Thursday, 24 May 2007

He'll be coming round the corner

The latest insightful and frankly bang-on assessment of the dumbing down of medicine and the empowerment of the pseudo-doctor has prompted me to offer my two pence worth. It is simply infuriating that the same old tired arguments come out in defence of the under trained practitioner.

Firstly one must distinguish between the nurse specialist and the 'noctor'. There are numerous extended nursing roles which get the best out of some excellent experienced nurses, for example the wound care nurse specialist or the home IV nurse specialist. These roles work because the experienced nurses work in a clearly defined narrow role, and that role is mainly in nursing related duties. It is not rocket science, but nurses are generally better at doing what their training trains them to do: nursing!

Secondly all health care professionals (HCPs-what a politically correct term) make mistakes. However this does not justify handed more and more medical work to less trained workers. This strain of logic would justify the hospital cleaner being allowed to operate, as 'we all make mistakes'. This is utter nonsense.

The problem comes when certain under trained HCPs are handed roles which they are simply not safe to practice in. It takes a doctor about nine years absolute minimum before they can practice independently, often this is too little even given the great depth to their training. Doctors are trained thoroughly in the art of history, examination and diagnosis. They are also educated to very high levels in anatomy, biochemistry, physiology, pharmacology, neuroscience et al. A key part of a doctor's training is learning to think independently and to make sensible decisions. It is drummed into doctors from day one that it is important for them to ask for help whenever they are not sure of what precisely they are doing.

This is in stark contrast to the levels of training that some HCPs are given before they are let loose on the public. Some experienced intelligent nurses can just about get away with it most of the time, however even they struggle with some of the dangerous new extended roles that the DoH has introduced to cut costs and dumb down the NHS. It is certainly nothing to do with their 'nurse practitioner' training that some experienced nurses can cope with their jobs. Hence when more junior inexperienced nurses are handed extended 'nurse practitioner' roles after a few months of mickey mouse medical training, the faeces inevitably hits the fan.

There are so many problems with these extended roles that I have no hope of summing them all up in this short piece. There is a huge danger to patients as under trained HCPs are let loose to practice completely independently in WICs and GP practices up and down the country. There are also huge dangers in hospitals as various new roles have left under trained workers free to make really big decisions that they are not trained adequately to make; the nursing triage system in Hospital at Night is one pertinent example of this. There is also a massive impact on the training of the consultants of the future, the NHS will not be able to provide a decent service in the future if the juniors of today do not get a proper exposure to clinical problems.

This dumbing down also applies to doctors, as there is arguably too little emphasis in medical curricula on hard knowledge in key areas such as anatomy. While MMC threatens to reduce the high level to which juniors are trained by reducing their levels of experience dramatically, as training is dumbed down to cut costs and create an inferior sub consultant led service.

The motive of this dangerous dumbing down is simple, it's all about saving money at the expense of the quality of the service delivered. It is also remarkably shorttermist and stupid, as many of these new roles are not cost-effective and the dumbing down of medical training could be incredibly damaging to the service in the long term.

This dumbing down cannot be excused by the same old tired arguments. I have got nothing against nurses, in fact a massive majority of the best senior nurses I have spoken to agree with me, while those who disagree cannot put a strong argument for their case forward. Medicine is an art form and cannot be practised effectively by the use of rigorous protocols and proformas. One needs to understand the art form before one can decide which protocol one should use in the first place, otherwise they are more of a hindrance that a help. Most dangerously it is not good enough to claim that anyone is safe working in any role as they will instinctively know when they are outside their 'sphere of competence'; they will not know when they are practising dangerously, this is precisely why medical training is so hard and so long, it does not come instinctively without the experience or the training. Interestingly look who delivered Gordon Brown's babies and who dealt with Tony Blair's dodgy ticker? And think who would you want replacing your knee joint or delivering you the happy gas?

It's just more New Danger from New Labour, and funnily they have never given the public a choice in this dangerous policy; would the public rather be seen by an independently practising doctor or nurse with their tricky diagnostic problem? Interestingly most nurses are far too sensible to be led into these dangerous new roles as independent diagnosticians, unfortunately it is often the least sensible nurses who are the ones to grab these new roles firmly with both hands; unfortunately for the patients that is.


Anonymous said...

The very idea that doctors have to defend their professionalism in the way you have written above is very disturbing and really sad. I never thought we will ever come to this as a profession. Let's not explain, let's fight for our patients, our profession, our training and ourselves. It's not over

Aphra Behn said...

I've said it elsewhere, and I'll say it again: there was a saying that pilots earned their pay once a year in 15 minutes flat, and the rest of the time they just sat next to the autopilot.

The ratios are different for doctors, but the same principle applies. Where peoples' lives are at stake, one should train to account for the most difficult situation, not to account for the average.

Yaya said...

I don't want to wait to audit and research how many patients died because of the so called HCPs so called 'practice.' We need to influence the way we train in the future and have every right to be involved now. Before it is too late.