What skills do doctors and nurses need?
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1722 (Published 18 September 2008) Cite this as: BMJ 2008;337:a1722All rapid responses
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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,
bmhegde
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
Competing interests: No competing interests
The author refers to "nurse doctors". The term "noctors" has been
coined, and is used disparagingly.
Competing interests:
None declared
Competing interests: No competing interests
Sole Discriminant.
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.
Competing interests: No competing interests