Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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It is not Doctors vs Nurses
- Sherief Elsayed (19 September 2008)
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Who will be doing the nurses job?
- Suvira S Madan (20 September 2008)
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Doctors and Nurses
- Hugh Mann (20 September 2008)
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Patient will see you now
- Phillip J. Colquitt (20 September 2008)
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Re: Doctors and Nurses
- Umesh Prabhu (21 September 2008)
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It's not what you do, it's what you know
- June Clark (21 September 2008)
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Noctors
- Phillip J. Colquitt (21 September 2008)
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Perfect order is the forerunner of perfect horror.
- BM Hegde (21 September 2008)
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Nurse diagnostician: a patient's experience
- Reza Nouraei (22 September 2008)
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Society and Superiority
- Hugh Mann (22 September 2008)
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Playing Doctors and Nurses
- Richard D Rawlins (22 September 2008)
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we are a TEAM
- Ambreen Aslam (22 September 2008)
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Protocols, case mix (and costs)
- john sharvill (23 September 2008)
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the probabilistic model of doctor-led clinical practice is currently the best bet
- oscar.m jolobe (23 September 2008)
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Re: Society and Superiority
- Phillip J. Colquitt (24 September 2008)
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Sole Discriminant.
- Andrew Mimnagh (25 September 2008)
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Lets return to the "Root cause"
- Sidha Sambandan (25 September 2008)
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I agree that we should return to the root cause
- oscar,m jolobe (26 September 2008)
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there is a big difference
- elaine r carter (26 September 2008)
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Call me Doctor!
- Vicky M Vella (29 September 2008)
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Re: Who will be doing the nurses job?
- Chris LN Chant (1 October 2008)
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nurses are not inferior they are simply different
- Ihab F Suliman (3 October 2008)
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Doctors, Nurse Practitioners, and Nurses
- Christian T. K.-H. Stadtländer (4 October 2008)
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Separate but complementary
- Anthony Papagiannis (5 October 2008)
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Nurse and Physician Skills
- Nazan Karaoglu (9 December 2008)
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Sherief Elsayed, Specialist Registrar, Trauma and Orthopaedic Surgery Nottingham
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Editor I read with interest the article 'Dr Nurse will see you now'. The issue surrounding doctors and nurses is sometimes confused by doctors as nurses 'taking over their responsibilities' and by nurses as doctors 'belittling their skills'. The main issue however must not be about who it is that looks after the patient, but who it is that is most appropriate to look after a patient. Should a patient have a straight-forward complaint (to be defined) that can be looked after by a 'nurse/nurse specialist/advanced care practitioner/insert title here' that has the specialist skills to deal with such complaint, then all well and good. The problem arises when the actual presenting complaint is not adequately defined. Whilst nurses may be expert at one particular clinical condition (pain, diabetes, wound healing etc), it requires more than such expertise to deal adequately with all patients. It requires not only depth of knowledge but breadth - and this is where specialist nurses pose a potential danger to the patient. The potential examples are endless - the diabetes nurse prescribing metformin to control hyperglycaemia in an acidotic patient; the transplant nurse suggesting an increase in the immunosuppressant medication despite evidence that it is such medication leading to a rise in creatinine in relation to the kidney transplant; the list goes on. Doctors and nurses have different training - fact. Anyone can become a doctor (subject to adequate academic achievement) - fact. Patients require medical treatment as well as care - fact. If nurses are keen to undertake the doctor role then we must ensure that they have the breadth and depth of knowledge required to undertake such role. Medical conditions/ailments/diseases can all present in a variety of manners and it is such breadth and depth of knowledge that helps us as doctors to reach an accurate diagnosis; or to to at least seek a diagnosis. In the 21st century this is achieved through 5 years of medical school with assessments throughout. The skills provided by nurses are invaluable, and some may argue more important than those offered by doctors. It is not an issue of hierarchy that is being debated, but of who is rightly placed to care for our patients. Competing interests: None declared |
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Suvira S Madan, Consultant physician S5 7AU
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It will spell only disaster to good quality patient care if nurses start doing doctor's job. Have we given a thought--who will be doing the nurses job---basic good quality nursing care like feeding a patient, pressure care,compassionate wholistic care,communication--the fundamental essence of health care will be sacrificed for inadequately qualified,poorly monitored second class so called "specialist nurse doctors" and shortage of nurses to do the excellent job they are trained to do. It just spells doom. Competing interests: None declared |
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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Life is competition for survival. This competition breeds conflict and jealousy, which affect all relationships, including those between spouses, siblings, neighbors, and co-workers. So we shouldn’t be surprised that there is some conflict and jealousy between doctors and nurses. However, we must ensure that no internecine competition ever affects the quality of patient care. Competing interests: None declared |
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Phillip J. Colquitt, Technician/RN Independent Comment
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I work with student nurses from university, and with student doctors from university, in what is termed a "teaching hospital". Have done for 30 years, in different countries, and in different settings. The cyclical nature of medical and nursing fashion observed therein, leads me to conclude that neither profession are acting in a rational manner. Doctors tend to turn a person into a patient, to fulfill the teaching hospital/clinical trial role, and nurses turn an adult into a child to fulfill their own maternal role. Doctors, through being told by teachers and parents from an early age that they are of superior intelligence, tend to think they know everything, but anyone who has researched in depth knows that they don't. And even if they did, the more vast the assemblage of fact, upon which a conclusion is based, the more it invites further assembly of fact needed for second opinion, when all that's really needed, is a decision. Nurses, through being in the only job a woman could return to after childbirth, feel very anxious about abandoning the entrenched "breeding club" format, and have tried unsuccessfully to make their estrogen driven thinking into something broadly recognizable, despite the community at large showing no interest. News items citing nurse research barely exist, while medical research is often cited. As a person seeking help, I would always choose a male medical qualified doctor I know, and avoid hospitals at all costs. Rather than choose a nurse, I would tend to go surfing - the risks seem the same with either. Competing interests: None declared |
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Umesh Prabhu, Consultant Paediatrician The Acute Pennine Hospitals NHS Trust, OL11 5RF
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I don't think it matters who actually provides the care, provided they are properly trained to do the job, have proper skills to do the job, always put patient safety and their well being at the heart of their duty, know their imitations, seek help and expert advice when appropriate and has some excellent communication skills, inter-personal skills, leadership skills and human emotional skills to take the patient through the difficult time during their illness and values, respects and involves patients as equal partner. The qualifications, race, gender, age, ethnicity or place of qualifications are all immaterial. It is wrong to expect nurses to do everything what doctors do and it is equally wrong to expect doctors to do many things what nurses do. The most important thing is to make sure that there are good quality assurance and performance management systems to make sure clinicians do the job for which they are trained and appointed. It is a team work and we must respect and value each other and make sure that our patients get the best possible care and NHS is a good value for tax payers’ money. Competing interests: None declared |
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June Clark, Professor Emeritus not applicable
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Both Fiona Godlee and your rapid response respondents are missing the point. Disciplines do not define themselves and distinguish themselves from other disciplines by what they do, but by what they know. What nurses and doctors do varies according to circumstances of time and place. Both doctors and nurses diagnose - as do all who use a problem solving clinical process. The difference is in WHAT they diagnose. Of course there is some overlap because some knowledge is shared, but doctors primarily diagnose and treat diseases because that is what they know about. Nurses generally know less about diseases and their treatment. Their knowledge base is different. One widely used definition of nursing(eg in the Nursing Practice Acts of most states in the USA and in many other countries) is that "nursing is the diagnosis and treatment of human responses to actual and potential threats to health". Sometimes these "nursing diagnoses" are symptoms or consequences of disease, but any two people with the same disease may have very different nursing diagnoses, and therefore need different nursing treatment. Nor is it true that nurses deal only in certainty - clinical judgement is just as important in nursing as in medicine. Indeed the core of the RCN definition of nursing is "the use of clinical judgement in the provision of care". Doctors and nurses are not in competition - their two disciplines are different and complementary. Competing interests: Former President of the Royal College of Nursing |
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Phillip J. Colquitt, Technician/RN Independent Comment
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The author refers to "nurse doctors". The term "noctors" has been coined, and is used disparagingly. Competing interests: None declared |
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BM Hegde, Editor in Chief, Journal of the Science of Healing Outcomes. Mangalore-575 004.
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Dear Fiona Godlee, Your editorial and the related articles make very interesting reading. When a human being is ill or imagines being ill s/he needs someone for solace in whom s/he has confidence. This could be a doctor, a well trained nurse or, as happens in many poorer nations, even a quack! I wonder if, at the end of the day, it makes much difference as long as any of these do not over-intervene. They all could “cure rarely, comfort mostly, but console always.” Diagnosis seems to be bugging us. Diagnosis itself has become a disease these days in otherwise healthy individuals! Mary Tinnetti, from the Yale University School of Medicine, cogently argues that our obsession with the diagnosis at the cost of understanding the patient and his/her problems has landed us in the mess that modern medicine is in today. I couldn’t agree more with her. Time has come for us to think! “Time has come to abandon disease as a concept in the medical field. The complex interplay between biological and non-biological factors, the changing spectrum of health, the ageing population, and the inter- individual variations in health priorities render medical care that is centred around individual diseases and their treatment at best out of date and at worst harmful.” She goes on to show, in that article, how the system has become a curse on mankind! (1) With that background, as Hippocrates rightly noted that there is a greater need to know the patient better than his disease (diagnosis), any one of the above three categories of people, who touch the lives of the patients, could do just that as long as they have compassion and understanding. The Placebo effect (Expectation Effect) does the rest. Some diseases do not get corrected at all despite our best efforts. They need palliation. If a nurse is properly trained, provided we have selected the right human being to be a nurse or a doctor in the first place, could just as well accomplish that task. Our “thought leaders” and sub-specialists ( I am sorry, I belong to that class) have come to know more and more about less and less and eventually, as Albert Einstein rightly pointed out, most of us have come to know more and more about NOTHING except our special tools and techniques. In other words most specialists are only well trained technicians, who have lost touch with the reality of patient care which, as Francis Peabody of the Mass. General Hospital noted, is just CARING for the patient. The science of medicine is not perfect, anyway. The fine art of medicine is what matters at the end of the day. Having said that I must hasten to add that if the nurse that sees any patient for the first time feels that the patient’s problem is beyond her field of experience and judgment, she should have to means and training to get a second opinion from a senior doctor or should be able to refer the patient to such doctors lest she should mess up with the management. Emergency care is the only exception where doctor and nurse should both be present. Emergency problems are less that 5% of the total patients load on any given day, if we took the incidence of all diseases in the population: I am not talking of hospitalised patients alone. Countries like Japan where the proportion of family physicians to specialists is the best, people live the longest and the mortality was the lowest among the fourteen industrialised countries studied with USA being the last but one because of their reverse ratio of specialists to family physicians. (2) Time and again when doctors went on strike and nurses manned the hospitals in Saskatchewan, Los Angeles County, Bogota, and lately, in Israel did not the mortality and morbidity fall only to return to the usual high levels when doctors came back to work? (3) Roman thinker Cicero rightly said that “we have to learn from history; otherwise we will have to relive history.” Yours ever,
References: 1) Tinnetti M. Freid T. The demise of disease. Amer J Medicine 2004; 116: 175-183. 2) Starfiled B. Is US medicine the best in the world? JAMA 2000; 284: 483-485. 3) Siegel-Itzkovich J. Doctors strike may be good for health. BMJ 2000; 320: 1561. Competing interests: Interested in patient care |
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Reza Nouraei, Specialist Registrar - ENT Surgery Imperial College Healthcare NHS Trust
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I read with interest the article about the blurring lines between doctors and nurses and in particular the increasing use of nurses as diagnosticians. To this discussion I would like to contribute my personal experience as a patient. Some months back I took a course of non-steroidal anti-inflammatories to discover that I was very sensitive to them. I had an upper GI endoscopy by a nurses endoscopist and this was done after I had experienced several episodes of melena, a documented 5g drop in Hb, an elevated urea:creatinine ratio, and while having orthostatic hypotension. Consent was obtained with the statement "I will be doing the procedure with Dr xxx". The proceudre, which on my request was done without sedation, took less than 3 minutes, no pictures were taken, and I was discharged with no follow-up arrangements and no medical involvement. On reflection I should have made a fuss but I didn't. Cutting the long story short, a peri-arrest episode, countless units of blood platelet and FFP transfusion, a visceral embolization, a therapeutic endoscopy, and several days on ITU later, the ulcer was diagnosed to be where NSAID- induced ulcers often are, the second part of duodenum. The key difference between a trained medical diagnostician and a technician, which in our enthusiasm to devolve our work we have been only too keen to belittle and dismiss, is our ability to take the patient's medical history into account when performing a diagnostic examination. Had this basic premise been applied to my care, with every single alarm feature having being present, it is unlikely that I would have had to glimpse the pearly gates. Conversely, when on ITU and on the ward I received exemplary care from the nursing teams and could not speak highly enough of their compassion and professionalism in looking after me, something that has too made a lasting impression on me. This experience overall has made me come to believe that as a multidisciplinary team we provide the best and safest care for our patients when we respect the work that we are each best trained to do. Competing interests: I had a near-death experience due to misdiagnosis by a nurse endoscopist. |
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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Society is based on institutionalized stratification. The monarchy has the royalty and the commoner. The military has the officer and the enlisted. The workplace has the employer and the employee. The bank has the creditor and the debtor. The hospital has the doctor and the nurse. Stratification is an elitist system, in which a few fortunate people, with special titles, blindly and arrogantly luxuriate in the delusion that they are actually superior to others. Competing interests: None declared |
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Richard D Rawlins, Consultant Orthopaedic Surgeon Bath
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Of course nurses can do many of the tasks traditionally done by doctors. And so can YTS trainees. But 'doctors' are defined as those qualified to practice medicine - so whatever else a nurse may be doing, she/he is not practicing medicine. Or if she/he is - she/he is not qualified to do so. Titles and professional status do not matter. The only issue for the patient is whether the practitioner is properly and fully qualified. If patients want a practitioner qualified in medicine - that must be a doctor. The photograph accompanying Rebecca Coombes article (BMJ 20th September p.660-662) shows a nurse wearing a ring and watch on her ungloved hand, twisting awkwardly to 'remove a mole' from the back of a sitting, not lying, patient. Whether the mole was a melanoma we are not told, but clearly there is a variation of standards in the NHS. The article itself is replete with phrases about 'nurses marching forward', 'nurses have made significant inroads', but short of the one clear remedy for their ambitions: Nurses who wish to practice medicine should qualify as doctors. Competing interests: None declared |
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Ambreen Aslam, staff grade wickham unit , Blackberry hill hospital Bristol ,BS161WS
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The debate for the skills that are required for either the doctors or the nurses is never ending. There seems to be some dis satisfaction expressed by either for the other if anything or something gets challenged or goes wrong. However, the truth is that doctors and nurses make a fantastic team to provide good care to the patient. But having worked in a low secure mental health unit I do agree with the editor's phrase that Doctors need to take risks and deal with uncertainty, while nurses are more attuned to following protocols and providing hands-on care. and this seems to be helpful as nurses would find it hard to just take a decision on their own for a patient's leave detained under section 37/41 by the ministry of justice. Perhaps more training in everything or as we do have specialist nurses can be the answer. But the question is can doctors be good nurses?????? something to think about. Competing interests: None declared |
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john sharvill, GP Deal England CT14 7AU
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The leading article and associated debate articles make predictable reading. As a GP I need to see the ordinary to cope with the unusual, this includes minor illness. If all I saw were complex co-morbidities and undiagnoseable problems etc I would collapse! I also see my role is sometimes to stop people being put on protocol escallators to morbidity or death- ie when to stop trying to lower BP or HBA1c etc. I have several patients now who see a diabetic nurse, a respiratory nurse,a heart failure nurse, a rheumatology nurse, a community matron, possibly several consultants, and pharmacist who likes to review medication. They all know their bit extremely well and adjust treatment along guidlines laid down escpecially those who are prescribers. How the patient copes I do not know. All I know is come Friday pm they all seem to be unavailable (perhaps last bit unfair). As long as nobody at the DOH does not think this saves money ! Competing interests: Trained as doctor |
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oscar.m jolobe, retired geriatrician manchester medical society, c/o john ryland university library, oxford road, manchester M13 9PP
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It has been said of clinical medicine that, as in biology and, for that matter in modern physics, its inherent complexity demands "attitudes quite different from those heretofore common in (traditional) physics"(1)(2). What is equally important, in the context of clinical medicine, is "the clinician's personal experience with the patient's complex behaviour observed over a long time"(1). What is unpredictable is the extent to which such experience will be eroded if its acquisition is "outsourced" to nurse-led practice at the expense of doctor-led practice. What is undoubtedly true is that, by virtue of the nature of their training doctors are better able to integrate into their own clinical problem solving strategies the probabilistic dimension which complex systems necessitate. As a result doctors are better able than nurses to resolve the tension between probabilistic strategy and the reductionist strategy so dear to protocol-driven and, hence, nurse-led clinical practice. Accordingly, until such time as all medical disorders become "protocol-friendly" our best bet is to adhere to the doctor-led model of clinical practice. As the saying goes "If it is not broke, don't mend it" References (1)Frey A., Suki B Complexity of chronic asthma and chronic obstructive pulmonary disease: implications for risk assessment, and disease progression control Lancet 2008:372:1088-99 (2)Goldenfeld N., Kadanoff LP Simple lessons from complexity Science 1999:284:87-89 Competing interests: None declared |
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Phillip J. Colquitt, Technician/RN Indpendent Comment
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Best post I've seen on this site lately - a doctor admitting the truth, instead of the patient. Competing interests: None declared |
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Andrew Mimnagh, GP Principal Waterloo L224QD
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One sole area appears to distinguish Medical performers from Nursing performers( with substantive indivdual overlap between the two groups I concede)- personal professional autonomy."The Buck Stops Here" A medical education encapsulates the belief and expecation that the performer will be ultimately personally accountable for their decision. Medical practioners expect the ultimate priviledge (and therefore accountability) for doing pretty much anything they can justify to a legal enquiry as appropriate and based on a genuine desire to improve the patients condition. A variety of extreme variations such as intravenous potassium as an unpublished experimental analagesic in terminal care (Regina Vs Lodwig 15th March 1990)have been presented as a justification of action. The nurse practitioner generally works to "Protocol" which is followed without variation, and engenders the belief that actions within "the protocol" are outwith comment or accountability of the individual practioner. Indeed subsequent individual scrutiny of a nurse working to protocol is frequently percieved as "unfair" by the peer group and the accountability is automatically regarded as a "failure of the System" The mechanism of resolution is to "redraft the protocol". The professions therfore roughly divide on whether final accountability is seen as "personal" or "system" attribute. I profess no view as to which is the more "just" for the patient; I merely draw your attention to what empirically seems the only remaining discriminating measure between task performers. Competing interests: Medical Practioner. Father a Nurse. Brother a Diabetes specialist Nurse.Other Brother a Medical Practioner too. |
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Sidha Sambandan, GP Yare Valeey Medical Practice, Norwich NR1 1TJ
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The current debate would not have risen, if not for the fact that the workload of doctors had increased tremendously over the last decade, which led to strategies to reduce this workload by delegating some of the "lesser problems and technical taks" to Nurses. The Managers loved the concept, as in their short sightedness, it was more "cost effective". A Medical doctor has to go through 5 years at Medical School, followed by at least 2 years thereafter, before spending another 5 years at least to practice a specialist in Primary Care or Secondary care. None of the other professions have such a degree of training with apprenticeships and life long learning, to hone in the experience needed to manage the complex human problems in a holistic way. Sadly, some Nurses trying to be doctors, have lost the very essence of nursing - caring,compassionate role that a nurse should have, which is as important if not more important than the medical treatment for the patient who is ill. The "healing" of the patient requires both the doctor and the nurse. Being a Nurse technician doing a procedure is different from being a doctor. The knowledge and experience at the other end of the Endoscope does matter. Competing interests: None declared |
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oscar,m jolobe, retired geriatrician manchester medical society, co john rylands university library, oxford road, manchester M13 9PP
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Although, as suggested by Dr Sambandan, managers loved the concept of delegating to nurses some of the tasks traditionally performed by doctors(1), the root cause of the consequent blurring of the boundaries between doctor-led practice and nurse-led practice is that doctors conspired with the managers to recruit and train nurse consultants and nurse specialists. In a nutshell, without doctors to train them(or half- train them, as the case may be), there would be no nurse specialists. In some instances the motives were altruistic, if not questionable, as in the instance of the doctor who said he could not cope if all he saw were complex co-morbidities and undiagnosable problems(2). And yet, dealing with complexity, even if one cannot put a conventional diagnostic label on it, is just what doctors have been trained to do, down the ages, because, like the poor, both the diagnosable and the undiagnosable, as well as the complex and the straightforward, will always be with us. What is also universal about the way medicine is taught is that it inculcates positive attitudes towards complexity, given the fact that "complexity demands attitudes quite different from those heretofore common in (for example) physics"(3)(parentheses are mine). Finally, "a clinician's personal experience with the patient's complex behaviour observed during a long period"(4) is probably what inspires confidence to a much greater extent than a protocol-driven encounter with the diabetic nurse, heart failure nurse, or rheumatology nurse. Accordingly, when we opt out of "complex co-morbidities and undiagnosable problems" we do so at our peril because, as we become increasingly deskilled in the art and science of dealing with complexity, patients will, sooner or later, realise that "the doctor- emperor" neither has solid experience or, for that matter, "any clothes on", and that recognition will hasten the demise of our credibility as a profession. References (1) Sambandan S Lt's return to the "Root cause" Rapid response British Medical Journal 25th September 2008 (2) Sharvill J Protocols, case mix(and costs) Rapid response British Medical Journal 23 September 2008 (3) Goldenfeld N., Kadanoff LP Simple lessons from complexity Science 1999:284:87-89 (4)Frey U., Suki B Complexity of chronic asthma and chronic obstructive pulmonary disease: implications for risk assessment, and disease progression control Lancet 2008:372:1088-99 Competing interests: None declared |
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elaine r carter, gp principal bridge road medical centre l21 6ph
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my experience tells me there is a big difference between the knowledge skills and abilities of doctors and nurses. I trained as SRN/RSCN for 4 years and worked as staff nurse research nurse and ward sister for the following 7 years. This gave me considerable clinical experience and knowledge of nursing and some medical knowledge. I then went to medical school and found I knew about 10% of the course already The only exemption i was given was to not attend the 1 weeks nursing experience. The clinical interest i already possessed enhanced my training so i got distinction especialy in physiology and pharmacology However anatomy , pathology and diagnostics were completely novel. A a gp I still feel that the knowledge and diagnostic skills i have now are not possessed by nurses. I do not find diagnostic agreement in patients who have been to the walkin centre, with district nurses dressing a wound for a week where angulation of colles fracture goes unoticed, or the overall evaluation of patients by clinical specialist nurses too influenced by an individual protocol. Nurses I feel realise that they have not got this ability. This is shown by the number of nurses who undergo clinician or prescribing training then dont use it. Prescribing figures would show that they dont prescribe much but otc medication and the large proportion trained who then move to a management only role ( all the nurse clinicians in our pct) Competing interests: I am a GP , a state registered nurse and sick childrens nurse , a chronic patient |
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Vicky M Vella, Associate specialist A&E Worcester
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I find it interesting and somewhat frustrating that these nurse practitioners, presumably wearing a nurses uniform find themselves having to stop patients from calling them 'Doctor', when for the last 22 years I have been examining and treating patients only to hear 'Thank you nurse' !!! Competing interests: None declared |
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Chris LN Chant, FY2 General Practice DN34 7XE
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I agree with Suvira S Madan above. Who is going to do the nurse's job? Talking with the nurses on the wards i have worked it is evident that many went into nursing because they enjoy the 'traditional' roles that nurses perform, that is the care of the patient as a whole and especially their basic needs while they are ill. This is the basis of a humane and safe environment in the hospital and an essential role and i feel the current debate denigrates this a little, as if the job a 'nurse practioner' or doctor does is more important or advanced than that a nurse does. I'm not implying that nurses should be confined to these 'traditional' roles, in fact it may help doctors to spend time doing jobs only they can do if a nurse can do some of their duties, this has to be balanced against de-skilling junior doctors however. Clearly there is alot of crossover in what doctors and nurses do. But ultimately, as others have said, they do different jobs for the majority of the time When a nurse does mostly duties done by doctors and hardly any or no jobs that a nurse normally does, it does beg the question, why don't they just become doctors? Competing interests: None declared |
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Ihab F Suliman, Associate Consultant King Abdulaziz cardiac center, National Guard hospital , Riyadh, KSA
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The basic skills from all health care providers are dedication, hard work & being a good listener. Nurses are not inferior to doctors, they are simply different, their role is essential in the medical care. Basic human values, should be taught well in medical or nursing schools, a reform is therefore needed in medical education. Competing interests: None declared |
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Christian T. K.-H. Stadtländer, Microbiologist and Epidemiologist University of St. Thomas, EdD Program, College of Applied Professional Studies, Minneapolis, USA
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I read with interest the editorial by Fiona Godlee about the skills doctors and nurses need (1). Often, these skill sets are overlapping and are not clearly defined. Godlee mentioned the standards for training and experience of nurse practitioners in the UK. Nurse practitioners in the United States play a significant role in health care. Nurse practitioners are licensed, independent practitioners who have completed advanced nursing education and training in diagnosing and treating a broad range of illnesses (2, 3). They take health histories, perform physical examinations, order and interpret diagnostic tests, and prescribe medications. There are many more services nurse practitioners provide (2-4). Nurse practitioners work in primary and acute care settings, such as pediatric and adult health, school/college health, geriatric health, and psychiatric/mental health, to name only a few (4). The profession of the nurse practitioner evolved in the US in the mid -1960s when there was a shortage of physicians (3). Since then, nurse practitioners provide high-quality, individualized, and cost-effective health care, but differ from physicians in that their primary focus is on prevention, wellness, and education. They differ from nurses in that they have advanced education and clinical training, as well as more responsibilities (2-4). Good health care depends on an optimal interaction between health care providers. In this regard, I fully agree with Godlee (1) that "As health care becomes more complex and fragmented, patient safety relies more than ever on teams of people with a range of skills working effectively together." References 1. Godlee F. What skills do doctors and nurses need? BMJ 2008;337:a1722. 2. American Academy of Nurse Practitioners. Scope of practice for nurse practitioners. Retrieved October 2, 2008, from www.aanp.org. 3. Mayo Clinic. Nurse practitioner career overview. Retrieved October 2, 2008, from http://www.mayo.edu/mshs/np-career.html. 4. Nurse Practitioner Central. About NPs. Retrieved October 2, 2008, from http://www.npcentral.net/consumer/about.nps.shtml. Competing interests: None declared |
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Anthony Papagiannis, Respiratory physician St Luke's Hospital, Thessaloniki, Greece
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One gets rather tired of seeing some themes recurring over time in the literature. My first rapid response on the doctor-nurse issue was published in April 2000 ["It is not the name, but the essence of the profession that matters", http://bmj.com/cgi/eletters/320/7241/1083#7430], and a letter of mine titled "Separate but complementary" appeared in the Journal on 7 January 2006 [doi:10.1136/bmj.332.7532.52-a]. The text of the latter is appended here: "Editor— In my several years of postgraduate training I have had the privilege to work with, and learn from, numerous nurses, male and female. They never pretended to be anything else than their title implied, and they expected me to authorise their suggestions about patient management, even though their experience (particularly in specialist units) was longer than my own. Through this collaboration I have come to appreciate the complementary skills that diverse professions can bring into the care (and occasionally the cure) of the whole person. Blurring the roles can never accomplish as much as mutual respect and cooperation between varied skills." Having read the preceding correspondence I do not see any reason for varying my opinion on the subject. Competing interests: None declared |
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Nazan Karaoglu, Assistant Professor, MD Medical Education and Informatics Department, Selcuk University, Meram Medical Faculty, 42080, Konya
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Dear editor, I read "What skills do doctors and nurses need?" and the responses with a great interest as a medical educator of tomorrow's doctors. The "white coats" of medicine seem not to be ready to abdicate their responsibility and honor to another profession. Honestly, as a medical doctor I am not ready to give up, but realistically when I thought about my education years, practice years in different hospitals and health care units I must say that I learnt a lot from nurse practitioners. While physician teachers have no time, nurses were always there to ask, to learn and to teach. Does it mean that they can be a doctor? No, but as a different profession of the team I know that they are always nearby me. I believe that some overlapping skills are well-done by nurses because they are always doing it in daily practice in patient care. As Godlee pointed out doctors takes risks, deals with uncertainty and this skill is neither easy to gain nor easy to quit. Competing interests: None declared |
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