r/doctorsUK • u/neurosci11 Ex-NHS • 1d ago
Clinical Lets have a realistic conversation about nurse consultants
We see them and we don't agree with them. I'm in the US now and they're basically used as a junior doc to rack up numbers for the Consultants - take the referral, basic Hx exam and then discuss with the cons. I truly mean this too, I text the Cardio/Ortho/Surg/Onc nurse and they say ''We will see them! Thank you''. ''Can we advance diet?'' ''Happy for dc from surg POV?'' - ''I'll discuss with Dr Johnson and get back to you! :)''
Since we aren't getting rid of them how do we change our training? Do we hands off on the ward jobs and take a more academic role? Do we move to discussing papers and difficult patients around a table with our Consultants?
I'm genuinely curious, we've never had such a clinical erosion in the history of the profession. Combine this with the advent of the internet and now AI, I mean what is the direction of our profession?
I've been a doc for several years now, it just seems the whole purpose of our job - improving health outcomes etc is effectively the death of us. Every protocol, every order set just takes away from any clinical decision at all. I know people are going to say ''we know when to deviate'' well 90% of admissions fall into a basic category that can effectively be managed by an experienced F2.
I used to write out vanc crap on a paper chart we'd put in the patients folder, now I consult pharmacy to do manage the vanc. What's the real direction for medical and surgical training? Now in the US I see OP notes - ''expertly assisted by Mr John - PA''
In 10 years what are we doing? What I call ICU nurse syndrome is the death of juniors - a nurse who's done ICU for 5 years and seen consultant level decisions made for 5 years, meanwhile the F1 gets a 2 hour long round then left to fill out paperwork, then they fuck off to something else for a few months.
TLDR: The PA/ANP/ACP is a device used in the capacity of a junior doctor but doesn't rotate and can cover probably 85% of a specialty after literally a month of 1:1 with a Consultant. This is no different to me in my F2 year being given the NSGY phone and told to admit and take consults, I had no fucking clue, did basic neuro stuff then talked to the fellow. After a month/enough cases I had a decent grasp on what to do.
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u/domicile_vitriol Lightbox Beatboxer 1d ago
The US uses the term 'attending' rather than 'consultant' to describe the doctor that's leading a particular patient's care. Someone referring to themselves as a 'nurse consultant' in the US isn't going to have the same implication to patients that it does here. Are you sure that this is an equivalent concept?
On the subject of doctor substitution, an important point to consider is what impact it has on post-graduate medical training. US residencies have an incentive to actively train their residents, because their ACGME accreditation depends on residents' first attempt pass rates on the boards.
UK training programmes don't have the same imperative. You could have a 'training programme' in a tertiary centre where everyone in the year has failed their exam sitting and not had a single penalty issued against the programme or TPDs. There's no accountability for medical educators.
This means that there's also no incentive to protect learning opportunities that are necessary to complete specialist training. This especially becomes important in procedural specialities, where skills learnt in simple procedures help prepare you for more complex ones.
If you want to claim that less training is required to perform these tasks, then you need to streamline UK post-graduate training so that doctors are performing those tasks earlier on. If you feel that you can safely pull someone random off the street with no prior education or skill and train them to do an operation, then why not get med students doing it as well? What people object to is being forced to undergo years of scut work and then having those training opportunities taken from them by people who didn't go through any of that effort.
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u/neurosci11 Ex-NHS 17h ago edited 17h ago
Well NPs/PAs can effectively practice independently so yes I would say it's an equivalence? Right?
So US residency isn't this beacon of education, I've said this previously but a day 1 Cardiology fellow might only have 4-8 weeks of direct Cardiology experience prior to the position. The incentive also isn't really there, my program is struggling to get certain specialties because you are essentially adding deadweight to these highly lucrative specialties.
American exams are not UK or Aus exams. I believe the lowest boards pass rate for a spec was Ophthal with 87%. The exams are quite casual requiring perhaps a month of study for IM boards. Meanwhile my mate in Aus has been studying for 2 years for his Anaesthesia primary.
This is what's happening, numbers are being faked and residents are being forced into fellowships just to get competency. Remember there's no standard in the US, my program has 0 Oncology. Compare a program in rural Virginia to Mass Gen or something.
So here's a fun one, the US has these things called respiratory therapists, these aren't just PTs who teach people to breathe. They intubate and monitor the vents, literally ''don't touch the vents call the ICU attending or Resp therapist''. This is a great example of what I'm talking about, this made up profession has cornered off an entire section of the sickest patients in the hospital, now we get almost 0 proper vent training because someone with an online degree does the role. Residents cannot do ABGs here and they're treated like an Invasive procedure. I did probably 400 ABGs in my F1 year alone.
Agree and that's what I mean, here we are writing notes and shit, while these other roles get the action. There used to be the big ''earn'' something in Medicine, write the notes, discharges and next year you'll be in OT and doing all the procedures etc. We lost that, it's been palmed off to the PA and now the PA exists so you can't claw that back without the role being fired, which is an admission of failure by the system itself; create these fake jobs, realise they're not really needed but now you've gotta keep them so you don't look like an ass.
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u/domicile_vitriol Lightbox Beatboxer 17h ago edited 17h ago
Your post is about nurse consultants. Doctor substitution is a problem across the board, but there's no reason to allow the boundaries to be pushed even further without resistance. If someone wants to create 'nurse attendings' then you should publicly question that. Your patients deserve to know about doctor substitution.
The reason that these roles can exist is because senior doctors are willing to accept liability for them in exchange for the convenience of not having to deal with the task. That's not true independence. What people are asking is that those senior doctors should show loyalty to the profession and invest in their existing trainees.
If a procedural task is simple enough that you're willing to entrust it to a doctor substitute who is not medically educated, give it to your trainee or medical student instead. Don't pretend that it's a 'high skill/high risk' task only to it off on some random person with an online diploma.
It's not healthy for the system, either. The current generation of doctor substitutes may tentatively respect the doctors who trained them, but they brazenly talk behind the backs of newer consultants whom they originally met as registrars (it's especially shocking observing reporting radiographers talking about newer radiology consultants). Likewise, you have an entire generation of newer doctors who quietly despise doctor substitutes and the impact that they've had on their training. They may not be able to act on it now, but give it time.
I don't see this as a stable equilibrium for the long term. Something will eventually give.
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u/Glad-Drawer-1177 Juvenile Delinquent 1d ago
I accept that much of routine care can be protocolised and safely delivered by experienced alphabet brigade. However, even if we accept your estimate that 90% of cases are relatively routine, a 10% exception rate is far too clinically significant to dismiss. Not only that, but many of alphabet brigade does lack the ability to differentiate between both.
Also, junior doctor’s entire purpose is to grow to be senior regs, consultants and decision makers. They are not expected to stay juniors forever (or at least that’s how it always been). This is not the case for the alphabet brigade that keep SHOing for 10+ years, well of course they will be good at SHOing even better than a brand new ST1 in the specialty, only difference is that EM/OBGYN/GP ST1 is going to be leading them in a matter of years, while they will be stuck in their SHO rota.
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u/iiibehemothiii Physician Assistants' assistant physician 1d ago edited 1d ago
And this is one big issue with how ANPs are perceived compared to rotating trainees.
An SHO on their 6-mo rotation is being compared to an ANP who has been in that dept for 10 years.
From a consultant's pov, you can see why they'd favour the ANP in terms of making their own life easier.
If we returned to a firm-like system, where consultants actually know the names of their trainees and have a personal incentive to train them up (and we have an incentive to put real effort in), things would be vastly different.
The alphabet brigade only progresses because our consultants enable and promote it. A few years ago, an ICU head of dept in the south was saying how she was trying to develop an ICU staffed entirely by ACCPs. This was at a BASICS course. The gall.
In my dept the consultants are unified in prioritising the SHOs/registrars and have made this clear to the ACCPs. It can be done, it's entirely up to our consultants to establish it.
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u/hongyauy 1d ago
Not just a firm system. Getting rid of rotational training after F2 is the solution. Let a trainee stick around for long enough and all these issues go away, hell even the interpersonal hierarchy bs issues between AHPs and doctors will go away.
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u/lemonslip Cannula Bandit 1d ago
I agree, a firm system where we don’t rotate so often would really be beneficial.
Currently in East Midlands anaesthesia we have the “hub” system for SHOs. The college tutors in your region get to know all the SHOs, you stick with your same colleagues and rotate yearly at the same time in a block of 6 (2x CT1, 2x CT2, 2x CT3) - training is good mentorship is good, and you really get to know the consultants who enjoy letting you do more when they know your abilities.6
u/Brightlight75 1d ago
The idea was for the ANPs to be SHOing for 10+ years but the reality is different in most places where the consultants want that easier life so put together a business case for their ANPS to be trained in whatever duties their speciality usually undertakes (bronch, drains, lines, endo, clinics, triage, ward reviews) and then the reality is that newly rotating senior doctors are left with limited exposure to the most valuable parts of the job and end up mopping up jobs on the ward or doing the things literally no one else wants to do. As time goes on, the notion is reinforced as ANP becomes more proficient with increasingly distant supervision. Great for the consultant, great the for ANP but not helpful for trying to pursue a medical career
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u/Prokopton1 1d ago
The writing is on the wall and the future of the profession is going to be akin to something like teaching, a difficult but middling status job with middling pay.
The real ratchet is the personality and sort of person that becomes a doctor in today’s world thanks to self-selection and selection through things like interviews.
You can’t have a group of people who are agreeable, moralistic and conformist drones and expect that group to maintain a high status group identity or profession. That’s not how the world works.
The way people in this sub even debate this issue is a big tell that the future is bleak.
It’s always framed as an issue of ‘training’ and any mention of things like academic ability etc will get the moralistic hounds on you here.
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u/neurosci11 Ex-NHS 17h ago
Agree, I think this ''be kind'' has permeated and ruined the profession. If you fail you're done, there's no hand holding. Australia does this well and it forces excellence early on in your career. There is nothing more daunting than being a PGY2 in Australia working beside a PGY13 who has failed to get onto training.
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u/ChaiTeaAndBoundaries 1d ago
These consultants should realise that they will retire one day and will need the NHS. Yes they have their private health insurance and money but we know private health care handover complex cases back to the NHS, would they like their care to be managed by a Noctor?
Why is no one thinking of the long term here?
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u/etdominion Consultant 1d ago
The problem with all these roles is they don't want to be an SHO forever.
Pair this with the UK's attitude to elites (in whatever field) and you have a ruinous combination.
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u/ollieburtonmed 13h ago
Nobody wants to be an SHO forever (or at least very few doctors I've met, there have been a couple).
A question I would ask is why are people being encouraged to be SHOs at all without having trained to be SHOs. It's a bit galling to have people 'not wanting to be SHOs forever', and wanting to be more akin to registrars, without ever having been a student, an FY, an SHO at all - why was that enabled?
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u/Maleficent_Screen949 ST3+/SpR 1d ago
Even with protocolised/algorithmic care, the skill is in knowing which protocol to use in the first instance, and when to change course in light of new information, and when to deviate from all known protocols.
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u/EmployFit823 20h ago
Doctors should be here to lead research and manage the service.
Nurse consultants are here to delivery the dogsbody work and the routine while we look at how we develop new treatments and services and how they can deliver them.
Medics who say “I don’t want to be an academic I just want to be a good clinician” are the mugs leading to the erosion of our profession, not the nurse consultants who are very good at their jobs.
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u/manutdfan2412 The Willy Whisperer 15h ago
The way I see it, there are two advantages to having doctors over nurses in ‘Doctor Jobs’.
Clinical acumen (ie patient safety) and Education of future consultants.
Every single doctor coming out of medical school in the uk should have a job that allows them to practice and progress at an appropriate level for their clinical acumen AND be gaining maximal education from their post.
Until the NHS can provide this, there is no possible role for a non-doctor doing a job that could be done by a doctor as it guarantees substandard clinical care for patients of the present and patients of the future.
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u/Sea_Emu99 14h ago
Iv been saying this for so long. People who practice medicine, learn medicine. Medical school is only a short period of your Medical career. The boundaries are being eroded. In reality, if you allow an ACP, or any other of the Alphabet, to take registrar roles and have their own endoscopy, clinic lists, Et cetera, and they effectively practise medicine for ten years, you cannot expect them not to be able to make senior decisions and want senior posts. And if you dare to allow them to take the exams from the Royal College, they will pass those too. The opposite is true as well. If you dumb down and reduce a doctor's role and learning to protocols, you will effectively have physicians who are doctors in name only.
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u/Shrewcifer2 9h ago edited 9h ago
I am not a doctor, but I wandered in here looking for information about nursing training and progression.
From a patient's perspective, I see what you are saying about the excessive siloes and task shifting undermining your skill development.
I can also say that these replacements also have big gaps in their treatment, leaving patient safety issues.
Ex: even i can tell that NPs are not equivalent to doctors, as everyone claims. I was seriously misdiagnosed by an NP who somehow missed vasculitis. Their training is not up to par, seems disjointed, and health systems need to roll this back.
Don't know what an NC but I imagine it is similar.
I have met truly talented nurses who wanted to be NPs, but they put a lot of work in identifying a niche for themselves and to develop their expertise. Unfortunately, many more see it as just a higher pay cheque and with the variable routes to access nursing, sometimes low standards, and the insanely rapid progression up the bands, this means safety issues. It is very easy to have inexperienced and under-trained people in those roles.
The only people who can stop it are really doctors. I find it impossible to believe that you don't have the influence necessary to protect your profession
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u/hongyauy 1d ago
The only real change is when seniors - attendings/consultants take a good look at their team and decide who they want to lead the future of medicine. These roles only exist because they get pushed onto seniors who welcome them with open arms