The utilization of physician extenders in the UK healthcare system has been quite controversial recently, with topics like training and validation requirements, impact on training and staffing, all bubbling to the surface. In addition, the lack of funding for physicians and residency slots has contrasted with the increasing spending on physician assistants. Dr. Ramey Assaf, resident and leader within Anesthetists United and Dr. Richard Marks, former Vice President for the Royal College of Anesthetists speak with Dr. Ludwig Lin on this topic.
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Dr Ludwig Lin
Hello and welcome to Vital Times, the California Society of Anesthesiologists podcast series. I am Ludwig Lin. I’m going to do something different today. Instead of discussing the issues relevant to anesthesiology within California and within the United States, I wanted to reach out and talk to some of our British colleagues. Anesthesiologists who are on social media are going to be aware that there’s been a lot of advocacy and conversations in the United Kingdom recently about the future direction of Anaesthetists there, the role of physical extenders such as anesthesiologists.
Dr Ludwig Lin
I’m going to save most of the conversation and the history for the conversation itself, but that is our topic today, British anesthesiology. With me are Dr. Ramey Assaf. He is a clinical and research fellow within anesthesia and intensive care at Guy’s and St. Thomas’s NHS Trust. Remy has a passion for cardiothoracic anesthesia and intensive care medicine. In addition, he has an interest in medical leadership and healthcare politics. As well, Dr. Richard Marks is with us. Dr. Marks trained in the UK and at Duke University Medical Center and now works in London. He was a vice president of the Royal College of Anesthesiologists and has been very concerned about the development of non -doctor associates with the scope creep that we are discussing in the United States as well.
Dr Ludwig Lin
I would like to thank both for being available to discuss all of this and I’m hoping that we can have an exchange of ideas and perhaps learn through our shared histories. Thank you. So to sort of give us the background, I’m going to ask Dr. Richard Marks to explain to us how the anesthesiology world is structured in the UK and talk about the evolution of the practice and to talk about how all of those different factors have occurred to cause so much recent, to be honest, dissension and agitation within the UK anesthesia world.
Dr Ludwig Lin
Dr. Marks?
Dr Richard Marks
Yeah, thanks. It’s quite a complicated question because there’s so much history involved. And perhaps the first thing to say is, in the UK, we have always had anesthesia delivered by doctors. We’ve never had nurses. We’ve never had anyone else giving anesthesia. And we’ve been called Anaesthetists rather than Anesthesiologists, really, because there’s nothing to distinguish us from that there has been no one else. A lot of places in Europe are now moving over to calling the doctors anesthesiologists. Ireland’s just done that. But for us, it’s always been an Anaesthetist. And right back since the inception of the NHS, every anaesthetic was given by a doctor. Now that changed in 2002 when the then Labour government introduced what were then called physicians assistants in anesthesia that were non doctors, that were people who had either got a health service background or had done a science degree, and who went on a two year training course and were then let loose on the anaesthetic room.
Dr Richard Marks
And the original reaction from the College, the Royal College, and also the Association of Anaesthetists was No Way. We’ve got these two groups in the UK. We’ve got the Royal College of Anesthetists and the Association of Anesthetists, and they both have a slightly different remit. The Royal College of Anaesthetists is primarily concerned with setting standards of delivery of care. And the Association of Anesthetists is concerned primarily with the standards for Anesthetists. So they’re slightly different. There’s a big overlap. And with this issue, they both saw very much eye to eye. No Way are we having these people. We’ll have nothing whatsoever to do with them and they will just go away. And maybe that was a naive attitude. But with the passage of time, anesthesia associates got more and more established. In fact, the name changed subtly from physicians assistants to anesthesia associates, which I think is quite significant change.
Dr Richard Marks
And right through 2010, 2015, there was more and more and more recognition that we have to do something about these people. We have have to get a handle on them. And slowly and perhaps belatedly, the the college has started to have some some influence. But the college isn’t really in the driving seat, the the government’s in the driving seat. And being a nationalized NHS with with everything planned and managed centrally, then the government’s been in a position to pour money into developing these associates. The numbers gone up, the the number of trained trainee, the number of associates in training has gone up. And earlier in this year, the the government or the NHS England put out a long term plan for how they’re going to increase numbers.
Dr Richard Marks
One of the things was the number of associates was going to increase by a factor of 10. Now, for a lot of people, we thought of associates as kind of a problem, but small problem really. Suddenly, this is such a big expansion of their numbers that everyone suddenly has got concerned. And we’ve also got concern because we’ve looked at what these people actually do in terms of their day to day work. And what we found is there doesn’t seem to be any rules that they’re trained. They can complete their training. When they’ve completed their training, the rules on scope are entirely undefined.
Dr Ludwig Lin
Just just ask you a quick question, Dr. Marks. Sure. When the anesthesia associates were first established as a job description by the government, was that a unilateral decision? Was there any input from, you know, the medical world?
Dr Richard Marks
Oh yeah, it was very much a unilateral decision and there was some input from the medical world and the input from the medical world is was no way do we want these. And the government decision was, well too bad you’re having them.
Dr Ludwig Lin
I’m sort of be followed by that part in that, obviously anybody who takes care of patients needs to demonstrate a certain level of, you know, competency, proficiency, and some group or organization should be the one that’s responsible for enforcing those standards, right? So, did the government do that? Did they liaison with the medical world to establish those criteria? Can you just explain that part to me?
Dr Richard Marks
Okay, again, it’s a difficult thing to explain because it’s a long story and it’s a long story because there are so many different bodies and institutions that have a little bit of a say. You’ve got the government who’s got the money. So in a sense, they have the biggest say. You’ve got the Royal College of Anaesthetists. The college’s job is to set standards. But the college really works by consensus. It has very little real power and all its power comes from kind of getting a consensus amongst doctors and amongst people from the outside. They, the college are the experts. Then you’ve got the trusts, the NHS trusts or the hospitals who are kind of autonomous in a strange way. So they have a, each of the trusts has a budget. They’re not directly run by the government, but they are indirectly run by the government.
Dr Richard Marks
Then you’ve got the universities. And it was the universities that trained the anesthesia associates and then put them into hospitals. So the Royal College was bypassed. The Royal College had nothing to do with it.
Dr Richard Marks
Now there’s another organization now which didn’t exist in 2002, which is the CQC, the Clinical Quality Commission. And it’s their role to ensure that things that go on in hospitals are done properly, but they weren’t around. So the thing became established essentially by default, that the universities trained them. The government threw money at them. The government is still throwing money at them so that places can take on associates at no cost to the institution, which is a very attractive way of running your service. And the college has been left on the sideline. The last part of the equation is, if you like, the mass of Anaesthetists, just like the rank and file people. And I think one of the things that we’ve seen this summer is a big uprising of the rank and file. And that came to a head in October when the organization that Ramey and I are part of, and the United, convened an emergency meeting of the Royal College of Anaesthetists. Under their rules, there’s possibility to do that, really for something which happens in a crisis situation. And we had 5 ,000 Anaesthetists vote, which is roughly a quarter of the Anesthetists in the country, with a huge mandate to the college to oppose the growth of Associates, to ensure that they’re properly supervised, and to ensure that patients are given proper information about who is actually looking after them.
Dr Ludwig Lin
I did read about that when it was happening. I was stunned that people were so united in having a voice in this. So that was impressive. But I think that also demonstrates the level of passion people have about this and the awareness that this is important.
Dr Richard Marks
Well, it’s a very existential moment for every doctor because you’ve been through your whole life thinking We are doctors with we’re different to other health care professionals That’s not to say that other health care professionals don’t have a big role because because they do they have a huge role I mean, I’d rather that my backache was looked after by a physio than by an orthopedic surgeon any day, and diabetic nurses and mental care nurses and breast care nurses and there’s a huge variety of nurses and other people Who make a fantastic contribution to health care But we’ve always thought that in order to give an anaesthetic you have to be a doctor and And we’ve thought that for various reasons Partly because of the breadth of knowledge that you have to go through to to get to that and Suddenly this rise of these non doctors who are giving anaesthetics is a real existential crisis for all of us You think well, what did I do all that training for what? what did I do those exams and Getting into medical school and racking up that huge debt And as a student and the breadth of training and the variety of training Why did I have to do that? And someone else’s come along that hasn’t done that, and that doesn’t seem right?
Dr Ludwig Lin
Who pays for the anesthesia associates when they practice?
Dr Richard Marks
So that’s a complicated question because the money comes from multiple sources. I mean, ultimately all the money comes from the government because outside the private hospitals, we are a national health service, so it’s all government money. But there’s various different routes that the money can take to get from the taxpayer to the salary. And it’s been deliberately confused so that there are huge subsidies, there are subsidies on training, a lot of the admin is subsidized.Some hospitals are being given Associates, essentially free of charge to get them on so you can get them established.
Dr Ludwig Lin
Well, that’s a that’s a large incentive. Let me ask you one more question. I know that most of the care delivered in the UK for patients is via the National Health Service, the NHS, but that there is a small subset of care that’s being provided through private hospitals, correct? Who are the Anaesthetists delivering anaesthetics in those private practice situations? Is it doctors or is it the combination of doctors and anesthesia associates?
Dr Richard Marks
It’s completely doctors, it’s 100% doctors. The majority of whom are… Do you use the phrase moonlighting?
Dr Ludwig Lin
Yes.
Dr Richard Marks
So the way that NHS contracts are worked out is because people work evenings, and because people work weekends, you often have time during the week to do something else,. Which you can spend on the golf course, or you can spend earning money.
Dr Richard Marks
And that’s where the majority of the anesthesia workload in the private sector comes from. There are some people who have quit the NHS for various reasons, I’m one of them, and work fully privately.
Dr Ludwig Lin
I find that interesting and perhaps instructive in that in these environments where the hospital and the other physicians, such as the procedurists, are the ones choosing who to staff as Anaesthetists that it’s the anesthesiologists who are being given that.
Dr Ludwig Lin
So I find that part interesting, but let’s go on and talk a little bit more about the evolving situation. So it also, so it sounds like the Royal College of Aesthetists has started to step in a little bit more, but how are you guys all negotiating, how to influence the supervision and the training and the certification of anesthesia associates? And what are the current questions and what are some of the future projects you guys are working on?
Dr Ludwig Lin
I think I’m going to get Ramey to answer this question because I know that Ramey is one of the leaders who founded the group that really has advocated for this topic to come to the forefront and to try to institute some changes.
Dr Ramey Assaf
Thank you. I think moving forward, what we told you are working groups to be formed within the college that will look specifically at the remit of work that anesthesia associates can undertake. I don’t think as a group within the United or even generally as Anaesthetists, we are advocating or saying that anesthesia associates shouldn’t exist as a workforce. I think they can exist, but what needs urgent clarification is precisely what is the scope of practice that is best for our patients. And what we do know is that this is caused a lot of controversy because the current scope of practice allows Anaesthetists, sorry, allows anesthesia associates to undertake work beyond it. Should individual trust or individual hospitals want to through a process that’s known as role enhancement. So an example of that is the current scope, which is in place since 2016 states very clearly that anesthesia associates should not undertake regional anesthesia, but we do know that anesthesia associates are administrating regional anaesthetics across the country.
Dr Ramey Assaf
So on the whole, I think clarifying what is the scope of practice and having that set in stone is important,and the college is the best organization to undertake that to set those standards. And what we hope is that working group is formed of various different stakeholders who can come together to say, actually, this is what we think is best. And I don’t think that individual trust or individual hospitals should have a say as to what anesthesia associates can and cannot do. There are also other things that we did as a group. So one of them was to deal with rotational training, which I know is beyond the scope for the discussion, but it’s also important to say the college is not it’s a large organization that’s also focused on other things.
Dr Ramey Assaf
And that is also just an important point to make on this podcast.
Dr Ludwig Lin
I definitely think that it’s great that the Royal College of Anaesthetists are establishing this criteria. I would like to know how you guys plan to get the various trusts, which sound somewhat semi -autonomous, as well as the government to follow suit, because they really are the ones that need to form some national standards, right?
Dr Ramey Assaf
Absolutely. So standards need to be there for safe care. How as a group we can advocate for hospitals not to be setting standards is probably tricky. However, the college can do that. Or at least I think they can. They can make clear what the standards should be. And that hospitals itself cannot choose to ignore that or to sidetrack those standards. At the moment we know that that is occurring all around the country. And that in itself, I think needs to change.
Dr Ramey Assaf
And we do know that the proposed changes that are upcoming is currently in the draft form still allow role enhancement. However, we hope now that following the emergency meeting that took place last month, that that can change and we’ll have to see what what happens with that hopefully in the coming months.
Dr Ludwig Lin
I have a question about all this from a very patient -centered perspective. So, you know, do people getting procedures in NHS trusts, sorry, do they know that they are being cared for by NACC associates?
Dr Ramey Assaf
I certainly hope they can . However, we did identify a video that was published online on a university that delivers the Anesthesia Associate course in which a very senior Anesthesia Associate stated very clearly that she does not introduce herself as an Anesthesia Associate but rather as a member of the anaesthetic team and that nobody would have questioned her about that, leaving the audience to assume that she is in fact an anaesthetist.
Dr Ramey Assaf
However, I hope that that is a mistake and that’s not really the case. However, I personally think that a person who’s delivering anaesthesia would be by a doctor and actually we had hoped that patients are informed from the onset that the person is either a doctor or an anaesthesia associate who is not a doctor. That was one of our motions in the EGM in our emergency meeting that made clear that we need every patient to know whether they are having an anaesthetic administered by a doctor or not.
Dr Ludwig Lin
I completely agree with that. We actually have a parallel situation occurring in California for sure with this, in that we are strongly advocating for clarity in one’s scope of practice that people, for example, should have very clear ID badge, you know, Mark saying this is a doctor, this is a nurse. Not that anybody is better than anybody else, but just so that the people that are interacting with us, family members, patients know who we are.
Dr Richard Marks
Can I say something about Scope of Practice? One of the things that the UK really got wrong was to create this new job without actually working out the job plan first. And that, when you think about it, is crazy. It’s, what, when did you ever hear of a job where you didn’t do it that way round? Every time I want to employ another member of staff I have to work out what that member of staff is going to do, I have to justify it. And then, and only then can I get that member of staff into post.
Dr Richard Marks
What’s happened with associates is that they were created. No one actually worked out what they were and were not going to do how they were and how they fit into the system. And now we’ve got these people that they’re kind of filling a vacuum.They were sold to the profession as being “the best assistant you ever had”. And let’s face it, who doesn’t want to have an assistant? Who doesn’t want someone to chase up on their phone calls and to run around after the surgeons and to get through the treacle of everyday hospital life? Like, who wouldn’t want someone to do that? But the trouble with these assistants is they don’t say assistants forever. They do the job for a bit. They get more and more confident. Whereas with me, as a doctor, after I’ve trained, my scope of practice gets less and less and less. I don’t do cardiac anymore.
Dr Richard Marks
And I don’t do obstetrics anymore. And I do less and less and less things. But with these associates, they’re doing more and more and more. They’re saying, oh, maybe I have a bash at doing that. And, and, and you can imagine while there are no rules and well, well, well, well, there’s no, no real definition of the job. The trusts are saying to people, look, we need someone to do this. You haven’t done it before, but someone will come and do it with you the first time and you’ll pick it up. It’s not that difficult. Anesthesia, of course, isn’t very difficult most of the time.
Dr Richard Marks
People describe anesthesia as being 99% boredom and 1% terror. So quite often you can get away with doing stuff. It’s only when you hit that 1% that your real training and background comes into play.
Dr Ludwig Lin
The thing that makes me wonder about all of this is that, for example, I’ve read on social media that there are situations where Anaesthetists Associates are the ones getting to do a lot of regional anesthesia, for example, and as somebody who is a regional anesthesiologist and is passionate about it, I think that’s a wasted training opportunity for the trainees in England. The other part is, you guys can tell me more about the duration of training involved for Anaesthetists associates. But when I’m doing, for example, a deep cervical plexus block, I’m very aware of the anatomy of the neck. I’m aware of the complications that could happen. Is that something that is in the mind of every practitioner that is doing that block? I certainly hope so. When somebody is doing another type of invasive procedure, hopefully aware of all the potential complications, the complications of pharmacology.
Dr Ludwig Lin
So I personally am very curious about this. Ramey, you’re still in training, I think, so maybe you can tell me how you feel about all of this.
Dr Ramey Assaf
So regional anesthesia is very difficult, as you know, to get training opportunities, particularly amongst trainees. So it is actually a big problem. So when you have, for example, an anesthesia associate undertaking a trauma list under distant supervision, perhaps with a consultant looking at two theaters, two to one ratio, undertaking such these procedures can become challenging. And I would argue that actually, what the issues are, is we do have a number of doctors who want to train in anesthesia. We have a very long training pathway, it’s seven years. It’s seven years for a reason.But we have at the moment, two and a half thousand doctors that want to apply to become an anaesthetic, Anaesthetist rather, and about only 500 or so getting jobs. It’s 2000 who are left without a training number or without a post. And that bottleneck is actually hampering the profession. Should we actually increase the number of training posts to create more Anaesthetists to cover that shortfall, would probably be a better solution, I suspect.
Dr Ramey Assaf
Though I do suggest that perhaps there are other issues at play here, but definitely the issue with regional anesthesia, it’s a very heated debate. Should it be the Anaesthetist undertaking the block and if successful then an AA can look at the, or undertake the care in the theater during the procedure might be a better option. But there are certainly from a training experience there’s lost opportunities there. And that’s something that as a workforce, certainly that we need to take up with our trainee reps to help deal with those issues.
Dr Ludwig Lin
Dr. Marks, do you have additional thoughts on this topic?
Dr Richard Marks
So first of all, I’m hopeless at doing blocks. So I’m in awe of anyone that can do them. But there’s two or three sides to doing a block. One’s the actual technically doing it, which as I say, I am hopeless at. But there’s also deciding who’s gonna have a block, who’s not, and what are you gonna do if the block doesn’t work, or if there are complications of the block. And again, it’s back to this 99% boredom and 1% terror thing a bit. I do feel sorry for the trainees who are desperate to get experience of blocks because those experiences are so few and far apart that they desperately want to do them. And, yeah, I haven’t got any more to ask.
Dr Ludwig Lin
that makes me personally very proud to be an anesthesiologist is that we do have a vast fund of knowledge and a lot of it is for those 1% situations that are absolute terrors, their catastrophes. And as you two were talking about this, it just made me reflect on all of that, when for example, I put the subclavian in and I get a hemothorax.
Dr Ludwig Lin
I know to look for that, or a pneumothorax, I know to look for the signs of the complication and I know how to deal with that complication. When I have a local anaesthetic overdose or let’s say immune toxicity, prokena mitoxicity, I’ve studied that, I’ve thought about how to deal with it and I’m ready to deal with it. So I think we know a lot, but that takes training and that takes education. So like you have both pointed out, when we’re talking about the practice of anesthesia, it’s the summation of all of that knowledge and all of that experience. So it’s a lot. I wanted to ask both of you more about this bottleneck in the number of training slots for aspiring anesthesiologists. I’m using the word anesthesiologists because they’re junior doctors who want to go into anesthesia. Why is it that there are not enough slots? Who is the organization that is determining that and is there a way to advocate for more slots? It sounds like with the advent of anesthesiologists that there is recognition that more people need to be available to provide anaesthetics.
Dr Ludwig Lin
So that is not in doubt. So why is it that more doctors are not allowed to be training in anesthesia?
Dr Richard Marks
Okay, so part of the answer to that question is the difference between what’s in the curriculum and what’s actually required of the service. So for example, in order to train in anesthesia, you have to do a certain amount of cardiac anesthesia, a certain amount of pediatric anesthesia, all the different specialties. When you look at what needs to be done across the NHS in the hospitals, you’ve got a huge workload of obstetric anesthesia, of intensive care, and some other things. I think what we’ve been very bad at in the UK is separating those two things, separating service from training. And we are constrained in the number of people that we can train per year just by these subspecialty bottlenecks. It’s not helped by the fact that the way health is organised in the UK is very regional, so that, for example, Ramey worked until recently at a specialist cardiac unit that was a standalone cardiac place that we have standalone pediatric places. So the way that we can get people through these training bottlenecks is difficult, and the doctors in training are required to do a large amount of service. When I worked in the States, I noticed it was very different, that almost everything that people did was in some way tied to training, and service was kind of hived off to someone else.
Dr Ludwig Lin
I think I might need a little bit more explanation about this. So, so you’re saying, Richard, that there are certain subspecialties within anesthesia that every trainee needs to complete, which is true here in the United States as well.
Dr Ludwig Lin
But those subspecialties are the, are the actual bottlenecks that prevent more training slots to be available. Is that what you’re saying?
Dr Richard Marks
Yeah, essentially, yeah.
Dr Ludwig Lin
Hmm. Ramey, do you have any thoughts about this? I mean,
Dr Ramey Assaf
It’s difficult because there are, in theory, if you have all the money in the world, you are limited to undertaking roles in all the different specialties, whether it’s obstetric, pediatrics, cardiac. There’s only so many personnel that can fulfill those rotas. However, a number of those roles are being filled by doctors who are not in training post. So they can be what we have here is clinical fellows, SAS doctors, associate specialists as well.These are all different tiers of doctors that we have here. However, the reality is, is that we have this massive shortage of consultants at this moment in time, and also that’s predicted to get even worse in the future. And we do not have a credible plan of what we’re going to do. That aside, if we are going to increase the number of anesthesia associates by a factor of 10 by 2040, it’s going to be even more important to train more doctors who will in turn have to supervise them. Because they are not independent practitioners. They have to work under consultant supervision at a ratio of two to one. So the question mark is, in terms of the bottleneck, a lot of work actually needs to be done.
Dr Ramey Assaf
There are loads of doctors that want to become Anaesthetists, but at the moment they can’t because of this. And I don’t know what the solution is, but certainly it goes back to the government. And it goes back to NHS England, who dictate to us how many Anesthetists will be trained at every single application round or every single year. So it has to be done on a central level, at a government level for this. Of note, the college itself is advocating very heavily that we need a massive increase in training posts and that needs to be stated very, very clearly. Unfortunately, however, it’s appearing to be a very difficult thing at the moment.
Dr Ludwig Lin
Yeah, it’s something. Can I give you a…
Dr Richard Marks
Oh, go ahead. Can I give another answer to that question? Please. As you didn’t like my first answer.
Dr Ludwig Lin
It just, it’s not that I didn’t like it. It sort of produced more questions for me than answers really. So please elaborate.
Dr Richard Marks
Okay, now I’m gonna give you a different answer.
Dr Ludwig Lin
Okay.
Dr Richard Marks
So in the UK, you’ve got to remember, we’re in a nationalized system and the government calls all the shots. And the government has decided to divert money from doctors into associates. Now there’s various reasons that that’s happened. And one of them is that the country is actually, this country is actually losing doctors. We’re losing doctors primarily to Australia and to Canada and to other countries for lifestyle reasons and because the working environment is so much better. And I’ve got a bit of skin in this particular game because my nephew, who’s the only one of my children’s generation that became a doctor is now living and working in Melbourne. So rather than addressing this problem, the government has decided it’ll create a new breed of people that can’t go to Australia, that can’t go to Canada, that can’t actually do any other work other than the job they’re going to be trained for and that they can train them quickly and get them into the trenches quickly.
Dr Richard Marks
And it’s a short -term fix to a problem that really would be much too difficult for them to face up to.
Dr Ludwig Lin
Yeah, I’m speechless because I feel like this is not something that is sustainable and it does seem like a solution that is only geared for the short term. And I also am still trying to figure out how the NHS could do two diametrically opposed tasks at the same time. One is limiting the number of training opportunities for junior doctors going to anesthesia and on the other hand, creating more and more positions for anesthesia associates. So it’s a lot for me to try to figure out as an outsider, basically. I also wonder about the whole medical legal aspects of this. As you probably know in the United States, we love to think about medical legal implications. The malpractice environment is just a lot more drastic, I think, compared to you guys. But my immediate question would be, for example, when there is negligence, not to even mention malpractice, this whole training, the rigor of the training and the amount of supervision are things that are going to be looked at and the lack of unified standards across the UK and the lack of ways of ascertaining that.
Dr Ludwig Lin
Either of you have any thoughts about that?
Dr Richard Marks
So there’s two sides of this actually. There’s the patient side, is the patient gonna sue and who’s gonna deal with that? And then there’s the professional side. It’s am I liable to my professional organization for malpractice or deficient professional performance? And we’ve got very little experience of how that’s gonna work in the future with associates because there just isn’t the case law and background. But we have seen in general practice in the UK with supervision, we have seen the GMC, the regulator, take the position that if you supervise someone, you have to be responsible for what that person does and you have to be assured that you are safely delegating to that person. And a lot of consultants in the UK looking at this growth in anesthesia associates and going, wait a minute, they’re gonna be doing stuff and I’m gonna be responsible for this professionally. That’s gonna be a problem. It’s something which hasn’t been addressed and really needs to be looked at urgently.
Dr Ludwig Lin
It sounds like a lot. And I am so happy that there are people, like the two of you, who are invested and who are taking steps to really bring this conversation to the forefront. Tell me how you feel about this, but I feel like something that physicians almost are trained to do is to be good soldiers.
Dr Ludwig Lin
We take very good care of our patients. We sort of, you know, duck our heads down and just get the work done. And then we sort of just, you know, just leave it. But I feel like in this modern healthcare environment, we all need to be very invested in the future. And to understand that we all need to be, stay engaged, and we need to be change agents. How do the two of you feel about that?
Dr Ramey Assaf
You know, it’s a good point. I think the future, I mean, it’s uncertain at best, but it’s incredibly important as the population becomes more comorbid and we get better in what we do, patients are living longer. You are undoubtedly going to be needing even more physicians to be looking after the next cohort of patients and that is where the investment actually needs to be. So the direction at the moment whilst might produce a very, very short -term fix is going to create even bigger problems in the median term in the next maybe five or ten years. So the future I’m not sure. I’m very worried about the future here of where it’s heading and I think that’s why we came together ultimately to try and address these issues, but that’s my take on it. So I don’t know, Richard, if you want to add anything to that or about what you feel about the future of where we go.
Dr Richard Marks
Okay, so yeah, my take on this, just to be slightly confrontational, is I think there’s a generation thing going on. And I think the current younger generation are actually quite militant and are quite angry for very good reason. And I think they are taking the attitude now, we’re not going to put up with this. Whereas previous generations would have been fed the line that it’s an honor to be a doctor and just being a doctor is enough in itself. I think the younger generation are kind of fighting back against that. And I think we’re living through a time of great social change.
Dr Ludwig Lin
I completely agree with both of you. And I do think that physicians were probably selected and self -selected to be good team players. I know that I was, that’s what I was taught in medical school. And I think we take a lot of pride in our skills and abilities and in our work ethic, but it is really important to be engaged and to take reins of the future. So Richard, I think you’re right. I think the doctors coming up understand that. And maybe the attitude is a generational thing. And I think that’s good because we have Raimi here who is trying to do that. And I am so impressed that you guys are openly discussing this and willing to agitate for change. I think there are various things that you guys have touched on that sound quite big in terms of projects to tackle. So you might as well just get started now. I’m going to wrap up this conversation. I feel like I need to, you know, debrief with myself for hours afterwards to think about all of this. But I always ask the guests for this podcast, whether there were things that were not discussed that you’d like to leave the audience with. So let me pose the same to you. Anything else that you want to make sure that we’re, you know, we all get to hear from you before we sign off today. That’s all.
Dr Ramey Assaf
I think one thing we haven’t really discussed is with regards to the general medical council who are or the GMC who are our regulator, particularly what their involvement is. So anesthesia associates will be coming under regulation in the next year or so under the GMC, which is the same regulator as the doctors, this is proving to be a very, very controversial issue here. But what I think I’d probably want to mention is that the GMC at the moment has said that the scope of practice for anesthesia associates will not be within their remit, but that should be left to royal colleges and individual trusts. So I’m not sure what was to happen if the college says that AA shouldn’t do one particular thing, but individual trusts say they can if the two don’t see eye to eye. But that is a question that certainly will need to be addressed soon, I hope. And hopefully the GMC does look at answering that. That’s I think one thing I think we haven’t discussed is what the role of the GMC is going to be in all of this. Wow.
Dr Ludwig Lin
Okay. Richard, do you have anything else that you wanted to mention?
Dr Richard Marks
So the one final thing that I don’t think we’ve really touched on is the attitude of patients. And most people don’t think of themselves as being patients. Most people don’t think of having to go into hospital because it’s fortunately an unusual experience. But when they do, people want to see the doctor and people want to see someone who knows what they’re doing. And I think there’s real lack of awareness of what is actually going on. And I think people are just not aware that when they go to see what they think is going to be a doctor. And I’ve already said, I think there’s a very strong case for physios and specialist nurses and all sorts of other therapists. But when people think they’re going to see the doctor, they think they really are going to see the doctor.
Dr Richard Marks
And I think people are shocked to find that these associates are actually not doctors. And I think there’s a big lot that needs to happen in terms of public awareness of what’s going on at the moment.
Dr Ludwig Lin
I completely agree with you. I really appreciate both of you taking the time today to talk about all this. It’s been very educational. I think this will be very enlightening for a lot of my American colleagues because we are going through parallel conversations on this side of the Atlantic.
Dr Ludwig Lin
At the same time, I think these things are universal. We’re all here to take care of our patients and we are all curious about what our patients’ experiences are about all of this. So there are definitely some universal truths there.
Dr Ludwig Lin
Thank you both for being here today. I’m going to take this chance to wrap this conversation up. This is the California Society of Anesthesia and Ligious Podcast series, The Bible Times. Thank you so much.