Future roles, responsibilities, and rewards

Doctors’ purchasing power has fallen over the past 15 years, a fact not lost on those entering further strikes. Pay for doctors requires attention, whether seen as calculations of average earnings or in the personal accounts of doctors struggling to meet their needs and salary expectations, as recounted by Adele Waters (doi:10.1136/bmj.q666), including one former ophthalmology trainee who was effectively paid around £4.50 for each cataract surgery he took part in.1

Poor retention of doctors and rising workloads have bolstered the argument for increasing use of physician associates, and three doctors give their views on this change. Consultant David Oliver summarises the concerns that have been raised about working with physician associates (doi:10.1136/bmj.q665): issue of supervision, scope of practice, regulation, and the need for greater understanding of the associate role among patients and the public.2 He also comments on what organisations are doing to tackle these challenges, sometimes badly. Junior doctor Alexander Mafi adds that a lack of clarity in how associates should work with junior doctors can create problems for doctors on rotation, such as knowing who is responsible for what (doi:10.1136/bmj.q657).3 GP Helen Salisbury observes that, although the Royal College of Physicians hosts the Faculty of Physician Associates, most associates work in primary care (doi:10.1136/bmj.q676).4 Associates are not meant to replace GPs, but some salaried doctors have been made redundant, giving that impression. The Royal College of General Practitioners may have created some “red lines,” she says, but “the gulf between the guidance and the real world is huge and growing.”

Greater clarity in NHS funding could resolve issues of workforce composition and pay. The BMJ Commission on the Future of the NHS continues (bmj.com/nhs-commission), and this week John Appleby and coauthors discuss funding (doi:10.1136/bmj-2024-079341).5 Evidence and public opinion support general taxation as remaining the NHS’s main source of funding. But choosing how much to spend, and how this should be decided, is harder. Long term sustainability and opportunity costs regarding other public services need more consideration. Appleby and his coauthors propose a new independent body to report periodically on the health of the nation and of health systems, and they argue for a five year strategic plan, aligned to government cycles, to increase accountability and planning.

Large scale changes to healthcare systems are beyond the influence of individual clinicians. But small changes add up. Rebecca Bromley-Dulfano and coauthors provide instruction on how to adopt reusable personal protective equipment (PPE) (doi:10.1136/bmj-2023-075778).6 World production of such equipment rose by around 300% during the covid pandemic, but reusable PPE is safe, saves costs, and is a sustainable alternative to single use PPE, they conclude.

A different glimpse of the future is provided by Bradley Menz and coauthors (doi:10.1136/bmj.q596), who examine safeguards against the misuse of large language models (LLMs), a form of generative artificial intelligence with the potential to produce medical disinformation.7 A variety of LLMs were “prompted” to generate health disinformation, and attempts were made to bypass any safeguards to prevent them doing so. In some cases the prompts led to convincing blogs, with attention grabbing titles, authentic looking references, and fabricated testimonials to target diverse groups. The authors conclude that effective safeguards are feasible to prevent LLMs from producing health disinformation, and they call for enhanced regulation to stop LLMs being used to create health disinformation in the future.