Philip Darbyshire and David Thompson make a powerful case for flattening hierarchies across the health service. However, the structure of medical training may well contribute to these persisting.
Both the authors and other respondents have presented the doctor-nurse game as being one of power dynamics, one in which doctors have, historically at least, held the power. However, it is worth considering that this power dynamic may well be reversed when one considers the interaction between junior doctors and senior nursing staff. An analysis of the annual #tipsfornewdocs advice on Twitter reveals many well-meaning tweets that caution new FY1s to respect the experience of nursing colleagues. Many of these are accompanied by the joshing "otherwise they'll make your life hell". Perhaps this is all good humoured punching up at a historically privileged few but the ubiquity of the joke hints at underlying power imbalance.
In my current role teaching final year medical students many report feeling anxious about how they will be perceived by the nursing staff when they start work. Several report negative interactions with nurses as students, where they may be able to control access to patients or clinical skills. Whereas nursing and AHP students are often treated as integral members of their teams, medical students often feel they are treated as a vague annoyance by doctors, just hanging around until they can be called upon to do something useful. After many years of being in the way and following a ward round, the student is suddenly wanted by everyone. In such conditions how can we be surprised that students learn the rules of the game?
Short rotations lead to junior doctors often becoming the most transient members of the clinical team. In one unit, the only people not on first-name terms with the consultants were the junior doctors. Joining a team where everyone knows everyone is daunting, even more if it is perceived that there are negative consequences to challenging the established hierarchy. A rotation of four months is long enough to experience the negative effects of the culture but also short enough to see the light at the end of the tunnel. Transience can be an important protective factor and raising concerns can feel like more trouble than escaping unscathed. You move on but the culture remains for someone else to endure.
For there to be any meaningful progress in ending the doctor-nurse game junior doctors must feel supported and heard in raising concerns about culture and hierarchy. Otherwise, like with so many things in medicine, we'll carry on saying "t'was ever thus".
Rapid Response:
Transience and Hierarchy
Philip Darbyshire and David Thompson make a powerful case for flattening hierarchies across the health service. However, the structure of medical training may well contribute to these persisting.
Both the authors and other respondents have presented the doctor-nurse game as being one of power dynamics, one in which doctors have, historically at least, held the power. However, it is worth considering that this power dynamic may well be reversed when one considers the interaction between junior doctors and senior nursing staff. An analysis of the annual #tipsfornewdocs advice on Twitter reveals many well-meaning tweets that caution new FY1s to respect the experience of nursing colleagues. Many of these are accompanied by the joshing "otherwise they'll make your life hell". Perhaps this is all good humoured punching up at a historically privileged few but the ubiquity of the joke hints at underlying power imbalance.
In my current role teaching final year medical students many report feeling anxious about how they will be perceived by the nursing staff when they start work. Several report negative interactions with nurses as students, where they may be able to control access to patients or clinical skills. Whereas nursing and AHP students are often treated as integral members of their teams, medical students often feel they are treated as a vague annoyance by doctors, just hanging around until they can be called upon to do something useful. After many years of being in the way and following a ward round, the student is suddenly wanted by everyone. In such conditions how can we be surprised that students learn the rules of the game?
Short rotations lead to junior doctors often becoming the most transient members of the clinical team. In one unit, the only people not on first-name terms with the consultants were the junior doctors. Joining a team where everyone knows everyone is daunting, even more if it is perceived that there are negative consequences to challenging the established hierarchy. A rotation of four months is long enough to experience the negative effects of the culture but also short enough to see the light at the end of the tunnel. Transience can be an important protective factor and raising concerns can feel like more trouble than escaping unscathed. You move on but the culture remains for someone else to endure.
For there to be any meaningful progress in ending the doctor-nurse game junior doctors must feel supported and heard in raising concerns about culture and hierarchy. Otherwise, like with so many things in medicine, we'll carry on saying "t'was ever thus".
Competing interests: No competing interests