Medicine and Science from The BMJ

In this episode of podcast we explore two clinical dilemmas - unrecognised drug side effects, and the outcomes from hip and knee replacements. When an unrecognised adverse drug effect is mistaken for a new symptom, the resulting prescribing cascade can end in polypharmacy and potentially preventable patient harm. New research on nearly 2.3 million adults in Ontario, has found 24 high-priority, potentially inappropriate prescribing cascades—including laxatives after iron, pain relievers following statins, and sedatives after cholinesterase inhibitors. Paula Rochon, Jerry Gurwitz, and Antonio Cherubini, three of the study's authors join us to discuss. Over 100,000 hip and, 100,000 knee replacements are performed annually in the NHS, and health systems are investing hundreds of millions to rapidly scale robot-assisted surgery, but is this expensive new tech delivering better patient outcomes? Two target trial emulation papers, using the UK's National Joint registry aim to find out if robots are better at join replacement. Hassan Mohammad, one of the papers' authors shares their findings, and Teppo Järvinen joins the conversation to discuss challenging orthopaedic surgery standard practice. Guest List Prescribing Cascades Discussion Paula Rochon, Geriatrician, senior scientist, and professor at Sinai Health and the University of Toronto. Jerry Gurwitz, Geriatrician, researcher, and professor of Medicine at UMass Chan Medical School. Antonio Cherubini, Geriatrician and clinical eesearcher at Università Politecnica delle Marche and INRCA (Istituto Nazionale di Riposo e Cura per Anziani) Robotic Hip & Knee Arthroplasty Discussion Hassan Mohammad, academic clinical lecturer in orthopaedics at Barts and The London School of Medicine and Dentistry Teppo Järvinen, orthopaedic surgeon and professor at the University of Helsinki, and Head of the Finnish Centre for Evidence-Based Orthopaedics (FICEBO) in Finland. BMJ.com Reading List Research Papers Exploring high priority potentially inappropriate prescribing cascades in older adults: population level retrospective cohort study Early national comparison of robotic versus conventional knee replacements for arthritis using National Joint Registry data: target trial emulation study Early national comparison of robotic versus conventional hip replacements for arthritis using National Joint Registry data: target trial emulation study Robot assisted hip and knee arthroplasty: It is high tech, but is it better?

Last year, in July 2025, the independent review of the physician associate and anaesthesia associate roles, carried out by professor Gillian Leng, was published. The review followed the contentious role out of PAs in the NHS - where their scope of practice differed across trusts, and GP practices, and concerns were raised about clinical safety. Some of the key recommendations were around seeing undifferentiated patients, training needs, and supervision - and we spoke to Gill at the time, and the government accepted her proposals. But questions remained about exactly how some of those recommendations might work. Today, with the publication of a draft clinical protocol - and we clarify some of those questions.

Something different for the podcast today: a live event. It’s the inaugural BMJ lecture, in partnership with the Academy of Medical Sciences and hosted at the historic Royal Academy of Arts. We want to talk about the big issues facing healthcare professionals around the world - and we’re starting with one of the biggest: how do we make decisions in the face of real risk and genuine uncertainty? Well, who better to talk through those big questions than the man who had to try to navigate those risks and uncertainties during the pandemic? Chris Whitty is England’s Chief Medical Officer and Chief Medical Adviser to the UK Government, advising on all aspects of healthcare. He is also a professor of public health at the London School of Hygiene and Tropical Medicine, where he was director of their Malaria Centre. In his lecture, Professor Whitty argues that medical training must better prepare doctors to manage risk, highlighting that "higher risk decisions, and accountability for these, have moved to later in training", causing a "substantial and sudden step up" in risk for new consultants. He acknowledges AI’s potential to speed up clinical diagnostics, but warns against public-facing AI tools that present diagnoses with false certainty while ignoring medical risk and uncertainty. Read the related Opinion article: "We must be more systematic about risk holding throughout doctors’ careers" This recording is available to view on YouTube.