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Physicians do not know much about surgery, haematologists do not know much about cardiology, psychiatrists do not know much about orthopaedics and GPs, well, they do not know much about anything. And yet, we all went to medical school and so, before we became specialists, we were doctors. We had learnt how to analyse problems and how to know our boundaries. Those five years were not wasted.
Another email arrives, this time from a Consultant Psychiatrist somewhere in the West Country. Her teenage daughter, who is herself about to go to medical school, fell off a horse last week and hurt her shoulder.
I had a look, and although I am but a humble psychiatrist, I knew it was a bust clavicle. Palpable lump, point tenderness, severe pain. Pretty obvious diagnosis. Sling and rest is all that is required but I am a psychiatrist. Better go to A/E and get it done properly. She should probably have an x-ray, just to confirm.
So far so good. I take daughter to the minor accident unit. Seen by an Nurse Practitioner, who carefully examines her, and diagnoses '?acromio-clavicular joint strain'
Oh well.
Off to x-ray. Nice radiographer chats to soon to be medical student daughter and points out the fracture to her.
“Cor!” says daughter.
Back to see NP. He looks at x-ray, gives daughter a sling and gives good advice about rest, mobility etc. I smell a small rat.
“How long do you think the fracture will take to heal?” I ask.
“Oh, it's not broken,” he said. “It's just a strain”.
Could I have I look at the film?” I say.
He in turn now smells a rat. “Do you know about X-Rays?” he asks. I say I am a psychiatrist, but I learnt a little about them at medical school. We look at the film. I point out the fracture.
“Oh, that's just a line on the film” he says, ignoring breaks in the line of the cortex, the increased density in the overlapping ends etc. etc.
“OK”, I say, “well, we'll wait for the report from the radiologist” and we leave. Daughter is impressed. "I never knew you could be tactful, Mum."
Now, this is all rather trivial really, but it illustrates a more important point. A poor examination gave a false diagnosis, which was then adhered to despite evidence to the contrary. We can all be guilty of this. But doctors are trained carefully, and have the knowledge to move on from this position of error. I have lost count of the number of times my teachers said 'Never make the facts fit a theory. Your theory must fit the facts.'
This NP, who was in charge of the unit, had obviously never gone through this process. It's not his fault. He is being used in a role for which he is simply not qualified.
In this case, no harm done. But what happens when he sends a child home with a sore throat, pyrexia and dribbling because he does not know of the significance of dribbling in a child who cannot can swallow?
I would not want this NP treating my daughter. Frankly, I would not want him treating my dog, which brings me on to the interesting case of Dr Susie Macleod who is an experienced veterinary surgeon in Hertfordshire. She employs a number of highly experienced veterinary nurses. In 2004 she set up a separate clinic seven miles away, entitled the Health4Pets clinic. This establishment was staffed wholly by veterinary nurses, with no resident veterinary surgeon on the premises, although there was regular communication by telephone with the main practice and webcam pictures could be transmitted between the premises. The clinic's main function was to furnish facilities for the vaccination of small animals by veterinary nurses at considerably lower cost than the charges made by practices where veterinary surgeons carried out vaccinations.
And why not indeed? Sending “nurse specialists” out into the community to manage asthmatics and elderly patient with heart failure and COPD is known to provide huge financial savings and free up doctors and hospitals for more important work. Why not apply the same cost savings to veterinary medicine?
The Royal College of Veterinary Surgeons were not persuaded. On the contrary. They considered that Susie Macleod’s behaviour constituted disgraceful conduct.
Section 19 of the Veterinary Surgeons Act 1966 makes it a criminal offence for anyone to undertake veterinary work unless they are fully qualified veterinary surgeons. Veterinary nurses are allowed to carry out certain limited procedures provided the animals concerned
are under the care of the veterinary surgeon and the treatment in each case is carried out by the nurses under the direction of the veterinary surgeon.
Susie accepted the following facts:
* a. she was not present at the clinic when the vaccinations were carried out;
* b. she had never examined the animals;
* c. she had never read the animals’ medical records;
* d. she had never discussed the animals with their owners or agreed to take on their care;
* e. she did not know of the animals’ presence at the clinic or their condition;
* f. she had no discussion with the nurse administering the vaccine about the animal or its proposed treatment;
* g. she had no knowledge of the animals at allSo what defence did Susie mount to these agreed facts?
Read the next bit carefully. You many have heard it before. Susie placed some emphasis, however, in her submissions to the Board,
on her provision of “protocols” to the nurses which they were strictly enjoined to follow. In each case the nurse had a sheet on which she was required to fill in details about the individual animal, ticking boxes as she went, with instructions to refer the case to a veterinary surgeon on making certain findings about its health or condition.
She went on to argue that…
a veterinary nurse could carry out booster injections, so long as it was under veterinary direction, which she interpreted as extending to the system whereby she gave standard directions to the nurses by means of the “protocols”.
And what did their Lordships think of that?
"Their Lordships also consider, however, that the treatment carried out by the veterinary nurses in vaccinating the animals cannot be said to have been done under the appellant’s direction. The appellant argued that her “protocols”, consisting of instructions to the nurses and forms which they had to complete, constituted sufficient direction to them. Their Lordships cannot agree. They do not wish to attempt to define in detail the circumstances in which treatment is carried on under the direction of a veterinary surgeon, for those circumstances may vary widely. The concept does, however, connote an element of immediacy and potential control of the treatment which was wholly lacking in the carrying out of vaccinations at the Health4Pets clinic.
…..At its hearing the Disciplinary Committee was advised by its legal assessor that disgraceful conduct in a professional respect is conduct which falls far short of that which is expected of the profession. Their Lordships consider that that was an appropriate definition and that the Committee was correctly advised...
…their Lordships have no hesitation in upholding the decision of the Disciplinary Committee that the appellant was guilty of disgraceful conduct in a professional respect. The detailed findings made by it and the expression of opinion contained in its judgment that the appellant’s actions were capable of jeopardising animal welfare give sustainable grounds for reaching its ultimate decision, and their Lordships are of opinion that that decision fell within the ambit of sustainable conclusions."
The Veterinary Profession is not dumbing down. It is not going to allow protocol driven tick-sheet veterinary medicine to be practiced by unqualified “veterinary care professionals.”
Susie Macleod was reprimanded for disgraceful professional behaviour. We can be sure that she will not in the future be letting her nurse specialists loose on animals.
The question for doctors, patients and the NHS is obvious and I will not labour it. But the next time the cardiac nurse quacktitioner pops in to treat grandma’s heart failure, or the next time you visit a quacktitioner run walk-in clinic, try to forget that it is illegal to treat a dog in this fashion.pen on nhs
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