In defence of “noctors”BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d6100 (Published 28 September 2011) Cite this as: BMJ 2011;343:d6100
Doctors often take umbrage at other healthcare staff using “medical” terms in their job titles, but these professionals believe that they use their titles with good reason. Helen Jaques hears it from the “noctors”
The number of professional groups in the healthcare workforce is expanding, and with these new professional groups come new names, such as consultant podiatric surgeon, operating department practitioner, and consultant emergency department practitioner. Many doctors, however, take issue with non-medically trained healthcare staff using titles that include “medical” terms such as “consultant” and “practitioner.” A poll of more than 500 users of bmj.com earlier this year found that four fifths (83%) agreed that the use of titles such as “consultant” and “surgeon” by non-doctors misleads patients, with only 17% disagreeing.1
Doctors’ main argument on this topic is that the use of these titles is confusing for patients: a patient who does not understand the level of qualification of the person treating them could have problems with consent, confidentiality, or even safety. Another concern is that such professionals are not governed by the General Medical Council’s strict guidance on professionalism and that any misconduct by someone titled “consultant” or “practitioner” could reflect badly on doctors and undermine the public’s confidence in the medical profession.
Look a bit closer, however, and it isn’t simply about clarity and conduct. Commentators online have said that the use of medical titles by non-doctors amounts to “disproportional self promotion” and “wonderful ways of self elevation without enduring the trials and tribulations of medical school and subsequent training.”2 Others have suggested that only those who have completed the “arduous and Everest like feat of medical school and foundation training” deserve to call themselves “doctor.”
But is it really fair to level these accusations against non-doctor healthcare staff, or “noctors?” They are, after all, trained in their own field and registered with the relevant independent regulator. So let’s hear the case from the noctors.
Operating department practitioners
One example of “practitioners” who are not medically trained is operating department practitioners, who assist surgeons and anaesthetists in the perioperative environment.
Initially the title for this group of professionals was theatre technician, then it changed to operating department assistant and in the late 1990s to operating department practitioner. “The change was because the ‘assistant’ part of the title did not reflect the evolving role when working as part of the multidisciplinary team,” says Helen Booth, chairwoman of the professional council at the College of Operating Department Practitioners. “It is very much about working together as a team, and ‘practitioner’ reflected the more autonomous aspect of the role and the responsibility we have.”
Operating department practitioners are required to register with the Health Professions Council, which regulates professional conduct and validates training programmes for several of the allied health professions. The council’s role is similar to that of the General Medical Council: it has the power to discipline and strike off professionals who don’t meet its standards on character, conduct, performance, ethics, and proficiency.
This independent regulation of the profession means that operating department practitioners are expected to practise the same levels of professionalism and treatment of patient confidentiality as doctors, says Ms Booth. Operating department practitioners are responsible for ensuring that they practise within their sphere of competence—any practitioner who works outside their competence and causes a patient safety incident risks being struck off, just like a doctor. “You hear a lot of medical practitioners say, ‘I ultimately have to take the responsibility,’” says Ms Booth. “Well, this is not strictly true. Because of registration, all practitioners have responsibilities for their actions.”
Patients don’t seem to have a problem with the title “operating department practitioner,” she adds, as they’re generally more concerned with the quality of care they’re getting than the job title of who is delivering it.
Another group whose rise in the ranks of medical titles reflects increasing expertise and competence is nurses, who can now practise at masters or PhD level as advanced nurse practitioners or nurse consultants. Advanced nurse practitioners generally run clinics in general practices, whereas nurse consultants tend to lead clinics in secondary care; both act autonomously.
Initially doctors seemed unhappy with nurses using the titles “practitioner” and “consultant,” because they were seen as taking away some of the roles that doctors would historically have performed, says Steve Jamieson, head of nursing at the Royal College of Nursing. “I don’t want to get into a battle about who does it best or who does the role best, though,” he says. “For me it’s very much about having the right people skilled, trained, and competent to carry out the service and give patients the best possible care they can.
“Medical consultants can’t do it all, and we’ve got some nurses out there who are doing some brilliant work and are helping to treat and manage patients with lots of conditions.” Medical consultants and nurse consultants in many areas work together very closely, he says, as each group brings different skills to day to day management of patients.
He admits, however, that although all nurses are registered with and regulated by the Nursing and Midwifery Council, at present no specific regulation exists for advanced practice in the United Kingdom. However, the Nursing and Midwifery Council and the Royal College of Nursing are currently working with the government on ways to regulate and standardise high level nursing practice.34
Dentists and doctors don’t usually coexist in primary care, although both use the title “practitioner” in this environment. Where there might be room for overlap and confusion is in secondary care, where dentists can practise as maxillofacial or oral surgeons. However, dentists practising in this setting will often either be dually qualified in medicine and dentistry or have taken courses accredited by the Royal College of Surgeons of England, says Peter Ward, chief executive of the British Dental Association.
“If you go into hospital to see an oral surgeon, you’ll be seeing someone who has done extensive training and has got extensive experience in that area,” he says. “From the point of view of a patient, I think the bigger issue is working within spheres of competence. I think that as long as people are clear about the areas in which they will work and the areas in which they won’t, I think that’s more important for patient safety.”
As a rule, patients’ main concern is whether the person treating them is competent to do the job, he says. “If you’re going to have your mouth or your teeth or your face treated, you go to somebody who has got the appropriate skills and qualifications in that area, in the same way you would with your spleen or your big toe.”
Dentists in the UK are also able to refer to themselves as “doctor” on the basis that dentists in other countries around the world use the title. However, last year the General Dental Council, the registration and regulatory body for dentists, held a consultation on whether dentists should be banned from using the courtesy title “doctor” unless they have a PhD or are a medically qualified and registered doctor.5 The council has yet to make a decision on the results of the consultation, but the British Dental Association is of the view that dentists should be able to use the title “doctor,” to ensure that dentists are appropriately valued at home and abroad.
Consultant podiatric surgeons
One group that seems to attract particular disdain from doctors with respect to their title is consultant podiatric surgeons, who perform day case foot surgery on patients under local anaesthetic. In fact, just last year the Royal College of Surgeons of England issued a statement saying that the variable use of the term “consultant surgeon” is misleading to patients and that the title should be restricted to medically qualified practitioners in a surgical specialty who are on the specialist register of the General Medical Council.6
Consultant podiatric surgeons try to ensure that patients understand their experience and qualifications, says Ron Finlay, a spokesman for the Society of Chiropodists and Podiatrists. “Part of our code of conduct states that we should make sure that patients recognise that we may not be registered medical practitioners, but nevertheless we are specialised and competent in the areas required,” he says. Patients simply want to know that the person who is caring for them is experienced, suitably qualified, and will give them a clinical result of high quality, he adds. “The track record and the audit processes of our podiatric surgeons show that patients can indeed get that quality just as well from us as from another source.”
Prospective consultant podiatric surgeons have to complete up to 11 years of undergraduate and postgraduate training before they are able to practise as podiatric surgeons, not entirely dissimilar from the amount of training required of a medical surgeon. “One accusation that has been levelled at us from some quarters is that we are not qualified to identify complications and that patients can be put at risk, but that is not the case: our exams and our clinical training are designed to ensure that the clinician is trained to recognise when other help is required,” says Mr Finlay.
He suggests that other health professionals regard podiatric surgeons as unwelcome competition in the area of foot surgery, which traditionally had been the preserve of orthopaedic surgeons. “Our view is that this is in fact a sort of disguised campaign by some other health professionals who feel threatened by podiatric surgeons breaking what they might regard as a closed shop,” says Mr Finlay. “We feel under attack, with the medium of titles being used to try to discredit us. We believe that this is a spurious issue; in truth, it’s all about competition and the fact that orthopaedic surgeons don’t like this competition.”
Of course, it could be argued that surgeons themselves are adding to the nomenclature confusion by referring to themselves as “Mister” rather than “Doctor.” Until the middle of the 19th century surgeons were trained by the Company of Barber-Surgeons and were afforded the title “Master,” from which “Mister” originates. Surgeons were not required to go to university to train for a doctorate degree like medical doctors but instead completed a diploma, so surgeons were unable to call themselves “Doctor.” Although surgeons now complete a medical degree before starting surgical training, consultant surgeons retained the title “Mister” as a “quaint anachronism,” says the Royal College of Surgeons of England.
We’re all in this together
All healthcare professionals in the NHS are registered, regulated, and expected to practise within their sphere of competency. It is possible that a non-medical healthcare professional might not clearly explain his or her role and qualifications to a patient, but doctors are just as liable to do the same, and both groups risk being taken to account by their regulator for this sloppy conduct. Irrespective of accountability, any good healthcare professional can be expected to behave professionally, as Ron Finlay says, “After all, any good practitioner or clinician will respect patient confidentiality whether or not they are vetted by the GMC.”
The main message from the noctors seems to be that all NHS staff operate in multidisciplinary teams where everyone has to work together within their level of competency. Whether the professional working next to you is an “assistant” or a “practitioner” is not really that relevant to you or the patient, as long as you are both working together to secure the highest quality care.
Competing interests: None declared.