What skills do doctors and nurses need?

What’s the difference between a doctor and a nurse? Our cover picture this week suggests that the differences are becoming harder to spot, and in this issue Rebecca Coombes explores the shifting and increasingly overlapping territories of the two professions (doi:10.1136/bmj.a1522). It’s easy to understand why the nurse’s role is expanding into traditionally medical areas of diagnosis and treatment: there’s the lower direct cost of employing nurses and the fact that they have more time to spend with patients.

But it’s not all plain sailing. There’s confusion over titles, a lack of nationally agreed standards on what training and experience are needed, and no proper regulation for advanced nurse practitioners in the UK. But other countries are further ahead, helped in some cases by graduate only entry to nurse training. So could nurses expand their roles even further? In our head to head debate, Bonnie Sibbald argues that primary care should now be led by nurses (doi:10.1136/bmj.39661.707083.59); Rhona Knight disagrees (doi:10.1136/bmj.39661.694572.59).

While roles are rapidly evolving, it seems clear to me that doctors and nurses are selected, trained, and paid differently for good reason. Doctors need to take risks and deal with uncertainty, while nurses are more attuned to following protocols and providing hands-on care. But if, as some argue, diagnosis is almost the only skill that defines doctors, it’s reassuring that machines can’t yet do the job better. As Christopher Martyn explains (doi:10.1136/bmj.a1703), computerised Bayesian algorithms and artificial neural networks have failed to live up to their early promise. On the down side, this has left us largely in the dark about how doctors reach their diagnostic decisions or what makes some people better at it than others. But the good news, he says, is that doctors are pretty good at diagnosis. “On the whole, doctors care a lot about getting diagnosis correct and they castigate themselves when they fail.” Martyn also thinks it’s admirable (as do I) that when doctors do make diagnostic mistakes they talk about them and write them up in journals.

What about telephone triage as a form of diagnostic decision making? Hay Derkx and colleagues don’t offer much comfort from their national cross sectional study of Dutch out of hours call centres (doi:10.1136/bmj.a1264). Using standardised patient scenarios they found that, in a high proportion of interactions, advice was given after asking too few questions and without properly interpreting the answers. In their accompanying editorial (doi:10.1136/bmj.a1167), Joseph Lip and colleagues raise serious concerns about the lack of consistency and transparency in the training of “triagists” and the protocols they use. They call for proper evaluation of the safety and quality of these services.

As health care becomes more complex and fragmented, patient safety relies more than ever on teams of people with a range of skills working effectively together. What these skills are—and how strictly they need to be defined, assessed, and regulated—are questions we must continue to ask.