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Role of Paramedical Staff in a Health Service

      To the Editor:
      I read with interest the report by Yang and colleagues
      • Yang Y.
      • Jackson S.L.
      • Rhee M.K.
      • Tomolo A.
      • Olson D.
      • Phillips L.S.
      Nurse practitioners, physician assistants, and physicians are comparable in managing the first five years of diabetes.
      on nurse practitioners and physicians' assistants. They found that these paramedical staff can manage diabetic patients in the early years after diagnosis and obtain outcomes that are similar to those achieved by physicians. The American Journal of Medicine readership may be interested to learn of another setting where nurse practitioners have proved useful. Our department in Britain is a service for ophthalmology, and in the last 5 years we have introduced nurses into niches that previously were the domain of the doctor.
      Ophthalmology as a field has undergone a vast change in the last 20 years because of the development of new drugs that can be injected into the eye. Ocular imaging has also improved considerably over these two decades. Disorders for which there was limited treatment, such as age-related maculopathy and diabetic retinopathy, can now be controlled with injectable drugs. The advances have led to a massive increase in the volume of patients who need to be seen, imaged, and treated, and then brought back to the clinic for similar repetitions of care. Yet the number of ophthalmologists has not expanded alongside the rapid expansion of the therapeutic burden.
      Recently, to sustain a public health service, we have developed some of our nurses into clinical practitioners. They have been placed into pathways of care in a way hitherto not seen in ophthalmology. Nurses have been trained to interpret tomographic images of the retina and taught how to safely inject medication into the eye. Consequently, these staff are now seeing patients in the clinic and performing a low-skill treatment.
      So what has been the experience of one department? It is apparent that paramedical workers are literally additional to the backbone of clinical medicine. They lack the depth of learning and training that is found in the physician and that equips the physician with a great degree of mental agility. Our nurse practitioners see patients and decide whether there is any pathology that warrants treatment. Their decision-making is binary: to inject the eye with a drug or not. They are compelled to consult a doctor if there is the slightest departure from a spectrum of clinical patterns.
      Evidently, paramedical staff can be trained and fitted into care pathways, but their exact role in the service has to defined clearly. Accepting then that auxiliary staff have a narrow band of competence, it is apparent that without them the busy pathways in our setting could not function. From the viewpoint of the patients, meanwhile, there is an acceptance of nonphysician staff as deliverers of medicine.
      Health care demand is fated to escalate in this century. Accordingly, in health services there is a need to stratify care and direct nurse practitioners and physicians' assistants more frequently toward the strata of lower complexity. This will free up physicians to concentrate their skills elsewhere in clinical pathways that have to manage more and more patients.

      Reference

        • Yang Y.
        • Jackson S.L.
        • Rhee M.K.
        • Tomolo A.
        • Olson D.
        • Phillips L.S.
        Nurse practitioners, physician assistants, and physicians are comparable in managing the first five years of diabetes.
        Am J Med. 2018; 131 (e2): 276-283