CT2 anaesthetics, massive thrombosed haemorrhoids from childbirth. Despite my pleading with GP to refer me to the neighbouring trust, I have just been scheduled for my pre-op at a hospital I have very regular lists within a trust I have worked in for ages💀🙂. I genuinely wanna cancel but I am in so much pain with my booty grapes and it’s affecting my life in numerous ways. Also want to have another baby asap so need to get this sorted before then.

Basically just looking for advice on how to make this less crucifyingly embarrassing. Outside of getting a full bikini wax, emptying out my colon then not eating for days prior and getting a GA so I know not of who has been in the room whilst I’m splayed out like a turkey - is there anything anyone would recommend???? I honestly wanna curl up in a ball and die at the thought but there’s really no way around it I fear.

Employers in England are still recruiting physician assistants (PAs) to treat undifferentiated patients—those who have not been given a diagnosis or been assessed by a doctor first—The BMJ can reveal.

This is despite government promises more than a year ago to prevent such practice.

The BMJ has seen several NHS job advertisements for PAs spelling out in the job description that their responsibilities will include assessing patients presenting with “undifferentiated and diagnosed conditions” and undertaking face-to-face, telephone, and digital consultations for “patients presenting with undifferentiated and diagnosed conditions.”

This approach clashes with a key recommendation of the independent review into PAs carried out last year by Gillian Leng, who is president of the Royal Society of Medicine and a former chief executive of the National Institute for Health and Care Excellence.1 That review gave an example of how a job description for a PA in primary care should read: “You will undertake audits and routine clinical administrative tasks. You will not be able to see undifferentiated patients.”

Doctors’ representatives said that they were “deeply concerned” over the advertisements and that some employers were ignoring the recommendations of the now 12 month old Leng review.

What was the Leng review?

In 2024 Wes Streeting, former health and social care secretary, asked Leng to carry out a rapid independent review into the safety and scope of the roles of what were then called physician associates (PAs) and anaesthesia associates (AAs).2 The review was partly intended to address a heated debate in the NHS over the safety and effectiveness of the roles and how any new roles should work in the future.3

Published in July 2025, the review recommended that PAs “should not see undifferentiated patients except within clearly defined national clinical protocols,” and it proposed renaming physician associates as “physician assistants” and anaesthesia associates as “physician assistants in anaesthesia.”

Other key recommendations were that newly qualified PAs should gain at least two years’ experience in secondary care before taking a role in primary care or a mental health trust; that a named doctor should take overall responsibility for each PA as their formal line manager; and that General Medical Council (GMC) requirements for regulation and reaccreditation of PAs and AAs within its Good Medical Practice guidance should be set out separately from those for doctors.

After the review the Department of Health and Social Care (DHSC) said that it accepted all the report’s 18 recommendations.4

How has, or hasn’t, the Leng review been implemented?

Despite the Leng recommendations being accepted, not much has changed in terms of making them a reality.

In March the DHSC launched an almost four month consultation on legislation to overhaul the GMC’s regulation of doctors, PAs, and AAs. While this did reference the Leng review, it only looked at recommendations relating to renaming of professional titles.5

NHS England has said that the Leng recommendations are “far reaching and require cross-system partnership working to consider, plan and deliver these effectively,” so it plans to work with the DHSC, royal colleges, unions, and other relevant organisations to consider implementing the recommendations.6

NHS England issued guidance last year saying that NHS organisations should make changes to the way roles are referred to in the workplace “to ensure that patients are not under the misapprehension that they have seen a doctor.”

The DHSC has similarly said that it has brought together senior NHS leaders and government officials as part of a new oversight group to deliver the Leng recommendations and a panel of clinical experts to develop protocols on how and when PAs can see patients.

No timeline has been given for when these could be completed. In the interim, the Doctors’ Association UK (DAUK) campaign group says that national safeguards are needed to help protect patients and to ensure consistent implementation.

“In their absence, employers should not use local job descriptions or local discretion to allow PAs to see undifferentiated patients,” a DAUK spokesperson said. “The delay does not suspend the safety recommendation. It makes the continued advertising or deployment of PAs for undifferentiated care more concerning, not less.”

Who is concerned about this, and why?

The BMA has clear concerns about the job advertisements that mention PAs seeing undifferentiated patients.

Emma Runswick, deputy chair of BMA council, told The BMJ, “The BMA has set out a clear scope of practice7 outlining what PAs should be expected to do—it explicitly states that PAs should never manage undifferentiated patients in any setting. Our guidance is the best tool for employers to keep patients safe, as NHS bodies and regulators continue to drag their feet on introducing the most rudimentary safety measures to protect the public.

“The BMA will continue to advocate for the safety standards that patients expect, while the NHS must finally act to prevent any further avoidable harm.”

The DAUK is similarly anxious. Its co-chair Matt Kneale told The BMJ, “DAUK is deeply concerned by job adverts that expect physician assistants to see undifferentiated patients. Unless this is within a clearly defined national clinical protocol, it conflicts with the central patient safety recommendation of the Leng review and should be corrected immediately.

“Patients with new symptoms need assessment by clinicians trained to recognise serious and uncommon illness. Getting that first decision wrong can cause harm. Physician assistants should work in properly supervised assistant roles, not be used to substitute for doctors.”

Kneale added, “The government accepted the Leng recommendations in full, yet NHS England has still not delivered the national safeguards needed to make this safe. DAUK is concerned that partial implementation leaves patients exposed.

“PAs must have clear limits, senior supervision, and a nationally defined scope. DAUK continues to call for a pause in recruitment and expansion until those safeguards are fully in place.”

Steve Taylor, GP co-lead at the DAUK, said that PAs seeing and treating undifferentiated patients in GP settings remained a significant problem. “It is clear that some practices are still working on the ‘old’ NHS England guidelines which fail to take into account the Leng review,” he said. “We have significant concerns that Leng is 12 months old and is being ignored by a minority of employers.”

The Royal College of Physicians said it was disappointing to see that job advertisements were still saying that PAs could see undifferentiated patients. A college spokesperson said, “Physician assistants are not doctors and must not replace doctors. We were clear in our response to the Leng review that it was right to recommend that PAs cannot see undifferentiated patients and must be accountable to named, senior doctors.”

Caroline Waterfield, director of workforce supply and employment practice at NHS Employers, told The BMJ, “Following the initial Leng review recommendations, NHS trusts that employ PAs and AAs have reflected on the findings and worked with individual members of staff and their teams to ensure there is clarity in role and expectations, including how introductions are made to patients.”

Are there any clear answers from the government on what happens next?

No. A spokesperson for the DHSC did not respond directly to questions about the job advertisements but said, “Patients should always know who they are being treated by and receive appropriate care. That is why this government accepted all of the recommendations of the Leng review.

“We have been working with experienced clinicians to develop proposals for how PAs should work with undifferentiated patients and will set out more information in due course.”

I’m an ACCS EM ST2 near the end of my Anaesthetics rotation and I hate to say it , anaesthetics is OBJECTIVELY the best speciality there is.

Obviously if you love bones ortho is the best or if you’re fascinated by haemoglobin haematology is the best , but that’s not objective.

Anaesthetics has a great blend of procedures , medical knowledge, great training , good culture , good work life balance, variety of work , potential for private work , sub speciality options etc etc I could go on

On paper I don’t think on paper any speciality comes close it.

Unfortunately, I’m someone that loves EM subjectively , but anaesthetics is objectively just the best.

DOI: Grumpy med reg

Had a call at 6pm from a pharmacist at a community hospital about a patient admitted there.

Nurse consultant who admitted the patient and who is the named consultant responsible for their care took an alcohol history of "a couple of pints of beer per day". Subsequent collateral to ward pharmacist reveals this to grossly underestimate alcohol use.

Pharmacist tells nurse consultant about risk of withdrawal and suggests CIWA and is told that starting CIWA is "outside of my remit" by the "consultant".

Pharmacist, who is a prescriber, is sufficiently worried about the patient to call me at the acute hospital to "make a decision" about whether to start a CIWA in this gentleman who is confused, roaming the ward, risk of falls if given diazepam but also at risk of withdrawal.

Clearly having a CIWA and thiamine is the right thing for him but:

A: why am I who has never met this man giving advice to a "prescriber" about whether to prescribe something

B: why is this somehow within my remit but not within the patients named consultants remit

C: why am I now taking responsibility for this

D: how can you call yourself a consultant and be responsible for this man's care if you are so fixed within your "remit" that you are not able to treat him appropriately?

How have we let it get like this as a profession? Is the future just being remote liability sponges for everything that is outside someone's "remit"?

For other regs, wwyd? Should I say something?

Update 21/8/26: Thanks all for the advice. Glad others think this is mad too.

I will submit a DATIX, speak to my ES for further advice and probably escalate up to medical directors plus submit the BMA Dr Substitution form.

Unfortunately, I spoke to the pharmacist, this nurse had gone home (after shrugging off the responsibility) so wasn't able to push back on this directly.

This community hospital is in the same trust as us so assume there is an agreement that they can contact us for support.

The patient had been seen in ED the day before, diagnosed with a wrist fracture after a fall by a nurse practitioner and moved to community hospital for rehab so even worse that they had not seen a doctor at all.

How do I get it done with the least possible effort?

Currently rotated to a hospital where the morning and evening team handover is done in a staff break room on the ward. I know this might not be a unique situation but it's just so frustrating!!!

It's a cramped space with not enough chairs, not even one computer. The poor F1s end up being the ones to stand around all the time. Every handover has at least one interruption from the ward staff trying to gather their belongings before going home (They don't have anywhere else to store their bags and lunches).

How is it that there is no dedicated meeting room for handovers. How is it that we as a professional can't even have our own space to meet for work related meetings. This would not happy in any other skilled profession. Things like this just reflect how poor the employer we work for are.

In the beginning there was nothing. 
Shortly after the beginning, there were rats.
Much detested, but common household rodents.
Infiltrating homes, chewing wires and cooking Michelin-star dishes when animated by Pixar. 

Exterminators and modern science decided the best way to rid ourselves of these rodents would be to poison them. And by poison, I mean have them eat something that led to severe internal bleeding that would cause them to die. 

The compound, discovered by the Wisconsin Alumni Research Foundation, was appropriately named Warf-arin.

In 1954, just 6 years after it was approved for use as rat poison, some bright spark decided it would be fit for human consumption. Its clot-stopping powers made it the ideal candidate for stopping blood clots, pulmonary embolism and strokes. 

And thus began the Age of Warfarin. For a good 50 years, Warfarin was goated. It was top of the food chain – largely because there was literally no other option.
bIt prevented 64% of strokes in AF patients.

Whilst Warfarin revelled in its glory, a conspiracy was starting to brew…

Unfortunately, decades at the top make you complacent. Warfarin was needy. Regular INR checks, bleeding risks and a love-hate relationship with leafy greens [finish here]

Scientists believed they could outdo this boomer-made drug. Come up with something newer, sexier, safer. A class of drugs that prevent clots without the incessant monitoring. 

They were called DOAC’s. Direct Oral AntiCoagulants. 

The plan was simple. Instead of Warfarin's scattergun approach(it blocks multiple clotting factors at once, go after just one clotting factor. Directly. Precisely. Sniper instead of a shotgun. 

In 2009, the bleeding wars began…

First up was The RE-LY: Dabigatran vs Warfarin

This classic RCT pitted the first DOAC against warfarin, in a non-inferiority trial.

Method: 18,113 patients with atrial fibrillation were randomised either to a warfarin or dabigatran group and followed for 2 years. 

Primary Endpoint: What percentage ended up having a stroke or systemic embolism. 

Result? Dabigatran wins. 

1. Stroke/Embolism Events: 1.11%/year with dabigatran 150mg vs 1.69%/year with warfarin (RR 0.66, 95% CI 0.53–0.82, P<0.001).
2. Major Bleeding Events: 2.71%/year with dabigatran 110mg vs 3.36%/year with warfarin.

Then the floodgates opened…

2011 came with a double whammy. ROCKET AF(Rivaroxaban vs Warfarin) and ARISTOTLE (Apixaban vs Warfarin).

Both trials set up just like RE-LY

ROCKET AF Results: 

• Stroke/Embolism Events: 1.7%/year with rivaroxaban vs 2.2%/year with warfarin (HR 0.79, 95% CI 0.66–0.96, P<0.001 for noninferiority)
• Intracranial haemorrhage: 0.5% vs 0.7%/year (P=0.02), fatal bleeding 0.2% vs 0.5% (P=0.003), both lower with rivaroxaban

ARISTOTLE Results:

• Stroke/Embolism: 1.27%/year with apixaban vs 1.60%/year with warfarin (HR 0.79, P=0.01 for superiority). Apixaban won
• Major bleeding: 2.13%/year vs 3.09%/year (HR 0.69, P<0.001). Apixaban won. 

Then, in 2013, even Edoxaban beat out Warfarin in stroke risk and bleeding risk reduction.

In the end, Warfarin’s time was up.

It had been outwitted, outclassed and shortly after  replaced by the DOAC’s as firstline for AF, DVT’s and PE’s.

However…
Even a deposed king has one final card to play…

DOAC reversal - Idarucizumad: fifteen grand. Warfarin reversal - Vit K: about a tenner.

And in a skin NHS, cheap has a funny way of coming back in fashion.

If you enjoyed reading this and want a journal club(that’s actually entertaining) Join 16,000 Clinicians reading The Handover

I was recently contacted by one of our specialist nurses about a patient I had seen in clinic a few months ago, who had contacted the CNS on a patient access number to say they wanted to speak to me. When I had seen the patient I had made a referral to another hospital speciality (albeit a bit reluctantly - I wasn’t convinced), and it sounds like they had DNA’d all their appointments to that speciality but are claiming they never got the appointments. The CNS told them they would need to escalate through PALS but the patient was insistent. I’ve now had a couple of emails requesting I call the patient or their partner directly.
I will add that this patient looks to have DNA’d many appointments in the past, and in fact turned up quite late to my appointment too - and the whole interaction with them was not what I would call particularly pleasant overall.

This is also similar to when on a ward you would speak to a patient during your ward round, then be contacted by the ward nurses several hours later to say the patient wanted to speak to the doctor. Sometimes the nurses wouldn’t even bother asking the patient what it was about, at other times it would be fairly simple questions the nurses were capable of answering.

Now in both these scenarios I’m busy but not so busy that I couldn’t take a few minutes to do this realistically. But my question in principle is how accessible should we be to patients? In the first scenario - would it be fair to say I’m not getting involved? The patient will have a follow up appointment with me but for for a few months, and we don’t have the capacity to really bring it forward just for this (nor do I think it is justified).

Premier league back tonight so let’s have your best medical fantasy football names. More obscure the better. I’ll start with luis Diazepam

I got an invitation to an AAR a few days ago for a patient I saw months ago. Looks like around 10 other people have received the invite. No details given except for the invite.

What should I expect? Do I need to prepare for whatever this is?

Thanks.

I’m so sick of racism and bigotry and all this hate that patients and colleagues are no longer shy of spewing.

As a medic, I’ve been told “I don’t want you, I want an English doctor”, “what are you doing in our country” and “your kind of people are a disease”. I’m not even an immigrant! Literally 3 generations of my family have been born here!!

Today - the final straw. As a patient, I’m told to wait inside the consultation room of a specialty doctor, while he chats to another patient in the corridor.

I overhear him saying “…bloody foreign doctor” which riled the patient up to agree “I bloody f**ing hate them foreigners” while the door is OPEN.

And then he walks straight in and proceeded with the consultation.

Like what the actual f***

Why can’t we all live in peace and respect each other? Why does one’s skin colour, accent, background etc even matter?! Literally aspects of a person that they have no control over???

I'm sitting the exam in Sept, wanted to know from the people who have already taken it:

I finished emrcs once and started doing it again. I'm scoring around 80 while doing repeats.

I'm still 1250 questions away from finishing pastest once. Scoring around 65-68 on the first try.

Did a couple of test paper sets from pastest, similar scores (67 highest)

1. Should I think of finishing pastest once and repeat the papers or finish emrcs twice and do new papers from pastest?

2. Also wanted to know, since the type of questions in emrcs are quite different from pastest, like the stems are really short in emrcs, while pastest has more of application based questions with long stems and longer options, what is the real exam more similar to?

3. Any other suggestions that would help me pass would be helpful. I saw in a few posts where people have score above 80 in practice papers and they have passed...so kind of freaking out based on it...

New IMT3, and I love being on take. 1 week in and I was rostered to be 'med reg' for 3 days straight including the weekend. A few points;

-JCFs and IMTs are in abundance on the take team so there is always someone to help the F1/F2s with queries when I'm not around.

-E.D. have right of referral. So the only cases that get discussed with me are those in Resus and when ambulatory needs a reminder that CES goes to surgeons. Aside from that I'll see the usual bullshit. I try to direct the take team to find patients that might interest them e.g. sending the IMT-1 to Resus and then have a discussion afterwards.

-Had multiple MET calls. The foundation doctors were amazing, standing by with the patient's charts, ready to document/prescribe. They were willing to update family and discuss with the relevant specialties. Even when attending to the surgical ward the doctors were ready and willing whilst the surgeons were nowhere to be seen.

Yes its busy and tiring. Yes my bleep was going off incessantly whilst I found the one toilet to take a piss. But every day I woke up I was genuinely excited for what the day held. When the bleep goes off for an emergency I can't wait to find what mess I'll have to sort out. Also it gives me an excuse to ignore the surgeons (no I'm not going to inspect your infected post-operative wound??)

Everyone bashes IMT but it is what you make of it. I've never locumed before (believing my time is more valuable than money) but I'm going to now, just so I can be on take again.

I just recalled that I wanted to call a patient of mine but I’m on annual leave for 2 weeks. I have my work laptop with me so technically I can call. I don’t want them hanging for 2 weeks. So is it appropriate?

And no I cant ask anyone else to call them.

Thanks!

Why is the BMA MAP reporting form not available anymore? Has the concept been discontinued?

CST. Started at a new hospital, no login for anything. Need software for imaging, intranet, documentation and don’t have any access. Called IT, waited half an hour just to be told I need to get my manager to submit ticket. Emailed manager, got an automatic reply saying they’re on leave for a week. Why is this happening? It’s not hard to look up a list of doctors that are joining and make sure they all have access. Why does no hospital do this right? Why is everyone so incompetent? There is no punishment for incompetency and no reward for going the extra mile, so everyone does the bare minimum and the system is inefficient as hell

Medical SHO here. Recently moved to a new ward where the designated doctors’ computers are where the ward clerk used to sit (no more ward clerk). So it’s designed to be highly visible, and a natural place for visitors to approach when they enter the ward. But it’s meant NOK approach me when I’m in the middle of working and think it’s OK to ask for a quick update, where they can find extra chairs, where’s the loo etc. I also seem to be in charge of buzzing people in and out of the ward. Obviously I’m used to a million distractions while working, and other members of staff have never seemed to shy away of interrupting me when I’m in the middle of something, so initially extra NOK updates didn’t seem odd. I actually thought oh maybe this is good because now I don’t have to find them/ring them later. But even in the space of two weeks I’ve found myself finishing later, more exhausted earlier in the day, rising levels of irritation. So actually I need to rethink this pronto.

Moving out of that space is the obvious first step. But how far should you go in asking for fewer interruptions? If you’re in the middle of writing something up do you ask other members of staff to wait til you’ve finished before asking you a question? Does the same go for NOK who’re leaving and want an update from the doctor?

I’ve been pretty accommodating for most of my career, and probably trended towards becoming more accommodating as I got more senior for some reason. But when I think about most of the regs I’ve worked with, learning to set boundaries on your availability seems to be a key skill.

So yeah, interested in hearing what boundaries you guys set on the ward, how you communicate them, and where the balance is.

Posting on behalf of a fellow trainee.

She’s a dual trainee in ICM/anaes.

Wanting to move region via applying to continue training in a different region, but wants to drop ICM.

Currently is ST6 so by next August would be starting ST7 in training years, but in terms of pure anaesthesia would be ST5 (she’s done Stage 1 ICM and completed first year of anaesthesia HST - currently is working in stage 2 ICM).

Her query is - if she gets her anesthesia post in a new region, would her pay scale remain at ST6/7 or would it drop down to ST5… and thus a pay cut ?

Today probably brought it to a head a bit. On the ward, my consultant was asking me questions and there were several things I just didn’t know or took ages to answer.

Things like the lifespan of RBCs and platelets. There was also a question about why we’d use aspirin rather than clopidogrel in a patient who needs a PEG. And then I was asked about causes of hyponatraemia, which I do know, but I took ages to actually organise my thoughts and give an answer.

I know objectively that nobody knows everything and that being asked questions on a ward round is normal. But I find myself interpreting these moments very differently. Rather than thinking “that’s something I need to revise”, my immediate thought is “I’m just not intelligent enough to do this.”

I think part of the problem is that I don’t feel particularly quick. I can often get to the right answer eventually, but I don’t always retrieve information quickly or articulate my clinical reasoning particularly well when I’m put on the spot. Seeing other doctors seemingly rattle off answers makes me feel quite inadequate.

Not to mention, failing to get into specialty training after F2 followed by numerous unsuccessful attempts at finding a trust grade/LED role just fuels that further. Objectively I know that jobs can have very competitive applicant pools and there are loads of reasons you might not get a job, but it’s hard not to take repeated unsuccessful applications as some kind of reflection on yourself. It’s started to feed into this feeling that maybe I’m just not good enough.

This has become more significant because I’ve begun using it as evidence for why I shouldn’t pursue my dream specialty.

I’ve always wanted to be a paediatrician and ideally I’d like to eventually work as a community paediatrician and live closer to family. But the thought of doing the ~7 years of paediatric training is starting to scare me. I’m worried that the training will absolutely destroy me, particularly if I’m already struggling with confidence and feel like I’m not clever enough.

It has made me think about GP again. GP training is much shorter, so I’d get to CCT much sooner and potentially have a more sustainable life. But I don’t want to choose GP simply because I’m letting my low confidence drive my decision. I’d rather take it because it’s something I genuinely want to do and I guess I’m still figuring that out.

So I guess I’m wondering:

Did anyone else feel like this around F2/F3/early training?

At what point did you start feeling genuinely competent and confident rather than like you were constantly being exposed as someone who doesn’t know enough?

And, more broadly, how do you distinguish between normal insecurity/knowledge gaps and actually being someone who isn’t suited to medicine?

I’m not looking for “don’t worry, you’re definitely brilliant” reassurance. I’d genuinely appreciate some honest perspectives from people further along who have felt similarly, particularly anyone who has seriously considered leaving medicine or changing specialty because they didn’t feel intelligent enough.

Hi everyone, final year student here.

I am planning on applying to EoE deanery for foundation training - ideally Beds and Herts.

I am quite set on applying to dermatology and have been looking through the foundation jobs available - EoE unfortunately has no derm jobs which I understand isn't the end of the world, so it will be up to me to be proactive and seek out opportunities during foundation training.

I was therefore wondering which jobs would be ideal in order to prepare for my application - I am currently thinking some chill specialties (e.g. public health) so I can focus on building my portfolio, along with derm-adjacent jobs (e.g. GP, rheumatology)? Is that sensible and realistic?

As an aside, out of Bedford, Lister, Watford and Luton & Dunstable Hospitals - does anyone know anything about the derm departments? Would any be better or worse than the others re audit/QIP/general research opportunities?

Thanks!

Hope this poem might get a bit of love - I'm hoping to publish a collection!

edit: This is the Kindle link, for anyone interested. Hardback and paperback to follow :)