Reply to Roswitha Koch et al.

DOI: https://doi.org/10.4414/smw.2019.20009

Koch et al. address in their letter [1] the following two aspects.

Firstly, they consider the use of the term “practice nurse” an inadequate translation of the term “Medizinische Praxisassistenin (MPA)”. As mentioned in our publication, there is no comparable English term for the Swiss term MPA, the German term “Medizinische Fachangestellte (MFA)” or the Austrian term “Arzthelferin”. This is mainly because in most countries we have either administrative personnel in practices, named “practice secretaries”, or personnel with a medical background, most commonly nurses. There is no exact equivalent to the Swiss MPA in an international context. Naming them “practice secretary” would not reflect their medical background. In most studies from German speaking countries, MPAs have been called “health care assistant” or labelled with the term chosen by us, “practice nurse”. In principle, we are grateful to Koch et al. for pointing out an important issue when reporting about studies with MPAs. We are willing to use the suggested new term in future publications, but we are aware of the risk that an international reviewer might not readily accept this term.

The second aspect addressed refers to our statement that there is “a lack of appropriately prepared medical staff to ensure adequate care for chronically ill people.” Koch et al. write that this statement is “possibly based on the assertion by Frei et al. that ‘practice nurses represent the only resource for a team approach in primary care’. Chmiel et al. seem not to be aware that, since 1999, nurses have had the option to specialise in diabetes counselling. Nurses who have acquired this specialisation already work in family doctors’ practices and in the advice centres of the Swiss Diabetes Society in order to deliver care that is targeted and tailored to the needs of patients with diabetes.” We are very much aware of the situation within the Swiss healthcare system regarding the different healthcare professions. But of the 800 general practitioners we contacted for participation in our study, not a single practice actually employed one of the specialised nurses mentioned. Nor did any of the 28 practices that finally participated in the study. To date, we do not know of any practice in the canton of Zurich in which such a “real” nurse is responsible for the duties mentioned. We would be thankful if Koch et al. could let us know how many practices in the canton of Zurich, or even in the whole of Switzerland, have nurses who are operative as diabetes consultants. A survey addressing this could be an interesting source of data for discussions about the future organisation of chronic care in primary care – for general practitioners (GPs) as well as for politicians. Therefore, we invite Koch et al. to perform such a study, which we would gladly support. Currently, based on our experiences when recruiting GPs for studies addressing chronic care, we doubt that the current number of nurses in primary care and performing chronic care is large enough to perform an adequately powered study. Therefore, we are looking forward to the publication of a study providing an overview of the number of nurses and the extent to which they are currently involved specifically in primary care. Unfortunately, as long as the very desirable dissemination of nurses in general practice is so marginal in extent, as it was at the time of the CARAT study and obviously still is today, we will have to continue to perform our studies using the only available locally existing non-physician personnel, which de facto are the MPAs or healthcare assistants or, as suggested, the medical assistants with an extended scope of practice.

References

1 Koch R , Mahrer-Imhof R , Huber C , Schmid-Mohler G , Fierz K , Zuniga F , et al. Comment on: Chmiel C, et al. Four-year long-term follow-up of diabetes patients after implementation of the Chronic Care Model in primary care. Swiss Med Wkly. 2019;149:w20009. doi:.https://doi.org/10.4414/smw.2019.20009