Posted by: Witch Doctor | February 2, 2008

Hello – Sir John Tooke – are you out there?



Sir John,

My Black Cat is here to help with the difficult problem of defining “The Role of the Doctor”

My Black Cat thinks the doctor should at least be able to:

1. “Take a comprehensive patient history.”

2. “Carry out physical examinations.”

3. Use his/her expert knowledge and clinical judgment to identify the differential diagnosis.

4. ” Refer patients for investigations where appropriate.”

5. “Make a final diagnosis.”

6. “Decide on and carry out treatment, including the prescribing of medicines, or refer patients to an appropriate specialist.”

7. “Use his/her extensive practice experience to plan and provide skilled and competent care to meet patient’s health and social care needs, involving other members of the health care team as appropriate.”

8. Ensure the provision of continuity of care including follow-up visits.

9. “Assess and evaluate, with patients, the effectiveness of the treatment and care provided and make changes as needed.”

10. Doctors who are not either consultants or general practitioners work under the supervision of a consultant or a general practitioner, often as part of a health care team.

11. Provide leadership, particularly if the patient’s general practitioner or consultant. If a junior doctor, provide leadership appropriate to the situation under the supervision of the consultant or general practioner.

12. “Make sure that each patient’s treatment and care is based on best practice.”



Hey, My Black Cat.

Don’t be silly.

You’re mixed up.

That’s the role of the “Advanced Nurse Specialist”

No it’s not.

It’s different.

How is it different, My Black Cat?

Only doctors who are consultants or GPs can work independently.

The Advanced Nurse Practitioner can work independently.

And take full responsibility?

Are you sure?

Is that what you are saying?

If that’s what the Advanced Nurse Specialist does, do you know then what The Consultant Nurse Specialist does?

You suppose the Consultant Nurse Specialist must take legal responsibility for the very, very difficult patients?

The ones the Consultant Medical Practitioners took responsibility for in the olden days?

Don’t be silly, My Black Cat, the Consultant Medical Practitioners are the ones paying the really hefty Defence Union Fees.

You don’t think they need to any more?

You think the independent non-medical practitioners should pay the really, really hefty Defence Union fees?

Plus a really hefty top-up fee.

Why top up fees?

Because they have not had many years of rigorous medical training, so the actuarial risk of a calamity is higher.

Rubbish, My Black Cat.

The independent non-medical practitioner would just be sacked for not following a protocol somewhere along the line.

No expensive court cases, just sacked.

And probably struck off their competency.

But not their professional body.



The consultant’s neck would still be in the noose.

Or the GP’s.

For not giving enough supervision or ensuring enough training or over-delegating.

Or not writing a detailed enough protocol.

Are doctor’s writing protocols for other HCW?

Of course they are, My Black Cat, who else would write a protocol for someone other than a doctor, in order that they can take a history, examine the patient, and make a differential diagnosis?

Who else would be daft enough?

But a doctor…..

One way or another, it all seems a terrible muddle.

Doesn’t it, My Black Cat.

Wonder if Sir John Tooke has anyone in mind capable of sorting out the problem of who is supposed to do what nowadays…….

I don’t suppose that’s his remit.

No doubt a “Defining the Role of the Doctor Committee” will be appointed.

Try to find out if this is happening, My Black Cat, so we can pay a visit to some of the meetings.

redapple.jpg a red apple ……………………

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  1. Witch!

    In my experience the nurses are writing the protocols and doctors sign them often without reading them!

    I pay a hefty defence union fee and if I screw up then I will be the one taken to court not the GP colleagues I work with, who by the way respect my knowledge, experience and independence. They also ask for my opinion on areas where their knowledge lacks as I do with them.

    I agree the ‘Noctor’ that we see in many WIC and in secondary care do not have the training needed to call themselves advanced, but do not tar all with the same brush!

  2. Hello Advanced Practitioner,

    It is no surprise at all to The Witch Doctor that doctors are signing, but not writing, the protocols. Neither is it any surprise they sometimes don’t read them. The signature, however, indicates legally, that not only have they approved, but are also responsible for the contents of that protocol. The doctor therefore can expect to be in court if a serious mistake is made leading to patient mortality or morbidity.

    The Witch Doctor has many faults, but tarring all with the same brush is not one of them. Indeed it could be said this is one of the very reasons that we witches are so against protocols i.e. every patient and every member of staff is unique as is every situation. Our requirement is judgment based on experience, backed up with a very personal aide-memoir when necessary.

    The issues that I have with both medical and non-medical practitioners alike, are related to the background, experience and ability required to take a good medical history, and to perform a medical examination leading to a differential diagnosis, followed by appropriate investigations that will lead to a final diagnosis. There is no doubt in my mind, no doubt at all, that this requires proper training as a medical practitioner and, in order to maintain and improve diagnostic acumen, years of experience thereafter. The other issue I have is regarding who takes the ultimate responsibility for the care of a patient.

    If a member of staff without the training of a medical practitioner were, for example, to examine a patient but missed a serious diagnosis, then no judge would find him or her guilty of medical negligence in the sense that a doctor would be judged. He or she may, however, be blamed for not following a protocol or not seeking the advice of a doctor. That is a different level of culpability.

    If you read more of this blog you will understand that the reason for writing it is to do with a complex and insidious “creep” that has been infiltrating the NHS for over a decade now, and the fact that the medical profession in particular, are allowing this creep to happen, often unknowingly. It is not particularly directed at nurses, pharmacists, physiotherapists, scientists or the many other professionals working within the NHS. They all too, may have a role to play in the “creep” but I am neither considering this nor addressing it. Many of my friends and colleagues are members of these professions and I have the utmost respect for them just as the doctors you work with, have for you. However, everyone is caught up in the present “creep” – usually as innocent bystanders.

    You will notice if you follow the posts, that this “witch” does not spare the doctors.

  3. We’re scr*wed! .. I mean the patients of course.

    A ‘patients led health service’ … is a very sick health service indeed!



    1. a person who is under medical care or treatment.
    2. a person or thing that undergoes some action.
    3. Archaic. a sufferer or victim.
    –adjective 4. bearing provocation, annoyance, misfortune, delay, hardship, pain, etc., with fortitude and calm and without complaint, anger, or the like.

    —Synonyms 1. invalid. 4. uncomplaining, long-suffering, forbearing, resigned. 5. unexcited, self-possessed. 6. sedulous, assiduous.

    Given this first comment here and the third definition of ‘patient’, I name theeeee

    a ‘victim led health service’

    What do you think Witch doc?

  4. Patients might indeed become victims, more than they are now………

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