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‘Can I have an X-ray for this patient’s wrist? I think it’s broken,’ said the triage nurse.
‘Sure,’ I said. ‘I’ll just come and take a quick look at it.’
‘Oh, it’s okay,’ she answered, slightly disgruntled. ‘I’ll ask someone else.’
She was highly experienced and just as able to recognise a fractured wrist as I am. The signature on the request for ionising radiation, however, would be mine. Likewise, if I’m prescribing something on the request of a specialist nurse, I’ll always check their calculation. They’re no more likely to get it wrong, but in the final analysis the responsibility lies with the prescriber.
Long ago when I was a very newly-qualified doctor, I followed the hastily-given advice of a senior nurse and stitched a laceration with inadequate equipment to hand. The nurse was nominally supervising me as I barely knew how to suture, but she was busy dealing with a number of more urgent matters. The patient came to no actual harm, but it was messy and embarrassing.
Afterwards, the nurse – nicely – reproached me. ‘I thought you told me to do it that way!’ I complained. ‘Maybe,’ she said, ‘But you’re the doctor.’
It was galling at the time, but she was absolutely right. Being a doctor means taking responsibility. Of course, nurses often carry heavy responsibilities too, but if a doctor and a nurse disagree then generally the final decision, and therefore the potential blame, belongs to the doctor.
For that reason, I worry about the introduction of ‘dependent’ roles such as physician associates. If they’re clerking in A&E, or seeing patients in a GP surgery, someone – some doctor – will need to sign prescriptions and scan requests for them.
Either the doctor can review the patient again, duplicating effort (and bemusing the patient), or they can swallow their professional scruples and rubber-stamp the request. Neither is ideal.
If we trust non-doctor practitioners enough to ask them to perform doctor-like roles, we need to trust them to do so independently. That doesn’t mean they can’t ask for help and advice, of course, but they shouldn’t need a doctor’s signature for every decision they make.
Alternatively, if we don’t trust them to request tests and make management decisions, we shouldn’t try and use them as replacement doctors. To separate the decision-making part of a doctor’s role from the responsibility-taking part seems unreasonable.
There’s nothing magical about the title ‘doctor’, and professional boundaries are not cast in bronze. Many nurse practitioners and PAs can and do achieve great expertise. But in a system which relies on clear allocation of responsibility, the current awkward compromise risks putting us all in a false position.
By the Secret Doctor. Read the blog and follow @TheSecretDr on Twitter and on Facebook
This is an interesting conversation. One problem is how non-doctors are recruited to 'doctors' roles. They may have little experience, or experience in the area but not with a medical hat on. Such appointments seem unevaluated and the risk is that they become something they were not intended to be and do not therefore cover the work they were intended to do. There is then duplication and wastage. I would not do a nurse's job and would ask for their advice when required. I will also completely acknowledge the expertise of some nurses for example those with further diabetic training who I would rather seek advice from that the GP. Any such proposals need clarity of roles, need to be clearly integrated into the team, supervision must be clear and there should be a period of transition to the new ways of working.
Why should podiatrists and physios ask the GP to request xrays that they need for managing their patient ?
Or extended role nurse colleagues needing an echo etc
We need to allow many other health professionals to order tests and look at their own results and not funnel everything through the GP unless our colleagues need advice
The amount of extra admin we are asked to do has increased exponentially since I started in 1981 and that is affecting job satisfaction and causing additional stress
All so true and so valid. For us, in my general practice - and in so many practices - one way that this pinches at present is the "sick notes" question. (OK: fit notes...) Our nurses, and nurse practitioners, can assess a patient, very competently, as needing time off or being fit to return to work - and so they should be able to issue and sign the Med3 sick notes. It's BMA policy that this should happen; now, as I understand, it just needs government (London, Cardiff, wherever) to agree this and change the appropriate legislation. So: PLEASE will they do this? - they'll save so much doctor time - and patient time! - every week.
I think there is a clear problem between responsibility and management of workload. I completely agree with the author that of a doctors signature is needed he or she had to clinically assess the patient. Recently in our department there was a case when the midwifery staff asked for pethidine prescription for someone in early labour. The junior doctor obliged as it is quite common later on that patient was diagnosed with abruption ad delivered a dead baby. That doctor is suspended for being careless but the midwife is very well supported as there is a feeling that there is a training issue. I am really sorry no matter what the urgency is no form or prescription should be asked to be signed and hence the duplication of work in this situation is inevitable.
I completely agree , if another professional asks us to sign a request then we own it. If management has assigned the role to them then management should do the rubber stamping.
Can’t be doing with all this anonymity!
Our AQP service currently has a slightly different but related issue. The extended role non- Doctor clinicians can request as many investigations as the doctors, but then don’t feel they can deal with the result if it shows something sinister. The doctors in the service however feel any person who cannot deal with the result of a test - whatever that may be- shouldn’t be requesting the test.
Does the latest of your anonymous respondents, who says "The doctors in the service however feel any person who cannot deal with the result of a test - whatever that may be- shouldn’t be requesting the test.", really believe this. If so does he recommend that anyone seeing a report of, perhaps a malignant growth, ought to operate on it themselves, or prescribe and administer the chemotherapy. A nonsense statement; we all need the help of other staff at times, whether because of their special training or just greater or wider experience.
This is a "S.D.B." of greater thoughtfulness than usual, and raises a question that needs input from all the relevant professional bodies and also NHS managers.
I have worked with specialist nurses in both NHS and private occupational health practice, and have been happy to leave them to manage fitness to work and immunisation cases without reference to me, as the consultant in charge, trusting them to act professionally and seek advice when uncertain. The employers accepted this, too. It isn't a difficult issue, it just needs to be defined and accepted, rather than those in charge seeking to avoid any possibility of blame.
Common sense is needed, also. I know a paramedic trained Advanced Care Practitioner who is working to allow those with such training to prescribe in the way that nurse ACPs are; there seems little logical basis for the discrimination, though it is jealously guarded by some.
The NHS is hindered by too little joined-up thinking, too many old privileges, and avoidance of responsibility for the actions of those who are being supervised. It all gets in the way of patient care.
And, by the way, the previous comment mentioning ACPs and paramedics, etc., was not meant to be anonymous, but was from G Freshwater, retired OH Physician.
Because the policy is to try and do everything on the cheap, it looks attractive to employ less expensive practitioners to cut costs. But it is false in many ways. In this example, the person deciding to do the investigation or procedure should take responsibility - and liability for it. If they are qualified and experienced enough to do it, then there is minimal risk - but the corollary of that is that they should be remunerated at a compatible rate for taking that responsibility - and so paid more, and the savings disappear. We had two excellent nurse practitioners in our surgery, who had done prescribing course. They were paid less than the doctors, which was perhaps unfair, but their consultation length was half as long again, so the savings were not as great as you might expect, and again, clinical responsibility lay with the GPs, who had to countersign X ray requests, and sometimes review patients in the midst of a busy surgery of their own. If people do all the work of the doctor and take all the responsibility and liability, then pay them as Doctors.
I am a retired doctor after working in NHS for 40 odd years. As a student I learnt to take blood samples from patients by the Ward Sisters.. But as the experience increased and being fully Registered with the GMC I learnt to take the responsibility for my professional work. Being in neurophysiology I had to write reports on EEGs which had to be kept for 25 years (epilepsy). So I could be called for my missed diagnosis. I weep to see the introduction of para professions taking over the job of the medics. Politicians and the dramatic mistakes by psychopaths professionals our vocation has been down graded under the guise of the politicians who do not like our very much respected profession. So Royal Colleges think hard before you sell up to the cheap bidder. HCKL
Well said and you must have seen lots of cheap labour added to the field over 40 years of your experience!
Well said. Supervision takes time and at the moment non medical prescribers are seen as the answer to the shortage of doctors willing to work in the NHS. Doctors seem happy to accept responsibility for their work despite the fact that this reduces the caseload that they can personally manage. If doctors were less accommodating of this change in practice then perhaps managers and politicians would look at career structures, pension and tax changes and the other conspiring factors that have reduced the medical workforce to this crisis point.
To this anonymous comment:
"Well said. Supervision takes time and at the moment non medical prescribers are seen as the answer to the shortage of doctors willing to work in the NHS. Doctors seem happy to accept responsibility for their work despite the fact that this reduces the caseload that they can personally manage. If doctors were less accommodating of this change in practice then perhaps managers and politicians would look at career structures, pension and tax changes and the other conspiring factors that have reduced the medical workforce to this crisis point."
^^ I very much agree.
RE. Blog - in the end, exactly, your signature your head on the chopping block.
From another retired GP: when I was a junior hospital doctor in the ‘80s, I had more than one experience of nurses presenting a distorted version of the facts to manipulate the doctor’s decision towards one that was more convenient to them but with unnecessary risk for the patient. I was well aware this occurred because, once a doctor had authorised an action, the nurse was free of responsibility for the consequences. Am I to understand little has changed?