Issue 24 / 13 December 2010

SOME 60 years ago, Lord “Tommy” Horder, the doyen of British physicians of that time, addressed a meeting on the theme “Whither medicine?”.

He suggested that a visitor from Mars would have found such a question incomprehensible and would have responded, “Why, whither else than straight ahead …”

It was a time when the role of doctors was unambiguous: to care for patients and draw upon their scientific and clinical training to promote the “forging [of] still more weapons with which to conquer disease …”

Now move forward to present times and ask the same question.

Sadly, the Martian will be confused.

The central tenet of medicine has not changed, but the role of doctors certainly has.

This has become blurred by the significant influx of other professionals into clinical practice, often usurping doctors’ roles through task substitution.

We now have nurse practitioners and physician assistants in general practice, emergency medicine, rural and remote medicine, obstetrics, surgery and other areas of clinical practice.

Nowhere is doctor displacement more evident than in general practice.

Nurse practitioners now have access to autonomous practice, in which they enjoy Pharmaceutical Benefits Schedule prescribing rights and Medicare Benefits Schedule arrangements for which remuneration is not all that different to that of non-vocationally registered general practitioners.

To further compound this sudden elevation of their role, nurse practitioners’ earnings will soon exceed the current reimbursements for non-vocationally registered practitioners, through indexation.*

Nurse practitioners operate within the framework of recent federal legislation that requires loosely formulated “cooperative agreements” with GPs — an arrangement that is ripe for entrepreneurial exploitation.

One may well ask how we have come to this turn of events.

Firstly, the powerful Australian Nursing Federation has been without peer in influencing an ideologically driven federal Minister for Health and Ageing and promoting the cause of its members.

Secondly, there is the federal government’s implicit agenda of fostering competition through levelling financial rewards and downgrading comparative professional intellectual standards.

Underpinning this ongoing absurdity is the fallacious assumption that equivalence (between doctors and nurse practitioners) exists, where there is none.

Paradoxically, coverage and critique of these policy developments have mostly been confined to the medical tabloids.

We must ask ourselves: what can be done at this late stage?

The role-substitution campaign has been based on a blurring of what defines a doctor and what a doctor does.

These questions of identity have occupied overseas institutions such as the Royal College of Physicians and Surgeons of Canada, in its CanMEDS project and the medical colleges and British Medical Association in the United Kingdom, with similar projects.

But it remains an inescapable and uncomfortable fact that the respective university selection processes for medicine and nursing, and their subsequent training, are poles apart — in content, depth of learning, and intellectual rigour.

These inherent differences have been specifically designed to meet the needs of distinct and differing roles — valuable roles, which work best in a symbiotic relationship.

Unfortunately, we have no accepted definition of a doctor in Australian medicine.

It is long overdue!

For too long there has been a tendency to devalue excellence and achievement.

Furthermore, it could be claimed that organised medicine might be more affirming of the skill and expertise of doctors and less appeasing and accommodating of clinical practice by non-doctors.

In short, doctors need to affirm their expertise, as currently the only practitioners whose skills and talents are extolled, especially by the Minister, are nurse practitioners.

It is time for the profession to stand up.

* J F O’Dea, Manager, Medical Practice Department, Australian Medical Association, Canberra, personal communication

Dr Martin Van Der Weyden is the Editor of the MJA.

This article is reproduced from the MJA with permission.

Med J Aust 2010; 193: 634-635.

Posted 13 December 2010

10 thoughts on “Martin Van Der Weyden: Whither medicine?

  1. Anonymous says:

    Excellent article. Well said.

  2. iatros says:

    A further act of denigration is the restriction of prescribing imposed on retired doctors, mainly retired general practitioners. We are only allowed to prescribe if it is for a renewal of a prescription provided by another medical practioner within the previous six months. We are also forbidden to prescribe any drug that falls within the meaning of the Poisons and Therapeutic Goods Act.
    It would appear that with many years of experience once we retire, we become so medically incompetent that we are not permitted to prescribe the simplest of drugs. It also appears that newly qualified nurse practioners are now able to write these prescriptions. The denigration of our once mighty and highly regarded profession progresses unabaited.

  3. Anon says:

    Martin, good article, I have been waiting, and waiting for the furore to start. Frankly I am incredulous at the turn of events. And at the medical supineness that has resulted. It’s not just a turf war, what about clinical standards?It’s a sad day.
    Unsupervised nurse practitioners working equivalent to GPs is going to provide a lot of unintended consequences. The professions have to quickly pull togther, and we need assistance from our specialist colleagues and their colleges. What is the point of medical registration if NPs can investigate the same, prescribe and refer.
    The government should work with the medical profession not against it. What is next on this government’s agenda?

  4. Anonymous says:

    I agree whole heartedly.

  5. Iatros says:

    The General Practitioners Society in Australia warned about this more than thirty years ago. It may be too late, but it is time some of our representatives stood up for the rights of GPs.

  6. Guy says:

    The issue is is not that doctors are being forced out. After all there is a shortage of doctors, especially in rural areas.
    A century ago doctors were far more generalists than they are today. This was largely because there was less specialised knowledge. I would see the push towards nurse practitioners as a step backwards in time towards an age when less specialist expertise was necessary. The big question is how far can we let this trend go and how will we assess the relative benefits of it.
    A GP friend of mine recently told me that a nurse pracititioner had suddenly stopped all of one of her patient’s multiple antihypertensive medications.
    Who polices this sort of thing? How much malpractice cover exists if something goes wrong?

  7. Ella says:

    The problem of a lack of a definition of a doctor in Australia is easy to solve. A doctor is a health professional that a Labor Health Minister wants to see immediately if they or a family member are critically ill.
    This is in clear distinction to the rest of the population for whom nurse practitioners should be more than sufficient in the first instance.

  8. Anonymous says:

    Thank you Martin for writing this – we look forward to your next contribution.

  9. Physician says:

    I think this is a very important point. What now constitutes a doctor? What entitles you to ‘Dr’ as a title?
    As medical practitioners, we have between 12-16 years of training to develop the skills which qualify us as doctors. Furthermore, this involves very rigrous training programs, hours of experience (on average 60-80 hrs a week) and intensive examinations, involving up to 18 months of study in order to pass. How then can a nurse practitioner learn in 3 years what it has taken doctors 14 years to learn?
    Having completed a Master degree myself, the workload in completing such a degree equals less than six months of the amount of work completed in a (6 year) fellowship, so how can they possibly compare? How can the former possibly be justified in receiving greater financial renumeration?
    Furthermore, where do dentists, chiropracters and osteopaths come off calling themselves ‘Dr’ as a title? Are they not riding on the publics’ trust in the training and specialised skill of a true doctor? Surely completing a 3-4 year degree, with or without further training cannot compare to the 6 years of medical school, 1 year internship, 3-5 year fellowship. There is no doubt that using the title ‘Dr’ will make the patients assume that the person is qualified as a certified medical practitioner, bound by the high standard of checks, procedures and registration practices involved. Why then is there no body which oversees this gross misrepresentation by non-doctor health professionals?

  10. Rural doctor says:

    I would dispute the use of the terms “doctor displacement” and “usurping”. There is no evidence that any of these new practitioners has resulted in any doctor being unable to secure a position or being fired from an existing position. Neither is there any evidence in other countries such as the UK and the US where nurse practitioners and physician assistants are used that locally trained medical graduates are being forced out. The fact is that in a number of the settings mentioned (rural and remote, obstetrics, surgery) the medical workforce is unable to meet the demand. Doctors in the US and the UK remain in positions of leadership. Doctors in Australia can choose to work with new arrangements and see them as an enhancement to patient care or fight them and render themselves irrelevant.

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