Not surprising there is a "Turf War" going on! Doctors with elitist attitudes are going to fight like demons to protect their hallowed ground. Often, a nurse or paramedic can do a better job, especially in areas of first aid, minor ailments. Doctors, in my view should be a back-up where the first line of treatment needs are potentially life-threatening or not working.In many cases they are, but nurses should be trusted much more, in my humble view.

Some larger ships of the Royal Australian Navy carry Surgeons who double up as MDs, but most vessels, particularly smaller ones, carry only a Medic, maybe a Para-Med. These personnel have occasionally been called on to even operate on injured and sick personnel, where life is in the balance and the ship out of reach of a surgeon, owing to distance or weather conditions.

It was nurses, meds and para-meds who saved my life on three occasions, with the doctors trying to claim credit afterward, by putting the med on the carpet for over-stepping the mark. Complete twaddle, it seems the doctors would prefer I was dead, than have a nurse save my life - "dead men tell no tales," I guess.

In my military, repatriation and private hospital experience, gained the painfully hard way, over some 27 years as a patient, nurses and meds, para-meds have a lot more of what many doctors lack - common bleeding sense!

Common Sense seems to be a commodity in such short supply in our modern world, as we become more and more "clever" and more and more dependant on a computer and so-called "protocols."

Oh dear, hope I haven't upset too many?

Charles

Charles,
If the truth hurts you may have upset someone, certainly not me. I constantly ask myself why a government with a projected budget surplus of $17 billion, a world wide shortage of doctors, nurses with a university education, don't firstly train more Australian doctors? Secondly have more nurse practioners and thirdly increase both Public Health and Education spending to accomodate more Health and Educational infastructure.

Maybe they are correct, we need a tax cut, that should help us to live a healthy life, an extra $3.50 per week will make all the difference, not! Do you think the AMA may have a role in this, doctor numbers down, price for seeing a doctor up......

There are two turf wars.

There is the one between the federal government and the states over health care funding. Then there is the one between the medical profession and everyone else.

On the former, there have been recent signs of some movement. On the latter, it will be difficult to get action until doctors accept that they are not the hospital system's customers - patients are, or should be.

Do we have a doctor shortage? We certainly have serious maldistribution. But it takes half the time and rather less than half the cost of training a doctor to train a nurse-practitioner who, as Flezzey points out above, can carry out many of the routine duties that are today limited to doctors.

The health care industry operates with more than its fair share of dogma, superstition and politics despite the fact that it is more than 60 years since Dr Archibald Cochrane, interned in a German prison camp, realised that evidence might be helpful in determining effective approaches to health care. Occasionally, if all else fails, doctors are starting to consider evidence.

A recent example that received international recognition was when a group of doctors at Liverpool hospital realised it was more effective to treat patients before they were dead rather than after, http://www.ethics.org.au/ethics_forum/forum_posts.asp?TID=1333

Yesterday two studies were released containing the startling revelation that hospital overcrowding increases patient deaths, http://www.smh.com.au/news/national/doctors-link-deaths-to-crowded-hospitals/2006/03/05/1141493548871.html

We could do with more of this sort of work and policy initiatives that take it into account.

Can we please nuance this argument. There are doctors and then there are doctors.

By and large the fees charged by GPs are governed by the rebate provided for various services by the Federal Government. Within close levels of price sensitivity, GPs simply can't charge much more than the recommended levels. To that extent, they have much less turf to protect and a much greater openness to using practice nurses and even nurse practitioners. Yes, there are exceptions but, by and large, general practice is already in the throes of changing rapidly to team-based care that better utilises the skills of each person.

On the other hand, I think I've ever met 3 or 4 people who ever got a competitive quote from different specialists for a particular operation. By and large, specialists are able to charge what they like with quite massive differentials between various locations based on the demographics and demand. Hence, there was an article in the weekend Tasmanian papers calculating how a Tasmanian specialist could earn a half million dollars a year working half a day a week. It is these specialists with very large turfs to protect who are carrying on about role reallocation.

As evidence, the AMA had released a statement strongly condemning the use of nurse practitioners other than in very restricted circumstances. The ADGP, by contrast, representing general practice has welcomed nurse practitioners and wants them working with general practitioners as soon as possible.

Regards

Kevin

You are correct to some extent Kevin. The acceptance or other wise of role substition or degrees of it varies from group to group- but very few of the doctors unions are overly representative - and while different peak bodies have particular public positions there are dissenters in every group.

But my arguement remains that role substitution has been an evolving process particularly in the public sector. Whether it be physios nurses or OTs all these disciplines have moved into areas that have either been adandoned by doctors who have moved on to other technologies or who have seen it expedient to leave particualr work to other professionals.

Where we are faced with either genuine shortages or maldistribution the old ways of delivering health care are failing the consumer. To simply recognise the real face of the industry and how serviecs are delivered and have been delivered by non medical staff is doing little more than formally recognising a well established defacto form of health delivery.

And doctors are not monolithic on this front - in addition their support for well managed role substition seems to increase in direct proportion to their distance from a major population centre; the more remote they are the more they see and give recognition to the skills of the non medically trained staff who work along side them - they need all the help they can get.

A resolution to this tension will not solve the problem but it certainly needs to be part of the solution

Kym Durance

Kym

Thanks for that very reasoned argument. I accept the premise that no groups are monolithic or united in either their opposition or support. Having said that, just as with the more remote doctors, those who have least to lose will oppose change least as a general rule of thumb. In broad terms, that's GPs and nurses, though even some registered nurses in my local health district are carrying on like 2 bob watches about enrolled nurses taking over "their" work. It would be hilarious if it weren't so sad.

That said, folk in this area recognise that we will either work together to resolve these issues or we will have a major public health crisis on our hands. With many thousands of people flooding in, chronic disease on the rise and a rapidly falling workforce as older doctors and nurses retire, we simply can't continue to work the way we have done in the past. So, for good or ill, and regardless of what politicians and senior bureaucrats think, people on the ground are rapidly finding their own resolution to some of these issues and trialling a range of approaches.

Regards

Kevin