Why have doctors been made to jump through ever higher, smaller hoops if other health workers can do the job with a fraction of the training?
A few days ago, a nurse practitioner went on record that as saying nurses felt like victims of “battered wife syndrome” in their relationship with doctors.
“A collaborative arrangement (between doctors and nurses) is almost like forced dating,” Mr Chris O’Donnell said. “It’s pretty much like an arranged marriage where all the power sits with the husband and the wife can either exist under the rule of the husband or she can go and starve. And if that husband decides he doesn’t want you any more, well, you’re gone.”
Here’s my response.
Dear Chris,
I read with concern, dismay and a little bit of anger your comments about your profession and mine. Yours is not the only profession to abuse and insult us. When we raised our concerns about the harms of the pharmacy UTI pilot, the Pharmacy Guild famously said these concerns were merely “false and misleading claims of the subversive doctor lobby groups”.
When did interdisciplinary respect and collaboration die? And why am I not worth your professional courtesy?
It is my deep belief that discriminatory and offensive attitudes stem from ignorance, so I wanted to tell you my story.
Like the vast majority of my profession of general practice, I’ve had years of collaborative relationships with thousands of other health professionals. I started my career with a stint with the Flying Doctor Service, where I turned up to Broken Hill and asked the nurses to teach me. “I trained at Sydney University,” I said “I know NOTHING of practical use. Please help me learn, and I’ll work hard.” They did and I did, and 35 years later I still use their skills every day.
I did my GP training in a small rural practice in Victoria. My supervisors remain my gold standard for compassionate, deeply competent caring GPs, and they taught me so much of what I now know.
The practice used to be managed by one GP. That one GP was the most competent and humble professional I’ve ever met. We used to bring him into surgery to advise, and I remember him telling us we were to have a quiet word if he became too old and started to lose his capacity to practice safely. He did everything: burr holes, hernia repairs, and even delivered triplets on a kitchen table. In the decades before my time, he could do anything he needed to do, or thought he could do safely.
However, not all GPs were like him. Some were “butchers”. Some were abusive. Some were simply incompetent. The community and our democratic government decided it was no longer enough for doctors, especially GPs, to self-regulate. They argued that we worked in comparative isolation, and so the public were less protected than they were in hospitals. I think they were right at the time.
Autonomy vs governance
Somewhere in the last 40 years, the amount of autonomy I have has shrunk and the amount of governance metastasised. I was the first year when GP training was compulsory. I’ve seen a gradual increase in the oversight of our curriculum. I’ve watched the Medical Board increase its requirements, starting with national registration in 2010. Those requirements have become more and more granular.
I don’t just have a responsibility to do CPD, I now need to do the CPD the Board decides is “good for me”. As an ex-GP obstetrician, I’ve watched GPs being forced out of rural procedural disciplines, including anaesthetics and surgery, to the detriment of their communities, because they can’t meet the “gold standard” care of tertiary hospitals. Now these communities have no obstetric care at all.
I’ve seen compulsory courses increase, and our ability to make appropriate clinical decisions decrease. I can no longer order an MRI for suspected MS, write a diagnosis on a disability support pension form or order diabetes supplies, because apparently, I need “oversight” from a non-GP specialist, a general psychologist and a nurse respectively.
Scapegoating and professional disrespect
I’ve watched respect for us as people decline to the extent that staff and colleagues feel deeply unsafe. I was in ED recently with a family member, and was surprised to hear a nursing student tell me that “medical officers” are “incompetent” and I should ignore their advice. I asked why she called them “medical officers”. She responded “our professor of nursing has told us not to call them doctors because they don’t deserve the title”.
Even in the 1990s, when I was doing my master of public health, I remember being the only doctor in a sea of nurses and allied health professionals. I was young, and believe it or not, fairly meek. On day one, our lecturer stood up and announced: “Doctors have driven women out of the caring professions!” Most of the students got to their feet and shouted “YES!!!” I’ve never felt so intimidated.
I know the dominant narrative is the 1950s vision of a subservient, handmaiden nurse and a dominant medical bloke in a white coat. But let’s not let the stereotypes get away from us. The one thing I do know is we are all human. Most of us go into the caring professions because we want to make a difference. Because we care.
I have no reason to believe that motivation is captured by one profession. There is nothing magic about nursing that makes them more “caring” than my colleagues. There is nothing magic about pharmacists, even with white coats, that makes them more “evidence-based” or “scientific”. There is nothing magic about doctors that makes them more self-sacrificial. Each of our professions have caring, deeply competent people in them. We all know that all professions have people who are deeply arrogant, abusive and incompetent.
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The importance of training and supervision from experts
I have a few problems with your argument about professional autonomy, Chris.
- Length of training: What makes a nurse practitioner so inherently capable that they need less training than a GP registrar to do the job? I trained for 11 years, and then have additional training on top. Nurse practitioners at the moment train for about eight years. Pharmacists for four.
In hospitals, it doesn’t matter as much as all professions are onsite and work in teams with significant oversight. In primary care, people can set up as solo practitioners and have minimal supervision. This means incompetent, entrepreneurial, arrogant outliers are downright dangerous. If you want to know how we know this, we’ve lived it. Look at the cosmetic “surgeons”.
The argument for this is always “but if it’s complicated, and ‘out of scope’ we will send to a GP”. This is a fundamental misunderstanding of the highly skilled role GPs play in diagnosis. People don’t come in with a sticker on their forehead telling us they are “big sick” or “little sick”. A fever doesn’t look complicated in a child. Picking the one with meningitis over the one with the common cold is harder than it looks. And missing it is devastating.
Pharmacists may well think they are doing OK following a UTI protocol on the basis of symptoms. This works if we are happy with the greatest good for the greatest number, because most people will recover well. Some, however, will have devastating outcomes from their ectopics, bladder cancer and chlamydia.
It amused me to read the evaluation of that trial and see that only 2.5% of the population with dysuria were “at risk of an STI”. Given they were all women between 18 and 65, this is a VERY celibate population. Are we happy to treat the chlamydia with the wrong antibiotics in some women because, on average, most women are OK, and they are happy with the service? What cost does that bring in future infertility treatments? Will we ever know?
The undifferentiated patient deserves the best generalist diagnostician the system has. That is our superpower. Most of the time, diagnosing on probability will work. Often it doesn’t – six per cent of our patients have rare diseases. We don’t pick them all up, of course, but with 11+ years of training, we are their best chance. I think the average drop in training is a loss to the community and can be downright dangerous.
- Unconscious incompetence: As a long-standing medical educator and supervisor of GP registrars, I can tell you that the main thing that keeps us up at night is worrying that our registrar doesn’t know what they don’t know. The most dangerous situations are where they don’t know they need to seek help.
We have spent a century working on strategies in our profession to keep patients safe with new learners. We’ve learned the hard way how to work in the “swamp” of true primary care: the undifferentiated, multimorbid, diagnostic dilemmas that challenge us daily.
I just don’t understand why the other professions don’t want to train with us but want to develop their own strategies from the ground up. It’s inefficient to waste all those years of medical education learning, and it would be great if we didn’t repeat all the mistakes we made in our profession. Which brings me to supervision.
- Supervision: I don’t understand why it is so offensive when we suggest we have something to teach. After a century of training primary care experts to work in the unregulated mess that is unreferred primary care, we’ve learned a thing or two. Using supervisors who are expert is not turning a learner into a handmaiden. I was not a “handmaiden” to the midwives and obstetricians who trained me in rural obstetrics, or to the psychiatrists and psychologists who made me a competent and skilled mental health practitioner.
I don’t understand why GPs are seen as arrogant, dominant and insulting when we offer to teach what we know. Is it because everyone thinks our work as “just a GP” is easy? Or is it the political narrative of power and agency, backed by highly effective unions, that make it somehow offensive to do interprofessional learning?
Whatever the reason, I will say this. I am bewildered that after a lifetime of escalating requirements, nudges, regulations, restrictions, compulsory training, and burgeoning curriculum, I am realising that my pharmacy colleagues can just “diagnose” with a written protocol and a few days of online training.
What were those thousands of hours of compulsory everything for?
In the end, either you believe other health professionals have some inherent magic that makes them need so much less training, or you think I have some fundamental professional disability that I need double the training to do the same job.
It makes. No. Sense.
So before we talk about “rights” to be independent practitioners working “top of scope” (whatever that means) let’s think about what we are really trying to do. We are here to serve our community. Our “rights” don’t trump our responsibilities. And before we argue that giving everyone but us good stuff to do that challenges us, and makes us stay in the health workforce, let’s think about how the disrespect we are seeing in general practice is turning us into an endangered species.
I am tired of being a scapegoat. I am not a patriarch, and you are not a handmaiden. For goodness sake, can’t we work together?
Associate Professor Louise Stone is a working GP who researches the social foundations of medicine in the ANU Medical School. She tweets @GPswampwarrior.
