Wednesday, 15 August 2007

Diagnosis

Dr Crippen has strong views on the role of senior nursing staff in specialist areas. His views are widely shared. In fairness, there are also folk who have opposite views. I'm not opening up the Nurse Consultant/Specialist role is good/bad here, I'm wanting to touch on just one specific area . . . diagnosis.

I couldn't do my job the way I do without my senior nurse colleagues who are the most important members of the team. What they do, they do exceptionally well and do expediently. Patients and GPs love 'em, and rightly so.

What nursing staff are weaker at is diagnosis. Diagnosing things that are the bread and butter of a speciality is fairly straight forward. Diagnosing the obscure is harder. Diagnosing the exception that looks commonplace, presenting largely with commonplace symptoms, is exceptionally tricky.

I used to believe that only medics could robustly diagnose problems. I've changed my view. Nursing Staff can diagnose common problems effectively, most of the time. They can not diagnose atypical and obscure problems and should not be expected to do so since they've not had the training to do so.

The endless and involved teaching of anatomical structures, physiological function, pathological processes and outcomes from this necessitated years at medical school that nurse training rightly does not include.

The training process means a doctor may not know exactly what the condition he's looking at is, but can make sensible considerations of anatomy, physiology and pathological processes on these to ellucidate causes and generate diagnostic formulations. Nurse training precludes this process.

Worse, there's an implict and explicit acceptance amongst many senior nursing staff that getting it right enough of the time is good enough, so missing the odd wrong diagnosis isn't something to fret over. This was brought home when senior G and H grade nurses (erm, band 7 and band 8 in new speak) have undertaken the nurse prescribing courses over the last couple years. I've mentored many nurses (and physios) through this and been staggered by the attitude of the course lecturers and course organisers. Just one example. When talking through managing an unwell child with fever and sore throat there was anxiety from (these very senior) nurses over missing meningitis and what should be done to address this. They were told that nurse prescribers need to be confident in managing what's common, viral infection and bacterial throat infection would account for almost all presentations so manage the child as that. But what if it is meningitis, they persisted. Their lecturer explained that meningitis is so rare, viral/bacterial infection so common, if they worry about meningitis they'll be referring everything and never treating anything so it's best to ignore the rare diagnosis of meningitis altogether and focus on treating what it's almost certainly going to be.

I've worked in paediatrics. I saw children with proven meningitis. I've trained and worked in General Practice. When I worked in A&E I saw a child with meningitis who died.

Meningitis is not common. But it is present. To ignore it as a diagnostic possibility is madness. But it is what Practice Nurses, A&E Nurses, District Nurses and ward staff (all at the most senior level) have been told to do. They were not told this in "the bad old days" they were directed to do it this year. Let us hope none ever treat my children.

Diagnostic formulation is based on the probability of Diagnosis X accounting for the problems your patient's presenting with. Always listing obscure causes for a patient's common problem and referring on to exclude these is not helpful. The opposite, of only considering common causes, is equally unhelpful (yet it is what most nurses are being asked to do).

For nursing staff to be asked to do more than triage, to ask them to start to diagnose, is fraught with problems since it is manifestly outwith their training. They can be excellent at assessing what's common but I really believe that ignoring (knowingly or unknowingly) the uncommon and rare conditions is a grave disservice to our patients.

It is neither how I would wish to treat patients nor how I would want my nearest and dearest treated.

My nurses are exceptional at what they do. But let's not collude with managers and the Department of Health that cheaper nursing staff gives better outcomes. It gives decent outcomes for most patients most of the time. It gives disastrous outcomes for others.

11 comments:

Zarathustra said...

Before agreeing with you, I'll just briefly hop onto my soapbox about the whole Dr Crippen "quacktitioner" argument.

The thing I disagree with about Dr Crippen's stance is that he tends to lump all advanced nursing roles (nurse specialists, nurse practitioners, consultant nurses) into one amorphous lump as though they all do the same thing. This is not my experience. Nurse specialists are not the same as nurse practitioners are not the same as consultant nurses.

I don't have an objection to advanced nursing roles, so long as the role in question:

(a) is within the competency of the individual doing it

and

(b) has a specifically nursing (as opposed to doctor-substitute) rationale to it.

Basically, I'm with the "maxi-nurses, not mini-doctors" side of the argument. I'm in favour of extra-skilled nurses, but not of under-skilled doctors.

There are a lot of nurse specialists out there in areas like wound care, infection control, child protection etc that can be argued to fall well within the nursing remit. So long as they're working as nurses and complementing rather than replacing a doctor, I don't have a problem with that.

As for consultant nurses, I've worked with two of them. Both were highly respected, dynamic individuals combining clinical practice with teaching and research. They were valued by their colleagues and especially by the students.

Another point about Dr Crippen is that he tends to use "nurse specialist" as a shorthand for "any nurse who's annoyed Dr Crippen recently". He's called ME a nurse specialist on more than one occasion.

And finally, if Dr Crippen wants to convince people, he really really needs to drop some of the "nurse, you're too thick to do anything except eat bourbon biscuits" language that he uses. That just antagonises people and makes them defensive.

All that said, I would say that diagnosis is something that falls outside of the nursing remit. It's not our role and it's not something we train for. That's where the "maxi-nurse" tends to shade into the "mini-doctor" territory.

At the moment, Dr Crippen is only serving to polarise the argument. By saying that "All advanced nursing roles are bad, everywhere" that forces those in favour of these roles onto the defensive and wind up trying to argue that "all advanced nursing roles are good, everywhere". This is not a mature debate.

I would like to see the debate moving on from this to explore a middle ground argument that says "nurse specialists/practitioners/consultants should do a-b-c but should not do d-e-f."

Advanced Practitioner said...

The Shrink said...

Dr Crippen has strong views on the role of senior nursing staff in specialist areas. His views are widely shared. In fairness, there are also folk who have opposite views. I'm not opening up the Nurse Consultant/Specialist role is good/bad here, I'm wanting to touch on just one specific area . . . diagnosis.

For nursing staff to be asked to do more than triage, to ask them to start to diagnose, is fraught with problems since it is manifestly outwith their training. They can be excellent at assessing what's common but I really believe that ignoring (knowingly or unknowingly) the uncommon and rare conditions is a grave disservice to our patients.

*****************************
Shrink

Nurse traing pre-project 2000 did incompass anatomy, physiology and disease process throughout the three year traing programme, many of those nurses myself included have completed an advanced NP degree and advanced MSc which does teach anatomical structures, physiological function, and pathological processes combined with clinical-descion making process and effective history taking, with the knowledge that 95% of the diagnosis is made via the history.

I understand your concern and realise that I will never be considered an equal clinician to my GP colleagues, but I'm ok with that as I have never, and do not claim to be a medical doctor. What concerns me and many others who have completed extensive training both clinically and academically and are working at an advanced level, are the increased overuse of NP and specialist nurse titles that delude the nurse to think they are advanced and confuse the medical profession!

My local primary care trust, has climbed onto the Nulabour bandwagon and develop what they call a clinical skills course, which lasts as long as 4 weeks! My god, what can they learn in 4 weeks? They are then given NP roles in local walk-in-centres or take up NP roles in secondary care, with no true understanding or experience to what that titles true definition means.

Who ever is teaching on the nurse prescribing course needs sacking, unfortunately the prescribing course differs in it's content or how it is taught throughout the country. Never have i heard such rubbish as you mentioned regarding meningitis.

I do diagnose! I have diagnosed conditions that have been missed by my GP colleagues, this does not make me better or worse than the GPs, as i believe it depends alot on good history taking and experience.

I've been asked many times if I would like to train to be a doctor, and if not in my 50's maybe would have completed a fast track medical degree, but that aside I am happy combining medicine and nursing which I believe gives the patient a unique practitioner, a practitioner hopefully that is trained well and competent in what they know and don't know.

The Shrink said...

Zarathustra I'd be saying much the same. Nurses I work with are excellent at nursing roles, including extended roles. Diagnostic formulations are often spot on. But not always :-) Ilike the notion of "maxi nurses" not "mini doctors" and I'm wholly with you that good care is about teamwork with medical and nursing input, not replacing one or the other.

. . .has a specifically nursing (as opposed to doctor-substitute) rationale to it.
- my thoughts exactly.


AP as I said, I've shifted away from "never diagnose" to "can diagnose within their remit" so have sympathy with what you're saying.

For bright and experienced clinician to be seeing things that crop up often in Primary Care, I would expect that you'd be able to diagnose many conditions. But not all conditions :-)

And of course I'm away of the nurse training, encompassing basic sciences to underpin clinical training but I still maintain that both the content/depth and critically the nature of training mean that nurse training is not inherently oriented to robust diagnostic work.

The surgical sieve of "could it be metabolic, or neoplastic, or infective, or autoimmune or . . . blah" and applying this to structure and function is core medical training. It's part of nurse training but I'm sure you'd agree it isn't central.

It's one reason why medics get accused of treating conditions not patients . . . nurses have hollistic patient care at the centre, good medics try to think patient centred but training is massively focussed on the disease processes and diagnosis of these.

In psychiatry it was a sterotype that a doctor would want to know if a patient hearing voices was hearing them talk too or talk about them (the 'form' of the auditory hallucination) and wouldn't be interested in what the voices say (the 'content' of the experience). This is because the 'form' has meaning in ascribing significance to determine diagnosis.

Doctors weren't trying to be heartless, mean, insensitive souls (this was just an accidental side effect!). This was simply fidelity to their core training. Ellicit the relevant psychopathology to confirm or refute diagnosis.

Nurses can diagnose many conditions within their area of expertise most of the time.

Dangerously, this leads to The Great and the Good believing nurses can diagnose safely all of the time.

Nurse training in diagnosis simply isn't as exhaustive, extensive or ingrained as medical training. There will be exceptions (great nurses, lousy medics). Some conditions (like mental retardation, with ICD-10 diagnosis based laregly on IQ) can be undertaken by psychologists. I work with physio's who diagnose, sometimes, within their remit.

I'm not as hard line as Dr Crippen :-)

But I still firmly believe that medical and nursing staff working closely together, doing diagnostic and other work, is good. Nursing staff replacing medical diagnostic work is bad.

Advanced Practitioner said...

Shrink

But I still firmly believe that medical and nursing staff working closely together, doing diagnostic and other work, is good. Nursing staff replacing medical diagnostic work is bad.

I too believe working together is best, Well said!

Zarathustra said...

Hi Shrink

It's one reason why medics get accused of treating conditions not patients . . . nurses have hollistic patient care at the centre, good medics try to think patient centred but training is massively focussed on the disease processes and diagnosis of these.

I think that to me summarises what I would regard as the difference between a doctor and a nurse. It's the role of the doctor to focus on the illness and of the nurse to focus on the person.

Obviously there's a pretty large area of overlap there. I'm not suggesting that the doctor doesn't think about the person or the nurse doesn't think about the illness, it's just a matter of focus.

I'd agree that nurse training in anatomy (at undergraduate level anyway) isn't anywhere near the standard in medicine. My anatomy classes were rushed through in the first year in a "here's two hours to explain how the brain works" kind of way, and then you spend the following two years mostly forgetting what you've learned.

I think there's definitely a valid role for nurse specialists in, say, epilepsy or diabetes care. If we take the nursing role as looking after the person, then nurse specialists in epilepsy or diabetes can help patients to deal with their day-to-day management of the condition, to cope with lifestyle changes and so on.

I recently visited my local epilepsy unit and enquired what the epilepsy specialist nurses did. They seemed to be pretty much filling the kind of role I described above - mostly dealing with ongoing counselling and support to patients. Nurse prescribing was limited to increasing and reducing drug doses. Things like diagnosis and starting new medications were handled by the doctor. The consultant neurologist there certainly seemed to feel that the specialist nurses were working within their competency and were adding value to the service. One thing I also noticed was that there was very close teamwork between the doctor and the specialist nurses.

I blogged about this recently on the Mental Nurse blog with the result that Dr Crippen went absolutely berserk.

The Shrink said...

My oh my, Dr Crippen sounded more like Dr Rant or Mr Angry there!

You know, what's curious is that everyone is almost saying the same thing. Small degrees of difference where thresholds vary but broadly everyone seems in agreement.

Heck, even Dr Crippen said, "Well, you have CPNs who are nurse specialists with autonomous roles that complement doctors. They are very helpful."

Nurse specialists who are helpful, words uttered from Dr Crippens own mouth. As I've consistently said, Ilove my CPNs to bits and think they're the most important members of my team. You and Advanced Practitioner both believe nurses should work within nursing remits (and not get rid of and replce medics).

So it seems everyone's agreed that theer's a need for nurses, a need for medics and a useful place for nurses with extended roles.

The heated discussion should really draw to a close with recognition that the key contentious issue is not specialist nurses complementing medical staff. It's the current vogue for specialist nurses replacing medical staff. And this is something we should all be vocal about.

The Shrink said...

Gah, so many typos above, meh!

Teach me to browse t'interweb at 3.30am when trying to settle ill kids . . .

Zarathustra said...

Indeed. An unfortunate case of a bunch of people violently agreeing with each other.

Sadly Dr Crippen has rather muddied the waters by making it look as if the argument is about *all* advanced nursing roles, rather than some of them.

The arrogant and often insulting tone adopted by Dr Crippen and Dr Rant really hasn't helped, because it makes it look like it's about nurse-bashing and professional snobbery, with the result that nurses, understandably enough, instantly become defensive and feel compelled to come to the aid of their colleagues.

Dr Crippen's critique reached its nadir when he said,

"And note, she has been there for a mere 15 years but in that time has not learnt how to diagnose epilepsy.

She is not clever enough to do that. She has not been to medical school. She was probably not clever enough to do that either."

Quite apart from the "not clever enough" jibe, which was just guaranteed to get people riled up, there's an irony there in that he was insulting the nurse for respecting her role-boundaries and leaving diagnosis to the doctor - exactly the thing he thinks nurses should be doing.

Of course, some cynics might suggest that when I wrote the original post, I knew exactly how Dr Crippen would react, but wrote it anyway in order to give him enough rope to hang himself. Naturally I could not comment on any such suggestions...

Cal said...

Gah. I typed out a really long comment here, and then it just sounded all... weird and fake a poncy, so I just deleted it all, but I wish I didn't, because I did have a valid point.

Never mind.

The Shrink said...

Cal, spit it out the, girl :-)

Zarathustra said...

Yeah, Cal, repost it!

If I kept any of my utterances quiet because they sounded weird and poncey, I'd never open my mouth.