Saturday, 23 June 2007

Be sure before you drop your pants

This description of a GP's consultation with a patient is reproduced below, many thanks to the original author for his permission:

"Had an interesting consultation this morning. Paraphrased version:

"Hi, Doc. You got the fax from Urology? Can I ask who signed it?"

"Errrr... Mr Illegible Scrawl. Why?"

"When you referred me urgently to Urology, did you think I'd be seen by a Consultant? I thought I would be - especially as you thought I'd got prostate cancer."

"I got a bit suspicious about the doctor in clinic. He introduced himself as 'Fred', knew something about my cancer but really didn't seem to know anything when I mentioned being treated for mt blood dyscrasia and wasn't remotely interested in that. And he did what you did in the way of examining my prostate, looked at a blood test, then said he'd send you a fax and I should see you tomorrow for treatment"

"When I pressed him a bit and asked whether I should call him 'Doctor' or 'Mister', he replied I should just call him 'Fred'. Then he said he couldn't prescribe any treatment for me, I'd have to see my GP for that."

"When he eventually dismissed me, I made some enquiries from the clinic staff and found out he's something called a nurse specialist. So I've not even seen a junior urologist, let alone the consultant, and they've told me to come and get some treatment for my cancer from you. It was a bit of a waste of time sending me down there if you can't get a proper specialist opinion anymore. I wonder how many less enquiring patients think they have seen a consultant when they come out of there?"

This is not a rare problem either. Patients are being tricked by non-medically qualified staff who pose as proper doctors, in this case the nurse specialist strangely forgot to mention his actual title and this was certainly misleading the patient. When does 'misleading' result in the patent's consent to be treated becoming null and void? There is also the small issue of these nurse specialists managing patients without discussing cases with the medically trained specialists, resulting in the nurse specialist ordering GPs to start their requested treatment. What happens when this is the wrong treatment, does the GP carry the can as the one who is signing the prescription? A worrying situation to find oneself in really for any doctor. Who is going to carry the can when these nurse 'specialists' mismanage a patient's cancer?

Patients are being conned around the country. There are so many stories of this kind of deception that I cannot repeat them all here; but there are nurse consultants (whatever that's meant to mean) in A/E who call themselves 'consultants' only and there are podiatrists who pose as properly trained surgeons. The Witch doctor has already written expertly on this nonsensical drive to call everyone by a vague meaningless name; is this the government's way of pretending that this shoddy dangerous service is good enough for patients?

There are the protocol adoring outreach nurses who prescribe rapid IV fluids for everyone with low urine output, irrelevant of their rip roaring heart or liver failure. There are the acute pain nurses who perform simple arithmetic to convert one painkiller to another, while anything more complicated than this is left to the Consultant Anaesthetist. There are the A/E ENPs who spend hours seeing uncomplicated patients, while the doctors crack on through the majority of the workload. There are the specialist nurses in Dermatology who take hours to see patients with simple problems, only for the Consultant to come and do the job in two minutes. There are the community matrons who spend most of their time with a select bunch of patients, trying to prevent their hospitalisation; however evidence shows that their patients come into hospital just as often as they used to. There are the psychiatric specialist nurses who spend hours seeing each patient in order to produce their life history typed out on A4; it's just a shame they are seemingly incapable of producing a proper psychiatric history and mental state examination, their scribing often resembles an OK magazine feature and not a trained professionals work. There are more examples of this wasteful empowerment program, but I think I have made the point.

This is not a safe or cost effective way in which to reform the NHS. There is definitely a place for experienced nurses to become specialists in particular areas of their nursing expertise, however empowering inadequately trained nurses so that they can have a crack at being doctors is unfair on patients and a big waste of money. I am sure I will hear all the same old arguments coming out in defence of these quacks, but the tiredness of these defences is becoming more and more obvious.

There are going to be thousands of unemployed highly skilled junior doctors this August, while thousands of inefficient nurse practitioners are swanning around seeing patients at their leisure. Junior doctors have medical degrees and are trained to a much higher level, meaning that they have the potential to become independently practising consultants at the end of their training. Nurse practitioners may become nurse 'consultants' but what does this really mean, is it really safe to assume that the
unknowledgeable can be continually promoted to positions of increasing responsibility without any rigorous tests of their knowledge and skills? As a result the sustainable consultant led service is being put in jeopardy and a generation of talent is going to be wasted as medical standards plummet into an abyss of incompetence.

In this New Labour fantasy land, proper examinations and standards are cast aside in favour of a system that allows the untrained to pick and choose what they fancy having a stab at. New Labour's logic allows the individual 'quacktitioner' to be so magically gifted that they can instinctively stay within their 'competence' zone at all times. It's a shame that the ignorami in control don't realise that it takes years of proper training and experience to be able to safely practicise medicine independently, and even then it's a very tricky business indeed.

I am sure there will soon be a day when the advanced nurse practitioner in primary care can refer a patient to their nurse practitioner colleague in the cancer clinic, who can then refer the patient to the surgical nurse practitioner for the operation. The doctor will probably be the one changing the patient's sheets and scrubbing the ward floor by then, the doctor will probably also get struck off when the surgical nurse practitioner stumbles blindly into the patient's aorta with a scalpel, because they never studied anatomy beyond 'Jack and Gill' level. This will be called progress.


Anonymous said...

Not forgetting this Anaethathist practioner job you referred to before as well Gareth!

I think the moral of the story is to frieghten the public until they either die, for real, or get private health insurance. Only the poor will not leave the NHS but who cares about them if they die anyway!:-(

What I find baffling, why didn't the government allow private medical establishment to train doctors following existing Royal Colleges standards instead of the waste and destruction predicted for August 1st?!

The Witch Doctor said...

Thanks for the link Ferret Fancier.

At the risk of sounding like an old stuck gramophone record, The Witch Doctor can only say again and again - "This can only happen if the consultant establishment allows it to happen."

And they are!!!

Just as they allowed MTAS to happen. Just as they are not yet fully understanding the implications of MMC. Just as they are not understanding the sanctity of GP to consultant or consultant to consultant referral.

Its all getting very near the brink.

The junior doctors will need to give them a shake just as they did with MTAS! They will eventually waken up to this too!

Sorry about that!

I always get het up during the witching hour.

the A&E Charge Nurse said...

Interesting post Ferret - inspired, perhaps by Dr Crippen's monkey, baggage handler, bourbon biscuit addict, and recent illiterati ramblings, you have now decided to add your own 'liar/fraud' hypothesis.

The central tenet to your daring new theory is that the Quacks have taken to removing all forms of ID; name badges, Trust photographs, or any other form of insignia that might give the game away - and not only that, this fraudulant behavior is endemic across ALL specialties, as shady Quacks become increasingly economical with the truth.

The consent loathing Quacks feel no obligation to introduce themselves with a line something like, 'my name is Fred, I'm a nurse specialist I may be able to help you with your problem today, if you are willing to see me', no, far easier to cough into a hankey while staring into the middle distance during bollock inspection, yes, thats EXACTLY the way it these days, apparently.

It is reassuring to know that a dedicated army of researchers are out there meticulously detailing these furtive consultations - I can hardly wait for the fly-on-the-wall documentary that will finally expose this dangerous racket,and take Fred & Co down on national TV.

I expect this sensational coup d'etat to be bolstered by authoritive data, painstakingly accumulated during the last 10yrs of international Quackdom, proving once and for all that they are simply a bunch of shameless charletans.

For some mysterious reason, understood only by a few very clever doctors, these studies have never been released before, perhaps they would be too upsetting for patients wishing to discuss undifferentiated haematological problems when they have been sent in for a prostate biopsy, god forbid that a GP should have discussed this before referral.

Yes, its high time this wholesale lying and incompetency was finally exposed, and I'm sure ferret that you are not one those tedious docs who jumps up and down sceaming 'he's behind you' each time the pantomine villian, sorry nurse quack appears.

the A&E Charge Nurse said...

Incidentally Ferret, our department provides a leaflet briefly explaining the role of the ENP is and the type cases they are able to see. The leaflet is prominently displayed at triage.

Garth Marenghi said...


I am still waiting for any half decent defense of NPs extended roles when they are pretty much practising as unsupervised doctors without the proper training.

It is hard to find evidence against lots of reforms that the government have put in place, but this is not a credible defence of the reforms.

Reforms that change the working of the system should not be instigated unless there is evidence proving them to be an improvement in some way.

This government's shady behaviour in suppressing information and data that proves their reforms are dangerous or cost ineffective is well known.

In fact I have already exposed a worrying lack of evidence behind the dumbing down reforms.

If the government is using less trained staff to perform roles that were previously done by more highly trained staff, then they should have evidence to prove that what they are doing is safe.

They do not. Your argument or lack of it, defies logic and common sense.

the A&E Charge Nurse said...

Thanks Garth, obviously we are not going to agree but I think you weaken some decent points by rambling on about Fred, the dim urology nurse, then generalising this isolated consultation to ALL quacks, surely you can see that this not good enough ?

Fact: quacks are an international phenomena and have been going for many decades [if we start with the neonatal nurses in the USA in the 60s].
Whether you like it or not quacks have been a significant presence on the UK health scene for over a decade.

Fact: some consultants have found quacks to be reasonably safe and effective [look at the comments on todays Dr C thread], this is certainly the view of our A&E consultants.

Fact: some docs are anecdote rich but research poor - put very simply, if quacks are even half as inept as you suggest why are there no studies corroborating this contention ?
Or why isn't the MDU website littered with quack related gaffs ?
Lets face it [some] docs would walk over broken glass to obtain incontovertable and objective evidence to back up their incessant warnings, but so far they haven't been able to.

There is a certain breed of blinkered medic that can only ever see the bad when attempts are made to provide a more flexible system that provides safe and effective care most of the time.
I'm not so dim as to be conned by the political expediency, and downright cynicism, driving some of these changes, but at the same time there are very sensible and knowledgeable NHS staff out there, not all of them happen to be doctors though.

Garth Marenghi said...

AE nurse,

Please read my previous comments on evidence, it seems you are ignoring them! Your constant repetition of the same tired point will not turn me round to your way of thinking. In fact on nurse prescribing the evidence does suggest that nurses are struggling in this role. Go look it up.

I have checked the comments on Dr C's piece, nothing much there that does anything to back your argument up.

Seeing as you are so fond of 'facts'.

Fact- the dumbing down is a danger to patients.


dreamingspire said...

This dumbing down is supported by managerialism: in other areas, particularly those based on technology, progress permits methods to be passed down to lesser qualified (or in some cases non-qualified) people, so let us do it everywhere. That which initially needed very careful management becomes eventually commonplace. We can generate electricity at home now, and sell it back to the Grid. It is unthinking transference of this concept to an area where a lot of judgement is needed that is so dangerous. Farmers are doing to animals what vets used to do, so why not pass medical technology down the line? I was at first amazed to read that paramedics use ECG machines now, but should have realised that making the technology available at that level is just a natural progression – but one technician taking an ECG reliably in a crisis situation out in the field, without a second opinion, is very different from the quiet room at the health centre or even using it in A&E with several doctors present. Nevertheless, we should and will continue to see technology pass down to lesser qualified people, and I look to the medical profession to realise that they are embedded in a changing larger network of people, and not necessarily seeing every patient face to face every time. I had an example of this myself a couple of summers ago: suffering an infected wasp sting (the only one of a dozen that had not quickly healed – strange, because my immune system is very good with bacteria but not so with viruses), a practice nurse looked at it, interrogated the computer, and then went off to find a doctor to approve and sign a prescription. Had this not quickly solved the problem, I would have had no problem in seeing a doctor next time round. I saw the same nurse later for a routine test, and got some feedback: others had come in after me with the same report of an infected sting or insect byte.

Dr Ray said...

"I am sure there will soon be a day when the advanced nurse practitioner in primary care can refer a patient to their nurse practitioner colleague in the cancer clinic, who can then refer the patient to the surgical nurse practitioner for the operation."
You won't have to wait long; where I work GP practices are employing American physician assistants who can refer patients to hospital "consultant nurses" for investigation of chest, urology or GI problems. Barium studies and endoscopies are done by extended role radiographers while non-radiographers (radiography assistants) do the radiography. Patients are pre-clerked by a nurse and the first doctor the patient sees is the anaesthetist on the day of the operation.

Dr Ray said...

"Or why isn't the MDU website littered with quack related gaffs ?"
My turn to admonish you for lowering the standards of your usually well thought out comments A&E chargenurse.
The MDU insures doctors for private practice so they are unlikely to comment on cases involving quacktitioners. Quacktitioners are covered by the organisations they work for. If they screw up the organisation isn't going to publicise the mistake and damage their own reputation and I haven't seen the NHS equivalent to the MDU/MPS magazine which highlights the mistakes doctors make despite all the spin about the no-blame open culture in the NHS. In fact, because the quacktitioners are still nominally acting under the supervision of a consultant or GP you will find cases of GPs and consultants being criticised and answering to the GMC for inappropriate delegation when a quactitioner screws up. A case of heads you win, tails I lose.

the A&E Charge Nurse said...

Thank you Dr Ray - as you know the MDU has been taking the quack-shilling for many years.

You seem to be suggesting that all the teflon coated cowboys have to do is point a tremulous finger at the nearest consultant or GP after an error is made - then all will be well [for them] ?

Lets imagine a quack sends a patient away from A&E with some ABx claiming the patient has lower limb cellulitis - the quack then disappears for a couple of days to complete a prescribing course [yes, it's the extended one].

In the meantime the patient is 'blued' back into A&E having developed necrotising fasciitis, only to be advised that a below knee amputation must be carried out sooner rather than later.

In such circumstances the quack could be subject to disciplinary measures by the Trust [which accepts vicarious liability] or professional body [which might remove somebody from the register for gross incompetence].
In theory the patient could also take legal action through the courts - cases involving charges against doctors seem to be on the increase according to recent BBC reports.

The RCN state 'accepted legal advice is that a [nurse] practitioner would always be judged by the standard for the POST. So, for example, if nurses were carrying out a role that in the past might have been considered a medical role, they would would be judged by the standard of a reasonably competent doctor.

Hospital based NPs need to look to the equivilant medical standard for the role they are now taking on [such as an SHO in the A&E department].

It's usually the patient that loses after an error, negligence, incompetence, etc but I'm sure the potential repercussion for offending quacks is potentially much greater than you are suggesting.

Dr Ray said...

but I'm sure the potential repercussion for offending quacks is potentially much greater than you are suggesting.
Yes I am sure this is the case but it is not what you initially said and I replied to. If a NP makes a mistake the employer will pay compensation and, in all likelihood, take disciplinary action and sack the NP. The consequences for that individual will be severe. However this will be done on the quiet. The GMC is open about cases brought before it and it is possible to spend a quiet afternoon gloating over the misfortunes of doctors on its website but I would not get to hear of a cock up by a NP in my own department, let alone it coming to public notice so its no surprise that the papers are not full of NP cock-up stories.
Interestingly I accidentally came across a financial document for Powys estimating future liabilities for negligence and the two largest liabilities were for midwife errors- both over £1 million.

Mark said...

So why is the patient being referred at all? Why can't the GP do the magic things the NP is doing and save the patient the two hour trip and waiting room time?

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