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Editor,—Duthie and colleagues (Gut1998;43:711–14) have confirmed what we hoped, and wanted to believe, namely that properly trained nurses perform flexible sigmoidoscopy safely and effectively. This result offers the hope that we will be able to cope with increasing service demands but also addresses other important issues.
There seems to be a curious difference in our attitudes towards nurses and doctors in the performance of practical procedures. For the same patients and the same procedures we demand that nurses undergo formal training and assessment but do not insist on this for doctors. Where is the validated, agreed programme for medical and surgical trainees (or even consultants) who want to learn flexible sigmoidoscopy or indeed any other endoscopic procedure? There are excellent optional courses, outstanding teachers and willing students but no formal link to what goes on day to day in district general hospitals throughout the country. Calman has introduced the term “structured training”, but evidence of structure is difficult to find. The curricula list procedures in which competence should be gained but make little mention of how these procedures should be taught or learned. We had previously been concerned that the omission was because we didn’t know; it now seems that we do, but maybe believed structure and rigour were not necessary for doctors.
Just possibly we have come to believe that training is somehow inferior in status to education. This is to misunderstand the differences between the two activities. Rigorous formal training in practical procedures does not in any way negate the need for professional judgement, intuition and opinion but we no longer need reminding that the public are demanding proved, high levels of technical skill. The authors make the point that, “flexible sigmoidoscopy is a technical skill and. . .suitably motivated staff should be able to learn this technique.” This is a fundamentally important point; skill is acquired by motivated learners who are prepared to practice and who have expert instruction and feedback. Some doctors or nurses will become more skilful than others because they are better motivated, practice harder and are better able to learn from experience. Many of our most skilful practitioners are self-taught, but for those starting now good coaching can probably shorten the time to a given level of competence. Skill itself cannot be taught but has to be learned. The concept of innate dexterity and talent is not supported by evidence1 and is not conducive to the development of training. We would contest one point in this paper. The authors state that, “the theoretical, moral and legal information contained in a nurse endoscopy course was obviously (our italics) different to that required in a medical course.” Surely the type and extent of information depend on the procedural experience and interest of the practitioner. With increasing technical and professional development the practitioner revisits the concepts at increasing levels of complexity. This is the essence of spiral curriculum.2 Duthie and colleagues are to be congratulated for a truly structured nurse training programme that issues a challenge to doctors both in gastroenterology and other disciplines.
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