607
uncritically without some form of check as to whether their factual content is accurate. The comments which suggest dissatisfaction with the pre-
FAMILY NURSE PRACTITIONERS
them
be interpreted in a somewhat The current medical-school system, with its light. accent on academic rather than professional aspects of training, is producing M.B. graduates of good academic achievement and great keenness, but who are mostly to a considerable degree unprepared for the fact that a doctor’s work, if it is to be useful to the community and serve the best interests of the individual patient, is often tedious and repetitive and involves taking personal responsibility for aspects of management of the patient which may seem, at first, far removed from clinical skill or challenge. With, in many instances, the abandonment of the old three-month firm system in favour of more fragmented appointments, the newly qualified doctor is often unaware of the amount of humdrum routine that is involved in managing an efficient unit. Very often newly qualified housemen are unable to keep concise and relevant notes, and on questioning the students on my firm I found that during their clerkships they have rarely had their notes scrutinised or criticised by their teachers. I think that the more mature houseofficer realises that his preregistration posts last for only twelve months and that his responsibility for what may seem the nonclinical aspects of the job and for all the trivia does, in fact, make him realise that good patient care depends on these duties being carried out properly as well as on highly skilled medical management. To be on call for most of the time is a great opportunity to come to understand the natural history of disease processes, andI think this is accepted by most house-officers as a necessary period in their maturation and training. I am, however, very sympathetic to the house-officers of today because I think that in many ways they have more difficulties than their predecessors-particularly, the absence of mature and senior ward sisters since the introduction of the Salmon system. The chaos in hospital administration and in many departments such as medical records which are often chronically understaffed, leads La a great increase in the nonmedical work of which house-officers justifiably complain.
registration year may, I think, different
St George’s Hospital and St James’ Hospital, London
J. S. KIRKHAM
SIR,-You review (Feb. 26, p. 458) the book by Dr Hoole and his colleagues on the basis of a bias against nurse practitioners or the American system or both, instead of its own merits, and you make the mistake of comparing our two systems.
I have not seen the book but I have seen its protocols (misleadingly called "standing orders") in use by nurse practitioners in primary-care facilities connected with the University of North Carolina. The assumption that nurse practitioners are "some way off" in Britain does not tally with data which we are analysing nor with descriptions published by British general practitioners and nurses of comparable activities in this country. All that is missing in Britain is the careful attention which the Americans have paid to training their nurses for the demands of primary care and particularly at first contact. There is nothing like it in Britain-hence the insecurity often evinced by community nurses when asked to do this kind of
clinical work. These protocols
are not primarily intended for "quick referby busy nurse practitioners"; they are found to be a useful learning device whose principles soon became committed to memory during training. The stricter algorithm approach has largely been abandoned for nurse practitioners because algorithms are stultifying. Nurse practitioners are very well qualified-many of them have higher degrees-and are carefully trained to manage social and psychological problems for which there would otherwise be no help. It was precisely the absence of medical technology in the past which caused the intellectual and spiritual challenge of family doctoring to languish for so many years. ence
Medical Care Research Unit, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4AA
***Dr Reedy is wrong to suggest that The Lancet is biased against nurse practitioners. We merely believe that with a rationally distributed and flourishing general-practitioner system the widespread introduction of nurse practitioners to Britain is a long way off. The development of modern British general practice is by no means away from technology. All the same, the application of technology is only one aspect of the care
SIR,-I would three points.
disagree
with Dr Falk
(March 5,
p.
539)
of those in medical need.-ED. L.
on
availability of libraries is irrelevant if the houseman find the time to enter them or is too tired to read once he has entered. Dr Falk’s conclusion that most housemen favour the present system merely because they do not support the introduction of a shift system is not justified. The "unconscious learning" to which he alludes is an undeniable fact, but is not an unmitigated blessing. Because the learning is unconscious, the houseman develops a conditioned set of responses which form the basis of his treatment. While this reduces the likelihood of mistakes, it forms part of a continuing pattern of treatment which is never subjected to critical appraisal since it does not rise from a rational level. This gives rise to a conservatism in medical thought which is only
MAKING DO
The
cannot
upset
by
an
occasional innovator who somehow escapes the
general trend. As a houseman, enjoying his first six months of the preregistration year, I feel less complacent than Dr Falk about the year, and
am sure
and his colleagues 307b Clapham Road, London SW9
that surveys such are long overdue.
as
B. L. E. C. REEDY
that of Dr McManus
SIR,-In his contribution to your series Dr Jennings (Feb. 26, p. 474) that "it would be sensible to apply scientific methods to the delivery of treatment ..." After a commonsense description of the problems of providing an efficient anaathetic service, the "scientific method" is revealed to be a qualification of these problems. Variables are assigned symbols, and a complex algebraic formula is evolved. As an example of the use of the formula, actual quantities are substituted and the results are interpreted-but this interpretation could have been reached directly, from the initial discussion, without the intervening mathematical gyrations. The algebra is not an example of the scientific method. It is merely a re-statement of the original points-and a much inferior description of the problem when compared with the more straightforward arguments elsewhere in the paper. One of the flows in sociology for some years has been the disease
of
attempting
"scientific". It
qualify the obvious so as to appear that medical writing is becoming simi-
to
seems
larly infected. P. NISBET
Lancaster Lancaster
Royal
Infirmary,
P. R. CROFT
uncritically without some form of check as to whether their factual content is accurate. The comments which suggest dissatisfaction with the pre-
FAMILY NURSE PRACTITIONERS
them
be interpreted in a somewhat The current medical-school system, with its light. accent on academic rather than professional aspects of training, is producing M.B. graduates of good academic achievement and great keenness, but who are mostly to a considerable degree unprepared for the fact that a doctor’s work, if it is to be useful to the community and serve the best interests of the individual patient, is often tedious and repetitive and involves taking personal responsibility for aspects of management of the patient which may seem, at first, far removed from clinical skill or challenge. With, in many instances, the abandonment of the old three-month firm system in favour of more fragmented appointments, the newly qualified doctor is often unaware of the amount of humdrum routine that is involved in managing an efficient unit. Very often newly qualified housemen are unable to keep concise and relevant notes, and on questioning the students on my firm I found that during their clerkships they have rarely had their notes scrutinised or criticised by their teachers. I think that the more mature houseofficer realises that his preregistration posts last for only twelve months and that his responsibility for what may seem the nonclinical aspects of the job and for all the trivia does, in fact, make him realise that good patient care depends on these duties being carried out properly as well as on highly skilled medical management. To be on call for most of the time is a great opportunity to come to understand the natural history of disease processes, andI think this is accepted by most house-officers as a necessary period in their maturation and training. I am, however, very sympathetic to the house-officers of today because I think that in many ways they have more difficulties than their predecessors-particularly, the absence of mature and senior ward sisters since the introduction of the Salmon system. The chaos in hospital administration and in many departments such as medical records which are often chronically understaffed, leads La a great increase in the nonmedical work of which house-officers justifiably complain.
registration year may, I think, different
St George’s Hospital and St James’ Hospital, London
J. S. KIRKHAM
SIR,-You review (Feb. 26, p. 458) the book by Dr Hoole and his colleagues on the basis of a bias against nurse practitioners or the American system or both, instead of its own merits, and you make the mistake of comparing our two systems.
I have not seen the book but I have seen its protocols (misleadingly called "standing orders") in use by nurse practitioners in primary-care facilities connected with the University of North Carolina. The assumption that nurse practitioners are "some way off" in Britain does not tally with data which we are analysing nor with descriptions published by British general practitioners and nurses of comparable activities in this country. All that is missing in Britain is the careful attention which the Americans have paid to training their nurses for the demands of primary care and particularly at first contact. There is nothing like it in Britain-hence the insecurity often evinced by community nurses when asked to do this kind of
clinical work. These protocols
are not primarily intended for "quick referby busy nurse practitioners"; they are found to be a useful learning device whose principles soon became committed to memory during training. The stricter algorithm approach has largely been abandoned for nurse practitioners because algorithms are stultifying. Nurse practitioners are very well qualified-many of them have higher degrees-and are carefully trained to manage social and psychological problems for which there would otherwise be no help. It was precisely the absence of medical technology in the past which caused the intellectual and spiritual challenge of family doctoring to languish for so many years. ence
Medical Care Research Unit, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4AA
***Dr Reedy is wrong to suggest that The Lancet is biased against nurse practitioners. We merely believe that with a rationally distributed and flourishing general-practitioner system the widespread introduction of nurse practitioners to Britain is a long way off. The development of modern British general practice is by no means away from technology. All the same, the application of technology is only one aspect of the care
SIR,-I would three points.
disagree
with Dr Falk
(March 5,
p.
539)
of those in medical need.-ED. L.
on
availability of libraries is irrelevant if the houseman find the time to enter them or is too tired to read once he has entered. Dr Falk’s conclusion that most housemen favour the present system merely because they do not support the introduction of a shift system is not justified. The "unconscious learning" to which he alludes is an undeniable fact, but is not an unmitigated blessing. Because the learning is unconscious, the houseman develops a conditioned set of responses which form the basis of his treatment. While this reduces the likelihood of mistakes, it forms part of a continuing pattern of treatment which is never subjected to critical appraisal since it does not rise from a rational level. This gives rise to a conservatism in medical thought which is only
MAKING DO
The
cannot
upset
by
an
occasional innovator who somehow escapes the
general trend. As a houseman, enjoying his first six months of the preregistration year, I feel less complacent than Dr Falk about the year, and
am sure
and his colleagues 307b Clapham Road, London SW9
that surveys such are long overdue.
as
B. L. E. C. REEDY
that of Dr McManus
SIR,-In his contribution to your series Dr Jennings (Feb. 26, p. 474) that "it would be sensible to apply scientific methods to the delivery of treatment ..." After a commonsense description of the problems of providing an efficient anaathetic service, the "scientific method" is revealed to be a qualification of these problems. Variables are assigned symbols, and a complex algebraic formula is evolved. As an example of the use of the formula, actual quantities are substituted and the results are interpreted-but this interpretation could have been reached directly, from the initial discussion, without the intervening mathematical gyrations. The algebra is not an example of the scientific method. It is merely a re-statement of the original points-and a much inferior description of the problem when compared with the more straightforward arguments elsewhere in the paper. One of the flows in sociology for some years has been the disease
of
attempting
"scientific". It
qualify the obvious so as to appear that medical writing is becoming simi-
to
seems
larly infected. P. NISBET
Lancaster Lancaster
Royal
Infirmary,
P. R. CROFT
