Dr Rant encounters many tales from his medical colleagues around the country. A lot of them are regarding the gathering rise of the 'Noctor'. A 'Noctor' is a portmanteau term to describe a nurse acting as a doctor, but can represent any speciality who does not have a medical degree attempting to do the job of someone who should have one.
Here is a tale from one of Dr Rant's colleagues who describes a typical night on call, and a phone call from such a noctor:
While at the out-of-hours clinic, I got a phone call from an 'Emergency Care Practitioner' nurse at 2 am. The conversation went something like this:
Noctor: Eh, doctor, where can I get some Fluconazole at this time?
Me: Fluconazole-why at this time?
Noctor: Need urgently for this poor lady, she is not very well.
Me: Fluconazole!!?? What is wrong with her?
Noctor: She is 10 days post-partum and has swelling over one breast, red, hot, painful. She also has fever and chills. I have made a diagnosis of Mastitis (lot of pride in voice-well done mate!) and I need Fluconazole urgently for her as I do not want to admit her.
(They are on a mission not to admit, so that PCT can prove nurses do better than doctors. Sometimes it means asking patients to call-as they are in no condition to visit-their doctors early next morning.)
Me: Fluconazole!!!???
Noctor: (in complete confident flow now) Yes, can you tell me how to access emergency chemist? And oh-you'll also have to sign the prescription, as I don’t have the Directive for it. (Impatient now), will you help me? (Threatening tone now as “helping and supporting” them is part of our contract.)
Me: But why Fluconazole???
Noctor: (very patronizing and mocking tone now-I am, after all, only a GP; he has done all the courses.) Is that not the first choice for mastitis?
Me: Fluconazole??!!??!!
Noctor: Yes, yes, we always use it for skin infections. Isn’t it the first drug on protocol?
Me: What Protocol?
Noctor: I know doctors don’t use the protocols,(mocking, insulting) but we have one (proud) and it says fluconazole for skin infections, have you not seen that?
Me: (Like a broken record, in disbelief, and by now, just a niggle of doubt about my 20 year training and experience creeping in!) Fluconazole???###!!!??/###???###!!! Er, have you got this protocol with you?
Noctor: No, but I can show you next week, we were given it at our prescribing course. Look, we are all very busy professionals here, are you going to help me or should I call the night duty manager? (Patronizing, threatening, arrogant or just full of s**t-could not decide.)
Me: (Penny suddenly dropping now.) Do you, er, by any chance, eh, mean Flucloxacillin??
Noctor: (Silence for a long 15 seconds-----)
Me: Hello?? Are you there?
Noctor: Oh! Em , I mean, eh, yes, Eh, I think you may be correct.
Me: (thinking-yes you f*****g idiot, I am correct!) OK, so you need some fluclox?
Noctor: (Not admitting defeat, got confidence and arrogance back by now-is that taught on a course?) Yes I think we can try Fluclox, but I am sure Fluconazole is first choice!!
Me: Try drug box in car, you may find some.
Noctor: I’ll show you the protocol next week.
It is three weeks, and I am still waiting to meet this noctor, or to see the 'protocol'.
Rather than see someone who has been trained in medicine (including microbiology, breast disease and pharmacology) for five years, and has at least five years post-graduate experience dealing with these fields, the above patient was dealt with by someone who had been on a short course. Rather than use their brain to think about the pathogenesis of a breast infection, the most likely micro-organisms, and the class of antibiotic, they had followed the protocol 'mastitis = give drug beginning with F'.
For what it is worth, Fluconazole is secreted in high levels in breast milk, and is not a drug that should be given to a breastfeeding woman. Many cases of mastitis do not require antibiotics, either.
Dr Rant is aware that some doctors will act in a fashion similar to the above, but he hasn't met very many like this, and those that he has met would have backed down and apologised profusely as soon as the word 'flucloxacillin' was mentioned.
These noctors will be increasing in number. They will be seeing your families and friends in the middle of the night. They have minimal training in drugs, and can prescribe only a handful of them. How much do they know about other drugs your lil’ ol’ granny is on, at 3 am, while she is on the floor, or SOB, or confused, is any one’s guess.
There is a colossal shortfall in quality manpower of nurses out there, and taking nurses from the wards, and training them to be low quality GPs is neither wise nor productive. And in some cases will poison a newborn with an antifungal overdose.
Welcome to cost saving.
Watch this YouTube clip, then try to tell us we're being paranoid or protectionist. If you can't identify every single drug mentioned and what it's for, then you should not be prescribing anything.
With thanks to Dr Rant's colleague, who first discussed this case on another website, for his permission to use the details.
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29 comments:
This makes me want to cry...why bother going through 6 years of medical school and learning 350 drugs for year 2 pharmacology if people then don't believe you might possibly know more than they do?
good luck
if you could just try and stop PCSO's trying to do a proper coppers job
and teaching assistants taking classes of 30 for full days
and other general false economies
good luck
no one
As a nurse in a similar role, i have much sympathy with the good Dr RAnt.. I hav 14 years experience in a vast array of clinical specialities, and consider myself a safe competent NURSE, I have done the crappy training courses and the prescribing course and only when I have been put in the situation where i am expect to act and practice at a similar level to a Dr do i realise that whilsy t i am very experienced and competent I aint a doctor and there is a huge gap in both my knowledge and experience, whilst my experience to date allows me to independantly treat simple problems I firmly beleive anything more complex or anything with potentially serious or indeed fatel consequences should be left to those that have had the training to to it, or at least managed under close supervision from a competent GP. It is not (gernally) the fault of th eindividual nurses it is the fault of the clinically and managerially inadequate fuckwits that putthem in the situations, who form my experience are the ones who shouldnt be allowed to have any influence over these critical issues. The amount and standard of the extended training we get is generally woeful, a nurse without a broad clinical background and demonstratably competenat should not be put in this situation....
Rant over...
Dr Rant don't worry.
I just posted in Dr Crippens blog..about how we are saved, the first 20 PAs will be comig out of Brum uni in 2010!
They will have done 2 whole years training! They will be qualified to cover the hospital areas where there are no doctors so no one need worry...
Would those be the hospital areas that used to have plenty of doctor cover provided by dead-tired juniors, but now that we've actually got enough doctors to do the work properly, thousands of them are un/underemployed?
Did some one say 'money'?
My god, is that you, nurse Ratchet ?
You say - 'my experience allows me to treat simple problems'.
As you know, NR this is exactly what the quacks (in the UK) have been doing for more than decade now.
Just as there a spectrum of health problems, so there is a spectrum of workers to deal with them (from consultants to FY1's) - quacks entered the heirarch, essentially because of the EWTD, but also to validate roles often performed on the q-t.
I can accept all the reasons (both professionally and politically) why this gets up the nose of so many doctors but what I can't accept is the oft repeated accusation that quacks are harming patients, at least any more than junior doctors do.
If quacks are so dangerous why has not one study emerged demonstrating this fact - look at the blogsphere (especially DNUK, I'm told) surely some doctors would walk barefoot over broken glass to unearth such a study ?
We have a bunch of quacks where I work and there is no pattern of endangerment to patients identified through audit, consultant supervision, or personal stories (I appreciate there is no way for anybody to corroborate this claim).
Additionally, I hope the Rants (who I respect a great deal) can accept my scepticism about the anecdote supplied - indeed, I would expect any D-grade A&E nurse to know the difference between fluclox and an antifungal, especially since gallons of the stuff (+/- benzylpen) is regularly squirted into the viens of patients with cellulitis, especially brittle asthmatics with a severe penIcillin allergy........no, only joking, there.
Anyway, maybe there was a breast abscess that needed draining - sometimes antibiotics will not clear up the infection.
By the way, I have sympathy for any nurse wanting to escape the inadequately staffed hell-holes typified by the C-diff outbreak in Kent - if doctors think they are having problems maybe they should try 6 months back breaking work on one of these wards, then listen to the likes of Crippen pontificate about how university educated nurses are 'too-posh-to-wash', now that really gets on my tits.
A&E Charge Nurse, has it occurred to you that the reason there is so much back-breaking work to be done in insufficiently staffed wards is that the government has found it expedient to divert funding & staff to 'quacktitioner'-led services, with the connivance of many of your (& my consultant) colleagues
I'm a nurse working in A&E, Mark, and have done so for over 10years (I was a psych nurse before that, but thats beside the point).
I work weekends, nights, push patients to wards, attend to, aherm, hygiene needs, etc, etc.
Sometimes I put shoulders back in, drain paronychias, give IV's for cellulitis, etc, etc.
Nowadays, roles that wer performed on the q-t have become formalised but things haven't changed that much.
From the A&E perspective if ALL staff do not work to the max, then we become gridlocked, it's as simple as that. - we would simply by unable to cope with the numbers coming through the doors (exacerbated by current OOH arrangements, etc).
Remember, quacks constitute but a tiny fraction of the overall nursing workforce.
Conditions on the wards need root and branch reform [IMHO], a problem unlikely to be solved a by a few ageing noctors.
As I mentioned on a recent thread, doctors who worry about quack infringement are a bit like LFC supports worrying about Havant & Waterlooville.
But hang on, the none leaguers scored twice at Anfield didn't they ?
Dear Noctor Hater,
I took a Noctor up the arse once and it was truly wonderful - an empowering experience. They have their uses and this is certainly one of them. Learn to love, not hate my dear fellow.
Noctor Lover,
Prof Scrub
http://www.profscrub.com
I'm feeling naive, now.
In my corner, "noctors" don't seem prevalent. Mostly 'cause anyone stopping to think about it has realised that getting anyone other than a doctor to do a doctors' job is insane.
How prevalent is this "noctor" role?
http://ferretfancier.blogspot.com/2008/01/incoherent-logic-dumbing-down-standards.html
The Noctor role is actually on the rapid rise. I don't think it should be confined as being an NP thing either, it's a PA, GPsWI thing too. It's about replacing people with lots of training with those who have much less, it will not provide as good a service and it is not cost effective.
Look at the number of WICs that are being railroaded through by the Darzi back door APMS, these are full of Noctors with very shoddy levels of knowledge and training who are allowed to practice medicine unsupervised.
There's no excuse for it, it's just crap.
A&E charge nurse.
Noctors/Quacks what ever you want to call them WILL end up harming patients, as the junior doctors won't get the chance to see the 'simple' patients and thus be less experienced and less competent at their job overall. A large part of learning to be a good doctor comes from actually doctoring.
Dundeemedstudent....
Whilst i symphaphize with the general comments re Noctors etc.... i must take objection to part of your comment...
in my opinion...A large part of good doctoring actually comes from working with nurses....
How many of us can recall gently preventing the poor baby junior fresh out of med school HO administering / prescribing a fatel dose of something nasty....
An example of which would be gently removing a syringe of neat adrenaline from a HO intent on raising a fully conscious pts blood pressure....
I stand by my origanal posting tho - the public is being conned... safety is being comprimised... the whole safety net to the noctor experiment is either a protocol dreamed up by a maanger numpty and or the individual nurse acknoledging their own limitations - you need skill and experience to do this
IE a nurse with many years of multispecialty experince probably can achive this.... someone who has been qualified 10 mins and has a title of Nurse Practioner or alike and Done the courses soesnt have this general experience and then arguably the ability to recognize when enough is enough and the customer needs to be seem by someone better qualified.....
they didn't teach me about night nurse at my medical school. should I not be prescribing?
I think that "health care assistants" with little clinical knowledge and no accountability on the wards replacing nurses is really as scary. Even scarier is that people think that these people are nurses.
What is fluconazole...
Is there a protocol for it.....
Rant
I've been working in general practice for over 4 years and sadly have experienced the 4 weeks clinically trained, PGD protcol holding, sham the WIC's call NP.
The title 'NP' is very much in vogue and and I am saddened by these nurses who are being mislead by their PCT into thinking they have a sound knowledge base to do the jobs advertised on NHS Jobs.
I also understand many doctors despair concerning advanced practice, but as in my case my role came about on the first implementation of the EWTD, when there were no doctors to do the job. I unlike many nurses working in the WIC's do not use PGD's but prescribe from a sound knowledge base and know every drug mentioned in the short film, I also know what I don't know!!
i think advanced practitioner has hit a point- the question of knowing what one knows and doesn't now. territorialism aside, this culture of 'competency' is the real danger. granted junior doctors may have holes in their training but at least med school is structured. many years of wide clinical nursing experience is a vague and is not medical experience. attending courses and having signed competencies is not the same as having dedicated institutions structuring and validating training.
i just don't think it's helpful for nurses to demean junior doctors, just like it's not helpful for doctors to demean nurses. training is training. all med school means is that you shouldn't be making dangerous mistakes. it doesn't make you an independent practioner- pmetb does that now.
ultimately it's up to the people who do these competency driven jobs to think how safe they are. unfortunately, it may be that they can't even know how safe they need to be.
Yesterday a patient threw a fit on the floor.
As nurse in charge I co-ordinated the immediate management of the incident.
Psych reg attending decides to call a code blue - emergency medical team of 3 docs and 2 ICU nurses team attend the unit - IV in situ - Diaz given - GCS/neuros/vitals done - They determine to Tx to emergency for CT scan - ambulance is called as an emergency call as we're not attached to main hospital - pt tx and admitted to A&E - 2 staff escort needed as a detained patient - obs re-done by admitting nurse - CT scan ordered - at which point I've had enough and step in - as a mere nurse, - "Ahem, this guy is suffering nothing more than epilepticus bullshiticus. Why are we doing all this?"
Unfortunately, my 15 years of forensic mental health nursing didn't seem to count for anything in the face of 6 doctors who wouldn't chance being wrong or actually had little understanding of how some patients behave.
Today we discussed the incident (pt and I) - he said he was having a bad day and just needed some extra attention.
How much did those doctors poor/weak diagnosis and misdirected treatment skills cost the service?
On the other hand: I believe those who train in MEDICINE should be the ones who prescribe medicine. I have some concerns that Noctors (why didn't they get called Durses - or is that portmanteau reserved for Doctors who think they can do what nurses do, like Dr Crappen?) who are not backed by a good support structure (such as you have for an in-patient, may be working too far into unchartered waters. I may have preferred to see the Noctor on the hospital ward first.
There is scope for others to support the work of the medical staff. But how many doctors are happy to be called at 3am to attend and write up paracetamol or brufen for an in-patient - nurses do this in most places themselves already. How much medical training do you need to have in order to administer 5mg diazepam? I can give it anytime I deem status to be occuring without prescription. Mild laxatives and even enemas in the elderly are often nurse prescribed (and face it, GP's are the worst at polypharmacy for the elderly). Nurse initiated medicines have been around for a while; prison nurses have frequently diagnosed and treated conditions (cos doc can't seem to get there at 4am and spend the half hour being walked thru the prison to get to the patient and another half hour to be walked out, for some odd reason); district (community) nurses have been prescribing ointments and creams for several years now.
Further, do our dear doctors realise that nurses have always been legally and professionally accountable for the administration of the drugs they prescribe? That means knowing the effect, side effect, dose, route, contra-indications and drug interactions of what I'm giving - otherwise, I stand to be struck off the register +/or even, in the event of death, prosecuted under manslaughter charge and then sued for professional negligence.
My registrars prescribe what I indicate almost all of the time. They still insist on giving Clozapine to aggressive patients (and totally asymptomatic of any psychoses) then label them "treatment-resistive schiz" - cos without a drug prescribed what the fuck use is a doctor and how do they justify taking the lead role?
However, I know where my line is and I wouldn't have a fucking clue about respiratory medicine.
But then, that's when I call the respiratory nurse...
The anecdote on Fluconazole is confabulatory and sensationalism - nothing more than 'status bullshiticus'. If a nurse has to read a protocol and then can't read it right - you're talking of someone who couldn't even pass the nursing degree in the first place.
Interns and HO's make loads of mistakes to begin with; nurses help them out and prevent errors by virtue of the aforementioned responsibilities.
I guess we're just lucky we don't have people at such esteemed levels of 'Doctor' ever doing stupid things like hacking off the wrong leg or prescribing medications at stupid and lethal doses - except for the ones that do of course.
"tainted holo" reveals many of the small minded prejudices i worry about. s/he clearly doesn't realise that a peusdo-fit as such is a diagnosis of exclusion and that inadequate treatment of a true fit assumed to be factitious would lead to severe (and possibly justified) criticism. the comment '6 doctors who wouldn't chance being wrong' reveals the difference in accountability between medical staff and 'tainted holo'. is this i wonder the professional accountibility "tainted holo" claims nursing staff have but from this example, lack.
i've also seen nurses treat patients terribly, but regrettably as a junior doctor mindful of the need to maintain professional relations, have stayed quiet.
i would just like to re-emphasize the point that this sort of 'well doctors are all crap' criticism is simply unhelpful. if you think they're crap and you can do better then do it and make a real difference- don't just sit on the side making opportunistic remarks.
I hope tainted holo still has sufficient insight to recognize her own delusions. We lie at your feet o mighty one as we are not worthy !
Can't understand how you can give a prescription only drug (diazepam) without a signed, legal order but presumably the laws of the land do not apply to supernurse. At least you'll call the respiratory specialist nurse over in the early hours after the patient has a respiratory arrest.
Twat.
Dr Dude: tainted holo reveals many of the small minded prejudices i worry about"
That would be the same small minded prejudice that coins the phrase "Noctor" without feeing a tint of sanctimony?
and Anon: Can't understand how you can give a prescription only drug (diazepam) without a signed, legal order
It's called utilising my scope of practice and acting in the interests of the patient. Same with administration of s/c epinephrine for anaphylaxis. Why would I stand and watch patient die because I didn't have a prescription?
When it takes 10 minutes for the medical team or longer for emergency services (which don't have a doctor, noctor or quack in the ambulance) to arrive - I'm required to diagnose and treat a life threatening illness.
Or would you rather I waited for a medical review for confirmation on the cause of death?
Tainted halo seems unaware that waiting 10 mins to administer diaz for a fit is ok.
Status is only after 20 mins. Is a fit is not resolving after 10 mins then administering diaz is reasonable but by then they say the medics would be there.
Again clinical decisions are better than protocol.
Oh and not to mention 5mg diaz is too small a dose for status anyway.
lorazepam is the benzodiazepine of choice for status. Tainted halo likes to offer her expert opinions from Australia but benzos are lower scheduled controlled drugs in UK - presumably she's happy to give iv diamorphine for acute LVF without a legal script too ?
The comment about HCAs on the wards, with no accountability.. What a true statement. I am based in a ward where the nurses are good. But they do not have enough time to supervise the HCAs, who at times fake obs charts! (i have seen this first hand)
then to top this off, when the patient actually starts deteriorating... the nurses will call the outreach team. in theory this is meant to alert the itu/hdu to a possible admission. in all honesty a phone call from the SHO/HO to the gasman will suffice. but these outreach people will write a two page account of this patient, while he is crashing in front of them, AND then decide to get one of us or the anaes team.
We also have a ward in charge who thinks he is a doctor.... and for all intents and purposes, bullies the junior doctors into doing his wishes so to speak.
I agree experience is important... but experience through repetition is going to lead to catastrophe. Logic and thought process, not protocols and rigid implementation of these scraps of paper, will make a patient better....
the public will realise this in time to come....I am an SHO and i try to stand up to this bullshit... but my own seniors have not said anything.... one reg actually told me....the HOs can learn from the nurses, they have so much exp... he rather let the nurses carry on with what they are doing, rather than educate the house officers..... the future consultants in 10-15 yrs time....
when one's loved one dies.... one will realise the turd we are in...
Anonymous - I have never seen a paediatrician wait 10mins before using drugs to terminate a seizure in a child suffering a prolonged febrile convulsion, nor do doctors tend to let withdrawing/septic alcoholics continue fitting for more than a few minutes either.
Yes, titrated lorazepam may be the gold standard but securing IV access is often impossible, in which case buccal midazolam works a treat, or failing that good old diazepam, PR.
Most A&E departments know one or two regular pseudo-fitters and it is rare (in my experience) for them to receive the full panoply of medical intervention despite suffering mysterious and recurring symptoms.
quick reply to tainted_holo... 'a rose by any other name....'.
btw well said anonymous. what a twat.
Nursing bachelor degree (OP 14-19).
MBBS (OP 1, or post grad).
If you want to do nursing stuff - do a nursing degree.
If you want to do doctor stuff - do a medical degree.
Or, we could just have an OP cut off of 19 for all medical / allied health staff.
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