Sophie Reshamwalla

Former NHS, former aid worker. Aiming for Picard, failing as Locutus. The views I share are mine unless they’re crap, in which case they’re someone else’s.

[Rishabh @Rixhabh__]

This guy used AI to put himself in Game of Thrones and fix everything

[Sophie Reshamwalla @Dr_SReshamwalla]

@virginmedia absolutely appalling customer service. Been a customer for years. I have an ongoing complaint with a complaint reference number but nobody at virgin is replying. I’m trying on here to see if there is a human who can respond. Virgin can you respond??

[Doctor X @doctorxisme]

I couldn't hold it in😂😂😂😂

[Nature is Amazing ☘️ @AMAZlNGNATURE]

I AM SO SORRY FOR LAUGHING😭😂

[Munya Chawawa @munyachawawa]

‘Race Race!’ Far-Right Fun for the whole fam! 🤪🎲🏴󠁧󠁢󠁥󠁮󠁧󠁿 #comedy #satire

[Louella Vaughan @DrLKVaughan]

The issue of Scope is a vexed one.

Here are a few thoughts on why the UMAPs scope is so problematic. 🧵

https://t.co/AGqSkUEfBM
1/

[Sophie Reshamwalla @Dr_SReshamwalla]

The BEST thing about the USA…

[BBC News (UK) @BBCNews]

Student creates app to improve care for black babies https://t.co/JYsGokh5aS

[Ben Lovell @DrBenLovell]

A thread about consultants about giving feedback. 🧵

Consultants: Have you ever looked at feedback from rotating doctors - either end of rotation surveys or GMC survey data - that highlight a lack feedback in your department?
And thought ‘but I give feedback all the time?!’ 🤨

[Rob Galloway @DrRobgalloway]

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.

https://t.co/hnQdweHRpG

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.

[Sophie Reshamwalla @Dr_SReshamwalla]

Imagine this being your bio

[Sophie Reshamwalla @Dr_SReshamwalla]

Why is it called menopause instead of menostop? It’s not like it comes back.

[Sophie Reshamwalla @Dr_SReshamwalla]

When did bonjela start costing £6?

[Sophie Reshamwalla @Dr_SReshamwalla]

9. DVLA will send you confirmation of change of address in 2-4 weeks with a small piece of paper. Guard this
10. Address is changed

[Sophie Reshamwalla @Dr_SReshamwalla]

How to change your address with @DVSAgovuk in 3 easy steps:
1. Go back to 1985
2. Find a small slip of paper that was sent to you when you bought the car
3. Find the series of numbers on that piece of paper
4. Produce a small ampoule of blood and your first pair of socks

[Sophie Reshamwalla @Dr_SReshamwalla]

5. Take these items to the post office
6. Fill in an application form and provide details of your birth, educational history and how many rashes you’ve had since birth
7. Post office will give you a small piece of paper. Guard this with your life
8. Pay £25

[Roshana 🦴 @RoshanaMN]

REPEATEDLY told I COULDN’T be a surgeon 🔪⚒️🚫

🚫 I couldn’t do orthopaedics a woman

🚫 I couldn’t do it with a young family

🚫 I couldn’t train ‘part’ time

19 YEARS since starting medical school

I did it all.

My way.

✅Fellow of Royal College of Surgeons

[Dr Phil Hammond 💙 @drphilhammond]

Thank you for asking me this question

I generally refrain from comparing medical scandals because they are all tragedies in their own way.

The Bristol heart scandal arose because the unit had demonstrably worse results for paediatric cardiac surgery than other units, but was telling parents the UK average mortality rates rather than the unit’s actual rates. To compound matters, the problems in Bristol were widely known amongst the profession, the Royal College of Surgeons, the Society of Cardio Thoracic surgeons, the Department of Health specialist commissioning group etc. Everyone knew apart from the parents, until a very brave whistleblower called Steve Bolsin spoke up. The public inquiry, which finished nine years after I broke the story in Private Eye, concluded that around three dozen babies might have survived if they’ve been operated on elsewhere over a set period. Over a longer period, Professor Bolsin puts the number at around 170. The real tragedy of Bristol is that it made 198 recommendations, many of which have been subsequently repeated in all the other health scandal since, most notably the Mid Staffs inquiry and more recently the infected blood inquiry. The UK is a world leader in public inquiries, and then we ignore the findings so we can have another public inquiry.

The physician associate scandal may not progress to a public inquiry because so many people have raised concerns early, both here and elsewhere. Various Royal Colleges and the GMC have egg on their face and are reversing, or may shortly be reversing, their positions. Far more NHS staff are speaking up for patient safety and, with a new government in charge, constructive changes are more likely to happen and people will continue to speak up if they don’t.

There have been some well publicised disasters where PAs have either voluntarily or forcibly been put in positions that were beyond their competence, and serious harm and death has resulted. However, this clearly doesn’t just apply to PAs. In the Bristol Inquiry report, it was estimated that around 25,000 people die every year in the NHS from either substandard care, or failure to access care. More recently we seem to have settled on a number of 11,000 avoidable deaths a year. Only a tiny fraction of these will have anything to do with PAs.

I guess what I’m saying is that we need to look at patient safety in the round, and speak up forcibly about every aspect of it. My big lesson from Bristol was that how you raise concerns matters as much as the concerns you raise. I did it in a very aggressive way, that made people pull up the drawbridge and probably delayed constructive change and adversely affected the mental health of surgeons trying to do the hardest operations on some of the sickest children. There are plenty of competent PAs out there doing their best in very difficult circumstances, and suicide rates are high enough amongst NHS workers without making things worse.

If we see everything through the prism of patient safety, safe staffing and skill mix levels, it gives us something to unite around as healthcare workers. As Steve Bolsin famously said about the Bristol case, “if you want to prevent future scandals, never lose sight of the patient.” And the lesson from Bristol for PAs out there is that you have to be very explicit and honest with patients about who you are and what your levels of expertise are. If you give misinformed consent, there is no defence. And hospitals and professional bodies that misrepresent the expertise of PAs are equally culpable.

Does that answer your question?

[Sophie Reshamwalla @Dr_SReshamwalla]

So envious of Griezman’s hair. So luscious and thick. #EURo2024

[Sophie Reshamwalla @Dr_SReshamwalla]

I’m trying to figure out if they gave rishi sunak a smaller chair so he could mirror the (I assume) taller interviewer’s position? I’m a shortie and there’s no way I’d be able to cross my legs on that chair.