Competence and capacity: the right practitioner for the right procedure?

British researchers conducted a pragmatic, randomized trial aiming to compare the effectiveness of doctors and nurses performing upper and lower endoscopy.  The authors enrolled 29 hospitals comparing 67 doctors to 30 nurses who performed endoscopic procedures on 1888 randomized patients from 2002 to 2003.  Outcomes of interest included: gastrointestinal symptoms (primary outcome), endoscopy satisfaction, immediate and delayed complications, quality of examination, patients’ preferences for operator, and new diagnoses at one year.  

Researchers found no statistically significant differences except a higher level of satisfaction with nurses.  At 1 year, the authors reviewed medical records for 1674 patients. Fourteen (2 percent of the doctor group) and ten (1 percent of the nurse group) patients had received a new gastrointestinal diagnosis in the intervening year (p=0.154). There was no difference between the 2 groups in the insertion distance into the colon or in the mean duration of exam for upper endoscopy (18.8 min. for doctors vs 19.8 min. for nurses) or sigmoidoscopy (27.8 min. vs. 24.2 min.).

Results of upper gastrointestinal endoscopies were reported as normal by 30 percent of doctors and 18 percent of nurses (p<0.001). For sigmoidoscopy, doctors found 45 percent normal compared to 34 percent for nurses (p<0.001). More patients had biopsies performed by nurses compared to doctors (50 percent vs. 31 percent for upper endoscopy, p<0.001; 35 percent vs. 27 percent for sigmoidoscopy, p=0.006).   No endoscopic complications were recorded.  

 

Commentary:

Workforce shortages in nursing and primary care threaten access to quality care for patients. Researchers are increasingly investigating the efficacy of expanding the role of nurses, nurse practitioners, physician assistants, and other allied health professionals.  This article contends, much like studies evaluating the provision of primary care, that nurses with additional training can perform select procedures with comparable quality to physicians. 

What does this mean for physicians and surgeons?  First, change is coming. Doctors must either better delineate an argument for the value-added by an “MD” to the care of patients or better differentiate themselves from so-called “mid-level practitioners” through a new skill set of their own. That skill set may reside in a rededication to clinical research, quality improvement, or public policy.  An often heard refrain from physicians is that certain tasks must be done by a doctor.  This study, as has a growing body of evidence, suggests otherwise.

Secondly, if a nation can “free up” physicians and surgeons to provide care to patients at the highest levels of complexity and clinical uncertainty by triaging simpler patients to algorithmically-directed care by allied health professionals our workforce shortages may not be as dire as we have predicted.

BMJ 2009; 338: b231.

 

by

Stanley Frencher, Jr., MD, MPH

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