Whither medicine? The expansion of non-doctor practice

Some 60 years ago, Lord “Tommy” Horder, the doyen of British physicians of that time, addressed a meeting on the theme “Whither medicine?”.1 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.2 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.3 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 (J F O’Dea, Manager, Medical Practice Department, Australian Medical Association, Canberra, personal communication). 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 — exemplified by recent letters in Australian Doctor (Box).

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,6 and the medical colleges and British Medical Association in the United Kingdom, with similar projects.7 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.