Doctors need to give up professional protectionism
BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1757 (Published 24 April 2018) Cite this as: BMJ 2018;361:k1757
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Clifford Mann is correct in his assessment that new clinicians provide valuable skills and experience in a variety of roles. Whilst he is also right to recognise the benefit of their experience, it is important that this does not come as a detriment to the training of junior doctors.
Assessment, appraisal and reflection may have changed the shape of medical training but junior doctors (as pluripotential clinicians) need to gain experience to guide our differentiation. Systems have not necessarily kept pace with the growth in healthcare professionals and some tasks still require the input of a doctor. Unfortunately, these tasks are often administrative rather than experiential and this encourages employers to keep junior doctors writing discharge summaries, stopping medications and ordering radiographs whilst procedures and clinics are allocated to more experienced allied practitioners.
When junior doctors do have time in these settings clinical pressure may dictate that the practitioner still performs "traditional" tasks because they are more efficient (by virtue of their experience). This places juniors between a rock and a hard place, where consultants bemoan their lack of experience but they are denied opportunities to gain it.
Done well, the use of new healthcare professions will benefit both doctors and patients. In a strained health service, however, where it seems service provision is valued over training one can't help but be a little sceptical.
Competing interests: The author is currently a Foundation Doctor.
Re: Doctors need to give up professional protectionism
Mann is actually contributing to the diminution of his own profession by talking up the role of non-medical practitioners. The ultimate consequence of delegating a significant swathe of expertise to nurses and others is that doctors will lose their skills. If, as is increasingly the case, pain issues are delegated to 'pain nurses', wound care to 'tissue viability nurses' and infection control to 'infection nurses' then how do doctors maintain their skills in these areas? If I, as a clinician, never again have to tackle the thorny and challenging issue of pain control, because I just delegate it to the pain team, which is what is increasingly happening, then how can I keep up my skills in this area? And how do I then provide leadership to the pain nurses when they run out of ideas or when they meet a patient with multiple co-morbidities who needs complex input?
Mann even suggests we allow these practitioners to "request plain x-rays". Well I'm sorry but if you request an x-ray then you need to know precisely what question to ask and you need to be able to read the result. As a clinician with a sub-speciality interest, I am growing increasingly tired of being sent patients for medico-legal opinions a year down the line and finding that they never actually saw a doctor in the A/E department. They saw, instead, a 'specialist nurse practitioner' who missed the nerve injury or the tendon avulsion and sent the patient on his way. I have given up defending this practice and am now quite blunt in my reports . . . ."this patient never actually saw a doctor". Ultimately, and sadly, its the lawyers who will sort out this increasingly unprofessional approach to our patients. The fact is that it's NOT more "new clinicians" we need, it's more doctors, with more time to do their jobs well. In arguing otherwise, Mann is betraying our profession.
Competing interests: No competing interests