Friday, July 21, 2006

The rise of the Noctor

The Noctor is a strange beast, coming in a number of guises. It is known by a number of names – the Advanced Nurse Practioner, the Emergency Care Practioner, the Medical Care Practioner. You’ll notice a similarity in the nomenclature, as most ‘Noctors’ have appropriated the ‘Practioner’ title. This is because the term “Registered Medical Practioner” is the legally protected name for a Doctor.

A Noctor is what you get when you have someone who is not a doctor performing a role traditionally performed by a doctor. These jobs often involve things such as diagnosing diseases and prescribing medications, something which up until recently meant having five years of medical training.

The developing world have had Noctors for years, sometimes known as barefoot doctors. For countries with few resources these people can provide a basic health care system and play an important role. Why the UK, as one of the world’s richest countries, is adopting this third world strategy is beyond me.

A lot of doctors are quite wound up about the rising tide of Noctors. Dr Crippen has chronicled the tide of ‘quacktioners’ here, and here, and here, and here.
It might be because we are a protectionist bunch who want to preserve our earning power that many doctors object to these cunning plans. However I think its because we know how difficult a job medicine can be, and that even with years of training and experience difficult decisions have to be made daily, and if you get them wrong patients will come to harm.

Several recent cases come to mind
1) NHS 24/Direct – nurses with phones. Huge expense for a service which largely directs people to services they would already have attended. However in several highly publicised cases they have got it tragically wrong.

2) Paramedics are increasingly being encouraged to become Noctors, and as a result judging when patients need to come to hospital and when not. Again we have a case where this seems to have gone horribly wrong.

The cases above (septicaemia, ruptured aneurysm) have caught out plenty of doctors in the past. However we all know about this, and it seems likely that if one has a difficult to detect condition with potential life threatening effects then someone with years of medical training and experience is more likely to get it right than a nurse on the end of a phone, or a paramedic with a few months training.

Noctors are a false economy, whilst they may appear cheaper than doctors they are not – more referrals, more follow-up, slower to see patients and if left to make independent decisions outside of narrow protocols potentially dangerous.

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