What skills do doctors and nurses need?

doi:10.1136/bmj.a1722

Published 18 September 2008, doi:10.1136/bmj.a1722
Cite this as: BMJ 2008;337:a1722

Editor's Choice

What skills do doctors and nurses need?

Fiona Godlee, editor, BMJ

fgodlee{at}bmj.com

What’s the difference between a doctor and a nurse? Ourcover picture this week suggests that the differences are becomingharder to spot, and in this issue Rebecca Coombes explores theshifting and increasingly overlapping territories of the twoprofessions (doi:10.1136/bmj.a1522). It’s easy to understandwhy the nurse’s role is expanding into traditionally medicalareas of diagnosis and treatment: there’s the lower directcost of employing nurses and the fact that they have more timeto spend with patients.

But it’s not all plain sailing. There’s confusionover titles, a lack of nationally agreed standards on what trainingand experience are needed, and no proper regulation for advancednurse practitioners in the UK. But other countries are furtherahead, helped in some cases by graduate only entry to nursetraining. So could nurses expand their roles even further? Inour head to head debate, Bonnie Sibbald argues that primarycare should now be led by nurses (doi:10.1136/bmj.39661.707083.59);Rhona Knight disagrees (doi:10.1136/bmj.39661.694572.59).

While roles are rapidly evolving, it seems clear to me thatdoctors and nurses are selected, trained, and paid differentlyfor good reason. Doctors need to take risks and deal with uncertainty,while nurses are more attuned to following protocols and providinghands-on care. But if, as some argue, diagnosis is almost theonly skill that defines doctors, it’s reassuring thatmachines can’t yet do the job better. As Christopher Martynexplains (doi:10.1136/bmj.a1703), computerised Bayesian algorithmsand artificial neural networks have failed to live up to theirearly promise. On the down side, this has left us largely inthe dark about how doctors reach their diagnostic decisionsor what makes some people better at it than others. But thegood news, he says, is that doctors are pretty good at diagnosis."On the whole, doctors care a lot about getting diagnosis correctand they castigate themselves when they fail." Martyn also thinksit’s admirable (as do I) that when doctors do make diagnosticmistakes they talk about them and write them up in journals.

What about telephone triage as a form of diagnostic decisionmaking? Hay Derkx and colleagues don’t offer much comfortfrom their national cross sectional study of Dutch out of hourscall centres (doi:10.1136/bmj.a1264). Using standardised patientscenarios they found that, in a high proportion of interactions,advice was given after asking too few questions and withoutproperly interpreting the answers. In their accompanying editorial(doi:10.1136/bmj.a1167), Joseph Lip and colleagues raise seriousconcerns about the lack of consistency and transparency in thetraining of "triagists" and the protocols they use. They callfor proper evaluation of the safety and quality of these services.

As health care becomes more complex and fragmented, patientsafety relies more than ever on teams of people with a rangeof skills working effectively together. What these skills are—andhow strictly they need to be defined, assessed, and regulated—arequestions we must continue to ask.

Cite this as: BMJ 2008;337:a1722

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Skills are very different: Elaine R Carter
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