Doctors, surgeons, para-health professionals, nurse practitioners etc

[BelfastChild]

Hi guys. Just opening a new thread as an aside from 'limping grand daughter'. There was a lot of talk in there about the roles of doctors, surgeons, nurse practitioners, physios etc. Maybe we could discuss that in this thread

[Davaar]

My own arrival in the "other" thread was prompted by TheFlyingPhysio's reference to Sherlock Holmes. Conan Doyle modelled Holmes, of course, on Professor Bell of the Faculty of Medicine at the University of Edinburgh, famed for his inductive skills. He observed and reasoned. He diagnosed not only ailments but whole ways of life.

I have just erased three paragraphs because I wish not to disclose experience that anyone might even remotely identify. I'll just say that for any diagnosing neeeded on Davaar and Davaar's, qualified physicians only need apply.

I am quite ready to disbelieve any official public statement made about the ability of health scheme to deliver good and timely service. I do not automatically disbelieve such a statement, but the fact of its being made means no more than that it has been made. Spare me from the nurse practitioners.

[Mac the Knife]

OK, I'll bite (you knew I would).

I don't mind people doing anything, so long as they're properly trained for it. If a physio wants to start doing general medical diagnosis, then that's OK with me, so long as they do their xx years of anatomic and clinical pathology. Their legal position is less clear (what if they diagnose a notifiable disease?) and there is no established corpus of law that would define their duties and responsibilities, particularly if a diagnosis is missed or incorrect.

I can't help feeling (the point was made by another poster) that if the country is short of doctors or their training is unsatisfactory that THAT is the thing to remedy, rather than creating a new class of para-doctors.

I find it depressing that medical students now need classes in empathy, for if they are not empathic why are they doing medicine? I find it equally depressing that the same students now have more classes in practice management than in anatomy. Medicine is not at it's heart a business (we have a practice manager who does all that).

As I said in the other thread: "I don't suggest that [paramedics] in general are not competent to recognise scope of practice, but merely point out that when the borders of scope of practice start to become blurred, that it is easy to find oneself in tiger country."

The same applies in medical specialities. For example, I have a lot of urological experience in some areas, but that doesn't make me a urologist. We all have to be careful to stay on the path of what we're trained for and not let hubris deceive us into believing we're so clever. Know your limits and know when to ask for help or advice if your're puzzled or in doubt - there's no shame in that, only wisdom.

My auntie is a Nurse Anaesthetist (properly trained and qualified) in Denmark and must have given tens of thousands of anaesthetics for uncomplicated cases. Why should I have a problem with that?

Lots of other specialities now do aesthetic (read cosmetic) surgery that is traditionally the prerogative of the plastic surgeon. Some of then are "trained" by their peers, some just wing it. So long as they don't represent themselves as accredited plastic surgeons that's OK with the law. Some are pretty competent (if they restrict themselves to three or four procedures) and some are appallingly incompetent. I don't really mind (except insofar as they bring the speciality into disrepute), because I can do it all a lot better than they can. They're not a threat to me. I do get cross when they make a Horlicks of it and I have to try and remedy their less well judged efforts though.

It's a free world after all hey!. If people want to cure their skin cancers with rock-crystal or use Bach flower remedies for their hypertension that's fine! Why should I worry? The problem, if there is one, is society's, not mine. I think it's a bit of a swizz that they're allowed to make all sorts of fantastical claims without any basis, while I have to substantiate everything I do with solid evidence but c'est la vie and caveat emptor.

But retournons a nos moutons. Paramedics are an indispensible and valuable fact of life, long may they flourish! Their expertise is necessarily on a smaller front than a doctor, but within that ambit they can be as good or better.

The danger comes when the continued denigration of doctors by the press and State (and falling standards of medical education and training) begin to lead paramedics to adventure into areas that they are NOT trained in.

Lets all be careful out there.

[gingernut]

I don't mind people doing anything, so long as they're properly trained for it.



got it one!:)

[Loose rivets]

I have asked before, if there is not a case for doctors to specialize at an earlier stage than they do now. In this modern world there must be an order of magnitude more detail to take on board -- if they are to cover the full spectrum. This has to be counter-productive.

I do understand the concept of co-relating symptoms: not to have a broad overview could mean missing something important. However, to try to take on board the full subject seems as though it's asking for the knowledge to be diluted. This will be even worse if the suggestion of ‘fast-tracking' is followed.

In this modern world it is possible to ask, and get an answer from a specialist on the other side of the globe in a few moments...and with hi-def pictures. Why burden the mind with a sea of knowledge that may never be used?

[rhovsquared]

Well some things I think many health professionals forget
1. you can't be too judgemental :)
2. medicine is still an art and not a science (but based thereon with many techniques):\
3. First do no harm :eek:
4. History and physical exam BEFORE the Signal averaged EKG, the Doppler studies The CARDIAC MRI :=
4. the stethoscope also has a BELL as well as a diaphragm. thats why nobody ever hears third heart sounds :hmm:

TurboJets ONLY :}

rhov :)

[Mac the Knife]

got it one!:)

Like all Young Chaps With An Idea (and it's not a new one), Gingernut seizes only on the bit that he agrees with. He happily disregards the very real caveats that I tried to voice - a pity, but so it goes....

I have asked before, if there is not a case for doctors to specialize at an earlier stage than they do now. In this modern world there must be an order of magnitude more detail to take on board -- if they are to cover the full spectrum. This has to be counter-productive.

This has been happening for quite a while already. The Blair solution to perceived problem of not enough Consultants has been to pressurise the GMC and Royal Colleges into just this. Surgical training in the UK is now a real mess, complicated by the EU directives on working hours, and Consultants are now appointed far younger and with far less experience of their subject than ever before. Couple this with the amount of administrative work that is now required (despite the proliferation of professional administrators) and you have a result that is less than happy. Gingernut's solution is to train up nurses and paramedics to perform subsets of more narrowly divided tasks, like the Chest Diagnostician or the Knee Operator. This frees the Consultant to engage in his primary function in the Blair world, of sitting on endless committees, engaging in endless paperwork and participating in the vicious and Byzantine world of NHS politics.

I do understand the concept of co-relating symptoms: not to have a broad overview could mean missing something important. However, to try to take on board the full subject seems as though it's asking for the knowledge to be diluted. This will be even worse if the suggestion of ‘fast-tracking' is followed.

The airlines have analogous problems. With glass cockpits, increasingly realistic sims and far greater aircraft automation it is entirely possible to train pilots without them even leaving the ground. And as for fast-tracking, what about all the various direct entry schemes? Here on PPRuNe you can read lots of posts from grumpy old pilots bemoaning the loss of the ability of pilots to cope on raw data only and hand-fly aircraft. Welcome to the 21st Century.

In this modern world it is possible to ask, and get an answer from a specialist on the other side of the globe in a few moments...and with hi-def pictures. Why burden the mind with a sea of knowledge that may never be used?

Well, this presupposes that we function mainly in an office, have a reliable broadband connection and the leisure of time to do all this, rather than the need to make crucial decisions very fast that save lives and limbs. It also presupposes the ability to provide the guru on the other side of world with the right questions, for there's nothing more useless than having the answer to the wrong question.

"Sorry, I don't know the answer, and all the Guru's are busy answering questions from other chaps like me. I'll try again tonight. Can you come back tomorrow?"

And of course, most of the real world doesn't have either a computer, or broadband or even a telephone....

The fact is, that to be really good in your field, you have to know a LOT. Not only about your own field, but medicine generally. Learning all that and keeping up to date is VERY HARD WORK and I'm afraid that there's no getting around it.

[BelfastChild]

may as well put in my 2 cents seeing as I started the thread.....

I have often heard it say that "you can train a monkey to operate". In my view, this statement is pointing out that when it comes to managing a surgical patient, the actual operation is the least important aspect. What is most important is knowing which operation to do, or more importantly, when to do no operation at all.

Unfortunately, governments have taken this saying a bit literally and are going to get the monkeys to do the operating. At the end of the day, governments are responsible to the people (is that a bit idealistic???), and the people can have whatever they want. I think the medical profession has to educate the people about what is happening, so that these measures are not introduced by stealth. If the general public are then happy to be operated on by monkeys, who I am to stand in their way.

But I suspect they are not - there was a study in BMJ (sorry, can't remember the exact reference), where a survey was done on patients attending NHS podiatrists. 95% of them did not realise that they weren't seeing someone who is medically trained.

And before I get off my soapbox, one final point. It has been said many times (not just by posters in this thread) that it is unnecessary for specialists to learn things that aren't relevant to their specialty. I am involved with medical student training, and I am often asked 'what do I need to know'. My answer is usually that you don't need to know anything if you don't want - you are free to go sit on a beach if you want. It comes down to whether you want an education, or just training (in which case, medicine should be made a TAFE or tech college course, not a uni course).

Why does someone who is destined to be a doctor need to learn Shakespeare, Latin, WWII history or calculus at school? - it is called an education......

[Loose rivets]

Very interesting...and convincing arguments. Thanks.

Despite a life long interest in medicine, and despite being able to tuck into my dinner while watching complex surgery, I could never have become a doctor. First and foremost, I can't spell: that bit of my brain is quite simply missing. My patients would have been likely to be prescribed almost any random treatment or drug, if I had to commit instructions to paper. Probably the only talent that I have that would have been appropriate, is to think laterally. So, this alone answers...and defeats, my suggestion about broad spectrum knowledge taking up too much learning time.

In fact, if I were to suddenly find myself young, and starting out again, I would be at a loss to know what I could do.

In aviation, there used to be the potential to put natural ability to good use. Not any more. There now seems to be so little interest in a pilot's natural ability to fly, and yes, the reliance on simulators is to my mind-set, frightening. I spent years flying London to Spain, at night, without radar. I know what it's like to feel mind-bending terror, repeatedly, but still have to maintain a calm professional facade. I imagine it's a bit like being a young doctor in a hospital, when the product of a train wreck is wheeled in.

We trained on a shiny new air-plane, not that long after the deep-stall killed the 1-11 test crew. I can't imagine how crews can sit behind all that glass and let computers do everything; a totally different world. Some of these youngsters have never had anything significant happen at all. Hard to believe, having come from a world that once gave me three serious emergencies in one week. To me, it seems like qualifying as a doctor, never having seen blood.

What puzzles me is the extent to which the medical system has become overloaded in the UK. Years ago I recall an American on T/V describing our national health service as the ‘jewel in the crown.' I also recall spending a week in the 50s, in an immaculate ward, my car parked [free] outside by beautifully maintained gardens. My op? Tonsillectomy.

Why, when the population has increased only to a ratio of 4.6 : 6 in my lifetime, can we be so much worse off than folk in this new technological world?

If you read other threads, you will know my feelings about totally unbelievable population figures. But that's another rant.

[Sim Dude]

noticed this in the other thread

anybody thought want the patient wants... perhaps not too relevent with you medic types duelling at dawn.

well from a patient point of view who was diagnosed with a fairly rare and deadly condition i went through the mill which started one late night with bleeding from the mouth and a collapse.

from no symptoms to life threating in the blink of an eye

so i experianced first hand Paramedics to surgeon.

the Paramedics had no clue what was wrong but then i did not expect them to thier job as i understand it was to keep me alive long enough to get to hospital and get it sorted.

hey the stuff they were telling me might be trying to reassure me had the opposite effect since they assume joe public knows nothing well i have had some basic first aid training i knew i had internal bleeding.

anyway to cut out the boring bits i got investigated the following day after a stint in the room with all sorts of stuff i hoped they were not going to have to use

definitly feeling like something to be processed as i proceeded through the medical machine did not do my confidence any good

That all changed when i was refered to a surgeon who had a manner that i started to feel confident about.

first he did not treat me like an idiot or gave me any BS and in this day of the internet you can get a pretty good idea of whats going on

lets say a half percent chance of survival is better than none.

thier were quite a few wonderfull people in the medical profession on the journey to where i am now however it would be all for nought without the Surgeons work.

at the end of the day he was the dude who had to fix the problem and leave me with a good quality of life.

sure he had a team who most i would never know or meet but since he was leading the way he was the front end of what i had to go through and should i have popped me cloggs i suspect its his "stats" i would appear on.

he also see's me every three months and which i usually take one or both my very young children with me since my girlie was very pregnant at the time with the second one. I am sure he does not need reminding that he affected more live's then just mine, heck the guy came every day to see me in recovery and even brought his daughter in on a sunday.

i have since learnt he has to be in a tough area and a lot of his cases must not make it despite his best efforts and in todays stats mean everything age that has to be tough.

make no mistake the surgeon clearly went above and beyond what everyone else did and made the difference in fact i would go so far to say the only one where it really had to matter to make my future survival possible i think he took it personally i know i did

so who do i want to see

not somebody who sure can say how are you feeling today...fine...tick..next all very competent but somehow not quite satisfying

no i want to see the guy who fought the battle with me and who was there and i mean really there.

that some how, i dont think i am wrong is saying is more satisfying from both sides of patient/doctor

it's not just about competence but also confidence

So as a patient i side with and understand mac the knifes point of view i think he gets it

for those that just want a process however competant

Tick...next

[min]

Why, indeed. Perhaps the answer, to an extent, lies in your mention of the words 'technological world'. Technology means hugely increasing costs for our health systems - equipment, drugs, techniques, tests, new diagnosis, the list goes on. How many CABG's, transplants, knee reconstructions, hip replacements, etc were done 50 years ago? Technology has also seen a rise in life expectancy, such that people are needing the health system who in previous generations would have been, to put it bluntly, dead. At the same time, our lifestyles have changed to the extent that 'over' nutrition is more of a problem than 'under' nutrition. Our expectations of what the health system should provide has also increased. Wage pressures to staff hospitals are another factor. The answer is not a simple one.

[rhovsquared]

I agree Min, but without basics of proper test interpretation, what the hell is the use?
i'll have more to say later very good and fun to read thread, but my little brother's :mad: ing about my Pprune time
I have to go :( :{
personally I don't think there's enough Pain in MED school [I'm only half joking]. I think my 12 lead or porphyrias lecture would give my students A Horner's syndrome without a Pancoast's tumor :} :} :} , but although I'm 27 i feel i belong in the 1930's ;)

Turbocompressors Off :}
rhov :)

[Loose rivets]

How many CABG's, transplants, knee reconstructions, hip replacements, etc were done 50 years ago? Technology has also seen a rise in life expectancy, such that people are needing the health system who in previous generations would have been, to put it bluntly, dead.


Of course things have moved on a great deal. Memory is a funny thing, but an image from that ward suddenly came to mind. A dignified surgeon in pinstripe suit, was looking pleased with a patient. He was saying words to the effect, ‘Only a while ago we would have had to amputate (his leg) now we can take a vein from ???? and replace the blocked one.' Cutting edge (ouch!) Technology just that short time ago.

This year here in S Texas, a surgeon who had invested a vast sum in his own clinic, spent an hour showing me his latest kit. The most stunning was a CAT scanner with some really powerful software. Being able to remove unwanted images and leave the plumbing was impressive enough, but when he moved into the vessels and examined the inner surfaces, I could scarcely believe what I was seeing. The fact that he had invested millions was I suppose, a reason that the profession has become, in some strange way, ‘dis-balanced'. It's a bit like aircraft manufacture, one wonders how on Earth the investors will ever get their money back–let alone make a profit.

When it comes to people's well-being, I feel that such vast outlay should always be financed by a government, at least when a high proportion of the population are going to benefit. Looking for wealthy clientele to make the payments on medical equipment, is a really shaky way to run a company and also leaves the poor in an unenviable position. I hasten to add that I believe a dollar driven world works for many types of science and construction, but this is a different issue altogether.

[Mac the Knife]

Sir Frederic Treves was a eminent Victorian surgeon who was also a writer. I've always liked his description of a surgeon in the introduction to his story "The Idol with Hands of Clay", which was part of the book "The Elephant Man and Other Reminiscences", published in 1923.

I'm don't think that we're born surgeons, anymore than one is born an airline pilot and we're certainly no more complex or prodigious. But apart from that, those who hew true to our calling, rather than being seduced by money or fame, may find an echo here.

"The good surgeon is born, not made. He is a complex product in any case, and often something of a prodigy. His qualities cannot be expressed by diplomas or appraised by university degrees. It may be possible to ascertain what he knows, but no examination can elicit what he can do.

He must know the human body as a forester knows his wood; must know it even better than he, must know the roots and branches of every tree, the source and wanderings of every rivulet, the banks of every alley, the flowers of every glade.

As a surgeon, moreover, he must be learned in the moods and troubles of the wood, must know of the wild winds that may rend it, of the savage things that lurk in it's secret haunts, of the strangling creepers that may throttle it's sturdiest growth, of the rot and mould that may make dust of it's very heart. As an operator, moreover, he must be a deft handicraftsman and a master of touch.

He may have all these acquirements and yet be found wanting; just as a man may succeed when shooting at a target, yet fail when faced with a charging lion. He may be a clever manipulator and yet be mentally clumsy. He may even be brilliant, but Heaven help the poor soul who has to be operated on by a brilliant surgeon. Brilliancy is out of place in surgery. It is pleasing in the juggler who plays with knives in the air, but it causes anxiety in the operating theatre.

The surgeon's hands must be delicate, but they must also be strong. He needs a lacemaker's fingers and a seaman's grip. He must have courage, be quick to think and prompt to act, be sure of himself and captain of the venture he commands. The surgeon has often to fight for another's life. I conceive of him then not as a massive Hercules wrestling ponderously with Death for the body of Alcestis, but as a nimble man in a doublet and hose who, over a prostrate form, fights Death with a rapier."

:ok:

[rhovsquared]

I, believe that however important specialty medicine is in the modern era, we really have to have better incentives for entry into primary care physicans, FP, IM, ER, as a gatekeeper and medical management, for they must know that the hip bones connected to the endocrine system and the endocrine sytem's connected to the nervous sytem and the blood pressures [in part connected] to renal system which is connected to the heart system legbone....let's call the whole thing off :\

another thing oft' forgotten is that CELLS FORM TISSUES THAT FORM ORGANS THAT FORM ORGAN SYSTEMS ;) !!!


TurboJets Or Propellor-Turbine Transports Filed At Greater Than 250 Knots :}

rhov :)

[Davaar]

After that latest by Mac there is little I can add. From my own world, though, I offer something a little analogous. In "Guy Mannering", Sir Walter Scott has the hero meet an old Edinburgh lawyer. Together they go to the lawyer's house. It is modest from the outside, neighbours very close. Inside was a well-proportioned room, hung with a portrait or two by Jamieson ("the Scottish Vandyke") and surrounded with books, "the best editions of the best authors, and, in particular, an admirable collection of classics.

"These", said Pleydell, "are my tools of trade. A lawyer without history or literature is a mechanic, a mere working mason; if he possesses some knowledge of these, he may venture to call himself an architect".

As observed above it is hard work, but some of us try.

I do want to put a question to Loose. He observes:

There now seems to be so little interest in a pilot's natural ability to fly, and yes, the reliance on simulators is to my mind-set, frightening. I spent years flying London to Spain, at night, without radar. I know what it's like to feel mind-bending terror, repeatedly, but still have to maintain a calm professional facade. .

I used to occupy a modest position in an aviation concern. We operated four DC-4s. Nothing would do but we get one of Mr Boeing's latest 737s, so off we went to Seattle and bought one [some of the reasons were hilarious: the captains reported that passengers were claustrophobic in the DC-4s. What did those passengers work at? They were hard rock miners, working at around 3,000' below the surface. Oh Well!].

The pilots went down to Seattle to learn to fly their new toy, and at the end of a dog-watch there they were, back at base with the toy. Dead easy! they explained. We have the simulators. It took me seven months with the RAF to convert from piston to jet. Was I a slow learner? I think not, so I made a mental note to be busy at head office for the next while.

I read here and there in PPRuNe that instructors, even, are afraid to spin little aircraft these days. I have worked on the occasional investigation, and I have been amazed at what pilots will say. The computer or the simulator are better than actually flying. Really?

I recall a trip transatlantic once over the Greenland mountains in a fairly light twin. The photographs were beautiful, but they never could, it seemed to me, convey that little bittie anxiety about the icing on those damned boots. Yes, I know it was not severe, but it was severe enough for me to see it, and it could have got worse. How does the computer tell you that?

My statement is: I do not believe that the computer gives better training than flying the aircraft. My question to Loose is: Am I right?

[Loose rivets]

Mac, I wish I could write like that. I'm intending to paste that into my archive of ‘Prestigious Prose.'


Davaar
In short, I believe sims are a good systems trainer and they put the pilot to a good level of work-load while flying something resembling the aircraft type. I do not believe that they are a substitute for the real aircraft.

I guess the medical relevance is to do with stress loading, which can be achieved in the box, but it will never burden the candidate with the right type of fear.

Most base-checks are stressful, but it has little to do with the type of fear that I have talked about in the past. Some years ago I wrote about rational v irrational fear and talked of the type of symptoms that both could cause. For me, the peak stress in a base-check is just about the time I'm picking alternates for the first take-off. Everything after that is a free lunch by comparison...well, usually.

It's strange, but having all my ‘jet' training on a real airplane, I went into the work-place with no knowledge of sims at all. After about two years, some of our base checks were done courtesy of another airline. It was interesting to seen guys I had flown with for years, take off and spiral into the ground. One in particular was ex WWII and a line check captain on type. He just cussed at the ‘box' and blamed it for his violent over-corrections, he had the right mind-set for aviation. He would of course fly by the seat of his pants until retirement. However, another old-timer flew through all kinds of electronic hints, down to a landing somewhere below the ground. The box let him know in uncertain terms. He looked stunned to the point of needing medical assistance, but the point was that although it no doubt taught him some sort of lesson, the fear wasn't there before the ‘crash'.

[rhovsquared]

Forgot to say, IMHO;)
a physician is Teacher, and Student No-one really knows Medicine:\ :\ :\ :ugh: :{

You MUST TEACH YOUR PATIENTS, insipires compliance and reduces Iatrogenic [doctor caused] Hypertension i.e. white coat high blood pressure.
Teach in simple terms the reason what can you do-informed consent? what's wrong Mrs. Hill [75 years old] ? you're legs are still swollen, because of a build up of fluid so we should discuss a diuretic [Water-pill] to help remove the fluid so that your kidneys can help to remove the excess fluid,and help keep that young physique :} but, because of the risk we discussed earlier it remains YOUR Decision...


One TurboCompressor On :},

rhov :)