Bob Bury

Should the consultants of yesteryear apologise for the rise of the noctor?

Since I retired, I tend to keep away from debate on current medical issues, since I’m no longer in a position to be directly involved (except as a patient) and anyway, I’ve got plenty of other stuff to keep me busy. But I do occasionally venture on to the radiology forum of DNUK, just to see what my ex-colleagues are talking about, and I recently took a bit of stick as a result.

Someone had posted a reference to the Dunning-Kruger Effect, which was described in 1999 in a psychology journal. They elegantly demonstrated what anyone who has ever been involved in the teaching and assessment of trainees knows only too well: namely, that those who perform badly tend to overestimate their abilities, while those who are competent suffer agonies of self-doubt. In other words, we aren’t very good at self-assessment, which is why we don’t let people fly commercial aircraft without a bit of practice and an exam at the end.

So – an argument for proper training and assessment, then? Well yes, but it was being used here as a stick to beat the proponents of role extension, or skills-mix, in medicine generally, and radiology in particular. The point being, I suppose, that a little knowledge is a dangerous thing, and that noctors* invariably overestimate their abilities and constitute a risk to patient care.

There was a reference in the debate which follows to those radiologists, now living a life of luxury on the sort of gold-plated pensions denied to the current generation, who allowed skills-mix to take off twenty years ago. The words ‘selling off the family silver’ weren’t actually used, but the implication that old-timers like me had sold out our profession for a mess of politically-correct pottage was clear.

I duly declared my conflict of interest as one of the lotus-eating retirees who had previously been actively involved in the introduction and audit of role extension for radiographers. Then, partly out of mischief, and partly to argue what I think is a valid defence of our activities in Leeds over the past twenty years, I put the point of view that all the Dunning-Kruger Effect demonstrates is the need for proper training and monitoring of any role-extension exercise.

For example, our institution of radiographer reporting of appendicular trauma films involved a training scheme run by specialist musculoskeletal radiologists, followed by an assessment of performance and then regular audit in practice. This showed that the radiographers performed as well as A&E doctors and radiology trainees – perhaps not surprising when you take a staff group already well-practised in looking at plain films, and give them more intensive and focussed training in fracture recognition than is normally received by most doctors – radiologists or otherwise! This finding has subsequently been confirmed in other centres.

Given that many if not most radiology departments in the country can only cope with the complex imaging (CT, MR, PET et al) workload by farming out some of the plain film reporting to extended role radiographers and/or commercial teleradiology services, I have no problem justifying the practice, provided that the doctors keep a firm grip on the training and accreditation of the radiographers concerned.

But that brings us on to the ‘thin end of the wedge’ argument – which I’ve even put it forward myself in these very pages – and here I’m on shakier ground. There’s no doubt that in some areas of practice, the process of role extension has been allowed to go too far, and has not included an adequate assessment of performance against agreed standards. All too often, the process has been seized on by the professions allied to medicine (PAMs) as a means of increasing their status, a response to the inaccurate perception that they are subservient to doctors.

The impetus usually comes from ‘academic’ PAMs, who have achieved their elevated positions on the strength of a couple of papers utilising patient satisfaction surveys in lieu of real data. Doctors who are concerned, or just plain irritated by this tend to say, with some justification, that if these people want to be doctors, training is available – it’s just that it takes more than a couple of weekends on a course at the local Holiday Inn.

The argument of the anti-noctor camp is further reinforced by the perception that this is all part of a wider dumbing-down of medicine, a process which is now being seized upon by our medically-illiterate political masters as a way of driving down costs. You only have to look at the push for a sub-consultant grade, and the politicians’ naive belief that NHS Direct would reduce visits to the GP or A&E Department.

My reply would be that this was a battle we were always going to have to fight at some point, and the solution is an insistence on the phased introduction of evidence-based changes, in those areas where there is an established need to ease pressure on medical staff, and where it is possible to identify tasks which can be devolved to non-medics with no detriment to quality.

I’m not sure where this leaves me. I used to get as angry as any other radiologist when I saw adverts for weekend courses in ultrasound for other clinicians, or for PAMs. I shared the frustration of colleagues when those clinicians said yes, they wanted to do their own ultrasound scans, but it would all be OK, because they would only do the ‘easy ones’, failing to recognise that you only know which scan was a hard one when the patient comes back six months later with an inoperable renal cancer that was missed when you just had a ‘quick look’ at the gall bladder.

And yet, and yet. I don’t think there was any way to avert the push for role extension, and I still believe that the right response was to be encouraging and involved, while setting limits on the scope of any change. And when I’m asked, as I was, who should set those limits, I think the answer has to be the local medical staff working with guidance from the appropriate professional organisation, which in most cases should be the relevant Royal College.

Perhaps that’s where my generation was remiss. We just got on with it, without giving enough attention to establishing formal oversight of the process. And for that, if for nothing else, I apologise.

* for non-medical readers, ‘noctor’ is the term used to describe the increasing numbers of NHS staff who are not doctors, but who are performing tasks which were previously the sole preserve of the medically-qualified. Although in theory a neutral word implying ‘not a doctor’, it is normally used (by doctors, at least) as a term of disparagement.

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