Playing Games: Doctors and Nurses and Musical Chairs

Omnia mutantur, nihil interit [Everything changes, nothing perishes].
(Ovid, from Metamorphoses)

Nurses perform flexible sigmoidoscopy [1]. Nurses also perform colonoscopy, oesophageal dilation, variceal ligation, and endosonography; they treat patients in emergency departments; and manage viral hepatitis, inflammatory bowel disease, diabetes, and many other conditions. Aside from nurses, non-medically-trained technicians perform gastroscopy [2]. So, a question - What are doctors for?

This commentary is written from a UK perspective. The UK health service is unique but that does not mean that lessons learnt are not universally applicable. The answer to the question lies here.

Nearly all doctors in the UK, including specialists (“consultants”), work for the National Health Service (NHS). Consultants based in prosperous regions are more likely to do private work but this is only as an adjunct to their main contract with the NHS. The shibboleth of the NHS is free health care for all, no matter what the illness, whether it is acute or chronic. The NHS is government-run, funded entirely from general taxation, and, politically, is exquisitely sensitive. Until the late 1990s it was underfunded and medically understaffed, leading to long waiting lists and uneven delivery of care.

Funding is easily addressed in a reasonably buoyant economy; issues around manpower are not. Expansion of medical-school places feeds only slowly through the system and although the slack can be taken up by recruitment from overseas, this option is not without its problems. The recent increase in funding for the NHS has been accompanied by governmental pressure to change structure and to remove traditional lines of professional demarcation, allowing nurses to perform procedures previously performed by doctors and also permitting them to prescribe a range of specialty-specific medications.

These changes have been broadly supported by physicians and have been incorporated into practice guidelines from the Joint Advisory Group of the Royal Colleges; 65 % of UK units now employ non-physician endoscopists [3] [4]. The term “nurse endoscopist” is no longer used, and all endoscopists, irrespective of professional background, are expected to work to the same standards. No limit has been set on where this process might end. Therapeutic endoscopic retrograde cholangiopancreatography might be beyond the range of what might reasonably be expected, although this is merely a subjective opinion - it might make sense; then again, it might not.

Take endoscopic ultrasound (EUS) as an example of an advanced endoscopic technique. The range of indications for EUS is broad, demand is increasing, and there is a shortage of trained manpower. To date, discussion on how best to solve this problem has been narrow, repetitive, unimaginative, and anodyne - the question of how EUS services can grow efficiently remains unanswered. In such a maturing specialty, perhaps the answer could be separate development of diagnostic and interventional EUS, with non-interventional EUS (the staging of oesophageal cancer) delegated to non-physician endoscopists.

Clinical staff who perform EUS come from a broad range of disciplines, including gastroenterology, radiology, and surgery. No particular specialty background is known to afford a distinct advantage in acquiring the skills required for diagnostic EUS. As facility with EUS crosses specialty boundaries, it is time to question whether it might also cross professional boundaries. A pilot study suggests that it does, with an experienced nurse endoscopist and senior gastroenterology fellows found to advance at a similar pace in their ability to perform radial mediastinal EUS [5]. Building on this argument, a nurse endosonographer can perform oesphageal cancer staging to a high degree of accuracy, allowing physicians to focus on more difficult cases [6]. Two centres in the UK now offer non-physician EUS services. A nurse endosonographer routinely performs pancreatobiliary EUS at our hospital. This does not mean that all nurse endoscopists could perform EUS; similarly, nor should all doctors. What it does mean, however, is that some non-physicians can perform advanced endoscopy.

It is one thing to perform a diagnostic test; it is another to place the results in the appropriate clinical setting. In many countries, patients with cancer are discussed at a multidisciplinary meeting attended by surgeons, radiologists, oncologists, and physicians from other relevant specialties. In the UK, clinical nurse specialists form part of this team and their clinical interpretation is regarded as being equal in value to that of the other participants. This brings us back to our original question.

To become a doctor in most countries is not easy. It takes considerable application during school years to gain a place in a medical faculty; it takes application to progress through a university course that is longer than most; and it takes application and tenacity to pass postgraduate membership/board exams, to become a specialist, and (for some) to acquire a PhD. The result of all this effort is (potentially) reflected in a knowledge base that is both deep and broad. To become a nurse is to seek and to accept a lesser burden of education; the knowledge base of a nurse specialist is narrowly focused.

“Holistic” is a word used by nurses to encapsulate the marrying of traditional nursing values (empathy, support, and meeting the immediate needs of physical comfort) with an expanded role as a diagnostician/therapist but, realistically, the arena in which this can happen is small, restricted by breadth of expertise. The term “holistic” can equally be applied to physicians, reflecting a similar quality of empathy but with an ability to place the patient’s condition and medical needs within a wider framework of knowledge.

The UK health service needs both physicians and nurse specialists in order to function efficiently. Nurse specialists manage many patients who might be described as falling into the “mainstream” category. However, a significant proportion of patients need the benefit of the knowledge and skills that only derive from the long periods of study, training, and clinical exposure that comprise the nursery of the physician and which cannot be short-circuited.

Professional identity (for nurse or physician) has been blurred by the ability to define care pathways. In developed countries, the presenting problems of many patients can be readily categorised, investigated, and reasonably well treated, with surprises being rare. If drafted well, it does not matter who follows the protocol. Nor does it matter who might perform the required tests. The role of the doctor is certainly not defined by the ability to perform a specific procedure or follow a specific protocol. It is defined, however, by how such protocols and procedures are developed.

Would UK physicians have been so willing to develop and support non-physician endoscopy services if they were self-employed and dependent on private practice? Of course not, but the genie is out of the bottle now. Arguments about nurses not being capable of performing advanced endoscopy or of understanding their findings are unfounded, specious, and insulting to all concerned. Interestingly, nurses too now fall into this rut in their questioning of the ability of endoscopic technicians to place their findings within the correct clinical framework [7].

New world orders do not come without problems. Specialist nurses in the UK have fuelled some degree of antagonism from their medical co-workers through ill-considered attempts at philosophy and clumsy work practices. Some perceive a need to differentiate nurses from physicians in how they might deal with the same clinical situation, and in this philosophical struggle words such as “empathy” and “compassion”, and phrases such as “patient-centred” are tossed about glibly as though they are the preserve of nurses but not doctors. Nurse specialists prefer to have a stream of referrals that is separate from those of their colleagues in order to emphasise the “nurse-led” and autonomous quality of the service, a most “unholistic” approach if ever there was one. Senior nurses who perform rudimentary procedures such as flexible sigmoidoscopy have been elevated to the title of “nurse consultant”, which not only shows a great lack of imagination, but also irritates and insults specialist physicians.

Furthermore, salary inflation comes hard on the heels of title inflation. The pay scale for a nurse consultant is € 49 000 - € 80 000 ($ 60 000 - $ 97 000). In comparison, the pay scale for a consultant physician is € 97 000 - € 132 000 ($ 117 000 - $ 160 000), with a senior trainee having a salary of € 60 000 + ($ 73 000 +). Non-physician endoscopists are not a cheap alternative, and neither should they be. Standing back, however, these criticisms should be considered as minor ones and as no more than the teething problems of a profession attempting to characterise itself.

It would have been hard to define the purpose or value of a physician at any time up to the late nineteenth century; this is no longer the case. The move to teamwork has not obviated the absolute need for individuals with both breadth and depth of skills and knowledge. Physicians have a very definite role in gastroenterology and beyond, but it is a different one from the role they inherited. Midwives have been delivering babies for centuries - it is time to let a nurse deliver a polyp.

Competing Interests: None

References

• 1 Goodfellow P. Flexible sigmoidoscopy by nurses.  Endoscopy. 2006;  38 624-626
• 2 Swarbrick E, Harnden S, Hodson R. et al .Non-medical endoscopists: a report of the Working Party of the British Society of Gastroenterology, August 2005.  http://www.bsg.org.uk/pdf_word_docs/endo_%20nonmed. pdf
• 3 Joint Advisory Group on Gastrointestinal Endoscopy .Guidelines for the training, appraisal and assessment of trainees in GI endoscopy. London; Joint Advisory Group on Gastrointestinal Endoscopy 2004: 9-11
• 4 Douglass A, Barrison I, Powell A, Bramble M. The nurse endoscopist’s contribution to service delivery.  Gastrointest Nurs. 2004;  2 21-24
• 5 Meenan J, Tsang S, Anderson S. et al . Training in radial EUS: what is the best approach and is there a role for the nurse endoscopist?.  Endoscopy. 2003;  35 1020-1023
• 6 Meenan J, Doig L, Vu C, Anderson S. A prospective comparative study of staging accuracy rates for nurse performed EUS in esophageal cancer.  Gastrointest Endosc. 2004;  59 AB214
• 7 Chapman W. Lay endoscopists: who shall be accountable?.  Gastrointest Nurs. 2004;  2 22-23