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Time to make the term ‘noctors’ a relic of the past

Dr David Coleman explains why he believes GPs should drop the term ‘noctors’ and show more respect for advanced practitioner colleagues 

Dr David Coleman

I have never been comfortable with the term ‘noctor’ (see also: phoctor, mocktor). I’m not keen on portmanteaus at the best of times (let’s not mention the B-word), but any noun that offends a significant proportion of the group it identifies is best consigned to the past.

The fact it isn’t remotely funny or even useful as a descriptor also renders it worthless. Granted, it might not be as despicable as the frankly awful ‘murse’, but it deserves no greater role than that sexist term.

I work at a practice that has hugely benefited from the addition of advanced practitioners to our primary care team. We have four currently, with a further two practice nurses undergoing training.

For experimental purposes only, I tried referring to them all as ‘noctors' earlier this week. This didn’t end well for me. To them, the word ‘noctor’ casts them as a lesser contributor to the team. It defines them, not as what they are – an experienced pharmacist, two passionate and highly trained nurses, a dynamic paramedic – but what they are not, ie, a doctor.

Rather than mock advanced practitioners we should reflect on how it feels to be the target of pejorative terms

Or worse, it insinuates that they have ideas above their station: that they are playing doctors without the credentials to back it up.

Aside from momentarily losing the respect of my colleagues, my little trial confirmed what I already suspected: that ‘noctor’ does cause demonstrable offence. Now, what’s that I hear, the angry keyboard tapping of the It’s Political Correctness Gone Mad Brigade? I respect your right to defend your usage of ‘noctor’, but how come the impassioned defenders of free speech in these instances always come from the unaffected group?

We have a brilliant poster at our practice, a gift from one of our trainees, which is adorned with a genuine quote from one of the local neurologists (during a lecture to students at Sheffield Medical School). It is an example of GP-bashing at its finest: ‘If you don’t buck your ideas up and work hard at medical school, you will end up as a GP in Doncaster.’

As a GP in Doncaster, this makes me feel… actually, it makes me think the consultant who said it is a pompous buffoon. I’ve got a thick skin (I’ll even read the comments under this article), but I know some of my local colleagues would be deeply saddened by such a disrespectful remark. To a small minority in secondary care, GPs are viewed as a lesser form of doctor. Crap doctors. Coctors? Rather than mock advanced practitioners in their many forms, we should reflect on how it feels to be the target of pejorative terms.

I have read and do empathise with some of the concerns of more sceptical GPs about the proliferation of advanced practitioner roles. Similarly, I have heard about practices utilising ANPs as a kind of cut-price salaried GP, seeing unfiltered patients without appropriate supervision. This is far from ideal. My practice’s way of working, with a strong emphasis on triage and patient choice, couldn’t be more different. Talking to our ANPs, I also appreciate their concerns regarding the current situation, with the lack of agreed national standards and no specific register for ANPs. Addressing these issues would be a positive step.

Still, to each problem there is a potential solution. If you are concerned about polypharmacy, over-diagnosis and over-treatment, invest time in continuing professional development. Or better still, employ (or share) a pharmacist and encourage them to share their knowledge for the good of the team. After all, the University of Sheffield only offered me two or three lectures on pharmacology; my pharmacist has a masters degree, half a career of experience and an advanced prescribing diploma.

I firmly believe we need a range of solutions to solve the workforce crisis. At the top of my list would be more GPs, but the realist in me accepts that particular cavalry isn’t coming any time soon. Advanced practitioners, on the other hand, are here right now. And with the right support and mutual respect for both our skills and our differences, they can enhance our primary care teams significantly. Just don’t call them ‘noctors’.

Dr David Coleman is a GP partner and trainer in Doncaster

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Readers' comments (16)

  • Better not to ‘enbrace’ look what happened to Ted Baker.
    Specious to compare Consultants views of GP colleagues to competecies of ANPs/pharmacists. GPs do actually have a medical qualification.

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  • er you’re not supposed to call them noctors to their face silly!

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  • The people you mention should be recognised for what they are by us AND them, and they should recognise us as Doctors. The ones you mention are Nurse and Pharmacist.
    Skip 'Nurse Practitioner', it is a term meant to be offensive to GPs, who were quite happy to be abbreviated without objection, but there is no need to abbreviate 'Nurse', unless to DN and PN.
    BUT, a small number DO do fit in the category you mention , of :
    "have ideas above their station: that they are playing doctors without the credentials to back it up", and also, most often, unwilling to accept the responsibility that comes with 'Practising Medicine'.
    I am not even ashamed to admit I am still practicing and not yet perfect, unlike some, who just want the power and authority without the hard work and responsibility.

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  • I think "noctor" is definitely a conceptualisation rather than a way of referring to a colleague! Not a word I would use, but describes an idea I do think - perfectly described by the comment in the piece about "... practices utilising ANPs as a kind of cut-price salaried GP, seeing unfiltered patients without appropriate supervision."

    I work as a locum, so almost by definition in practices that are struggling a bit to a lot, and I regularly see nurse practitioners working in ways that leave me feeling that I would be terrified if I were the GP nominally supervising them. My experience is of nurse practitioners who look to be under pressure to cope beyond what is appropriate for them, with over-investigating and over-prescribing common. Patients end up seeing me after 3-4 appointments with the nurse practitioner, when, unsurprisingly to me, the prescription hasn't worked, and the panoply of tests, that I wouldn't have requested, are slightly squiffy. I then have to start again, which doesn't seem great use of resources.

    Don't get me wrong, in a well supported and well staffed practice, nurse practitioners seem to find their niche, and really add to the service - but this is too often not the case, and this isn't fair on them or patients, or good use of precious NHS resources.

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  • 'I firmly believe we need a range of solutions to solve the workforce crisis.'
    And I firmly believe that if they paid GPs appropriately (in line with solicitors and dentists) and made sure we worked under reasonable terms and conditions, there wouldn't be a workforce crisis.
    The shift towards other staff delivering healthcare is largely an attempt to deliver care more cheaply at the cost of quality, while pretending it is a positive and inclusive development.
    As a result, we will soon end up with a two tier service, I suspect, with GPs seeing those patients who make it through the layers of non-GPs, or those who shout loudest, or those who can afford it. When my kids are sick, I know who I want them to see, and it's a GP.
    Everyone else will have to make do with Apps, Call-centre employees using algorithms, and Healthcare Assistants with 6 months' training. Pharmacists, Pharmacists and Nurse Practitioners will quickly prove too expensive for the Brave New World (as they sensibly generally see far fewer patients for almost the same money as a Salaried GP).

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  • It's all BS and the attempt at reductionist flowchart medicine. Patients fundamentally want to see a doctor who can assess and decide on treatment, taking responsibility fully for that because of experience.
    But no-one wants to pay for it.
    Or trust GPs with things like god forbid, the knowledge to order CT/MRI etc.
    So we have this BS.
    And we are now the laughing stock of the developed world.
    Who still believe that a doctor is more than a referral monkey , flowchart or a f*****g smartphone App.
    We are alone in the UK with our misguided descent into daily medical vacuity.

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  • I have a different concern.
    I am sure these ancilliary practitioners are quite capable of sorting the simple stuff. However that leaves the GP with unrelenting hard cases of multiple morbidity or neuroses/heart sinks. This makes our job depressing and exhausting. we actually need the simple stuff as well to keep our own morale up and provide light relief now and again.

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  • It’s a wonder that your wee audit didn’t turn into a significant event analysis. The ‘red herring’ you blithely ignored might have been repurposed as a ‘wet fish’.
    Let’s just KIS (keep it simple). What the purchasers and users want is a quality, fast and cheap/free service. You can’t have everything so the ‘powers that be’ have plumbed for ‘McDonalds medicine’ I.e. ‘fast and cheap’. Ancillary practitioners might be fine for simple stuff but would you personally be comfortable with them managing your acutely unwell loved one? I.e. ‘being properly unwell’.

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  • Tom Gillham

    Not used the term “noctor” in Herts but we have recently gone on something of an AHP recruitment drive in our practice, taking on 2 NPs, a pharmacist, paramedic and mental health nurse. This has been on the back of well managed total GP led triage which has enabled us to fully audit and understand our demand. It is the only sustainable model of primary care but one of which practices seem perpetually suspicious.

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  • Nice experiment- you use a term which intrinsically makes you uneasy on your employees no less, to see if they were offended, and you reckon you only lost their respect momentarily? I bet you got them onside by saying "Din't mean nuffin by that-one of me bezzy mates is a noctor".

    You also seem a little confused about the role of the pharmacist-I accept they are better placed than most GPs when it comes to polypharmacy but I'm not so sure about over-diagnosis. Your lumping of pharmacists who have advanced knowledge of a restricted field together with NPs who have a very superficial knowledge of a broad field renders your position into a jumbled mess.

    I also dispute your assertion that a minority of secondary care doctors think GPs are crap; they just have enough sense to not say it to a GPs face in contrast to your rigorous ethically approved trial which may or may not have undergone peer review.

    We all tend to view others through the prism of our own knowledge and experience, and this cannot do other than create a sense of superiority when presented with work which we know to be poor.Hence a neurologist when presented with a referral letter from a GP whose assessment of the case is comical will reflexively think "How useless". Pomposity or realism? That is an open question.

    A large part of this attitude is a consequence of this era of super-specialization where the GP is the last of the (poorly equipped) generalists who are responsible for the whole gamut of clinical medicine; the hospital specialists in the medical specialities are better informed than GPs to perform the generalist physicians role but they have no incentive or responsibility to do so, and have simply decided to get the GP to refer to the appropriate speciality (or not so appropriate ie stroke physician diagnosing a non stroke in a patient with visual disturbance sent their way as ?TIA by the GP with the advice to refer to neurology and/or ophthalmology). Nobody it seems has the courage of their convictions any longer and palms the case off or on to some-one else.

    The GP with copious ANP support will "triage" the "simple stuff" (which when really analysed properly may not be that simple) and as has been alluded to in one of the replies above may well end up back on his/her plate when the ANPs interventions have achieved bugger-all, making more work, increased use of resources with a delay in identification/resolution of the problem. I would not envy having to over-see and take responsibility for the work of the ANPs, who like the exemplars of "independent Practitioners" the midwives are prone to want the glory without the responsibility.

    We really need more GPs with a better grounding and deeper knowledge than what they presently have, and compensating for this need with ANPs is dumbing-down, when observed through the prism of quality medicine, or even GP-quality medicine.

    I would regard the ANPs as the "Territorial Army" of Primary Care, and when the bullets really start to fly the sentient conscious individual would want proper troops supporting them in battle.

    DecorumEst asks an interesting question about who one would be comfortable managing an acutely ill loved-one, Personally it would not be an ANP and probably not most GPs either.

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