors.
However, while we have been improving patient safety among new doctors, there is another group of staff that I am increasingly concerned about. Physician associates (PAs) have been working in the NHS for more than 20 years, recruited to help relieve some of the administrative and routine tasks of doctors.
However, over the years their role has changed and they are now used to fill the gaps left by the lack of general practitioners and young doctors, carrying out entire practices on their own.
This is unfair to the PAs themselves and puts patients at risk.
In 2022, Emily Chesterton, a 30-year-old actress, died after a GP misdiagnosed her with anxiety – she had a blood clot in her lung.
A blood clot is not uncommon, but detecting it is not easy. That is why, in addition to a medical degree, there is a minimum of five years of training to become a general practitioner.
This extensive training is designed to train unconscious incompetence and knowing when to ask for help.
Those who control the money have been using physician associates as a cheaper way to provide medical care.
But Emily was not treated by a family doctor, as she thought, but by a junior doctor.
They only have two years of training after a non-medical degree and can start working in a GP surgery, seeing patients without the need for further training.
This new model of healthcare has been introduced into the NHS more by accident than design, with medical leaders (some of the Royal Colleges, GMC and NHS England) promoting the role without regulations on what PAs can and cannot do and the levels of supervision required.
The family practice that employed the associate physician in the Emily Chesterton case did not break any rules, because there were no rules.
Without fully understanding the risks, those who control the money, such as medical practice owners and hospital administrators, have been using PAs as a cheaper way to deliver care and fill gaps.
They have even been given incentives to do so by the Additional Functions Reimbursement Scheme (which ended on 2 August). This funding could be used to hire medical assistants, but not GPs (the professionals patients actually want to see!).
While I am not against the idea of physician assistants, we need them to work as they were originally intended: registered with a non-medical regulatory body, with a defined set of skills and performing specific care with protocols, under the supervision of a senior physician.
However, from December they will be regulated by the GMC, adding to the confusion that they are in fact a type of doctor.
It’s not the junior doctors or Black Wednesdays that cause real anxiety, but the departure of unregulated associate doctors who look after you.
And unless there is an urgent rethink, what seemed like a good idea to improve care will end up doing exactly the opposite.
@drrobgallowaand
