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Substitution spiel

Martin B Van Der Weyden
Med J Aust 2008; 189 (6): 297.
Published online: 15 September 2008

Medicine is on a pathway that may culminate in a defining moment that will transform its practice forever. In the past, such moments in Great Britain have included the Rose Case of 1704 and the Medical Act of 1858.

The Rose Case resulted in tradesman apothecaries (whose legal role had been to dispense physicians’ prescriptions) winning the right to “practise physic” — that is, to visit, advise and prescribe for patients. This change in role marked the beginning of an evolution that defined the specialty of general practice.

The Medical Act of 1858 unified the various disparate groups of doctors through a General Medical Council that was given the power to decide who could be in the profession and who could not, through enunciation and policing of professional standards.

Modern medicine is besieged by tribes wishing to break down the walls of the perceived practice citadel. This struggle has a language of its own: task substitution or transfer, physician assistants, nurse practitioners, medical practice assistants, and so on.

Recently, I came across another new term: “physician extenders”. This is superb substitution spiel, as it conveys the sense that the professional attributes of doctors can be extended to other individuals (with a competence on par with doctors), and is dismissive of doctors’ long and comprehensive training.

What is missing from the substitution debate is the equivalent of a General Medical Council that will prescribe the training of these physician extenders, assess their competence, and adjudicate professionalism.

At the moment in Australia, these matters seem far removed from the ongoing debate on task transfer, as the idea that this transformation of medical practice is a panacea to our health care troubles has become embedded in political philosophy and policy.

Substitution spiel is easy. Substance is much harder.

  • Martin B Van Der Weyden


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