Clare Gerada: Dissecting resilience
BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4974 (Published 28 November 2018) Cite this as: BMJ 2018;363:k4974
All rapid responses
We were interested to read Clare Gerada's very pertinent and topical comments about the overlooked value of colleague and peer support between doctors at all career stages, medical student, junior doctor and consultant. When we and Dr Gerada were medical students, hospital doctors were organised into firms so that small groups of students provided a basis for discussion of all topics from basic medical topics through to contemporary politics, ethics and many other topics not otherwise included on the formal curriculum. Furthermore hospitals still had doctors' messes where students could sit and interact with junior doctors, both newly qualified and more senior, so acclimatising to the problems and needs of of our future careers.
As Dr Gerada points out, areas where doctors can now get together for discussion and support have either been greatly reduced, or completely eliminated, so that interaction at an informal level is frequently absent or only present in minimal degree. The problem has been greatly compounded by the move to shift working so that if a doctor is on duty there is not felt to be time for even brief relaxation to get to know and relate to colleagues. If a doctor is not on duty then it seems to be considered that actually being in hospital is frowned upon. The shift system also removes most of the times when doctors or students on the same firm, rotation or discipline can meet.
These changes, removal of doctors' messes, accommodation and other facilities which foster relationships and provide fora for exchanging experiences have all happened insidiously over the last three or more decades, with political correctness and financial pressures being used to justify the impoverishment of medical personnel and their careers. As Dr Gerada points out, the net effect has been to remove those structures that in the past readied medical students to become balanced, thoughtful and caring doctors, and also provided a continuing means of psychological support for qualified doctors, both during their time in training and then on into GP and consultant practice.
The resulting social and psychological isolation of the modern generation of doctors compared with their forebears has reached an all-time low, and as Dr Gerada suggests, must be given urgent consideration for resuscitation and reinvigoration if future medical generations are to be able to practice safely, securely and with confidence. While we appreciate that it is not possible to put the genie back in the bottle, the shortages in the medical workforce and the high reported incidence of stress disorders among juniors, with many leaving the profession early, warrants serious and urgent consideration of the present situation.
John Hood, retired Paediatrician,
Jeremy Plewes, retired Orthopaedic Surgeon
Competing interests: No competing interests
Dr. Gerada highlights the reality of building resilience amongst doctors [1].
As a medical student the idea of entering this emotionally tough profession is daunting. At our medical school, cadaveric dissection is still promoted and taught. This offers a unique way to discover the fascinating anatomical structures within our bodies and to collaborate with peers. We catch each other's faints at the first sight of a human body, navigate our way through the abdominal structures but most of all gain a vital support system during our first steps on our medical journey.
Although the traditional structures within medical schools are rapidly changing, we feel that some newer structures do prepare us psychologically for a career in medicine. Cardiff University has a relatively new curriculum, C21, which consists of case-based learning sessions. In these sessions, we discuss pertinent medical cases in groups of 10, meeting twice a week. This facilitates discussion of personal experiences of various conditions, our thoughts on evidence-based medicine and good clinical practice. It is a safe place to debrief after seeing potentially upsetting situations on placement. These spaces allow us to build resilience and learn from one another. We share our knowledge to promote camaraderie, offer incentives such as cake to make the pain of learning cell-signalling a little easier and importantly celebrate our achievements. We are a team and with that we value the skills each member brings to the table.
However, despite this sense of togetherness in medical school, there are a few factors which cause an underlying competitive streak and promote a rift between our classmates. First is the hot topic of rankings. This creates dispute and results in individuals gaining an inherent power to intimidate others. Nevertheless, it should be recalled that each ‘number’ is a person with a special skills sub-set and this cannot be undermined on the basis of an exam. It is a common joke that number 300th in the year still graduates as a doctor – and this holds true. Therefore, our focus should be to empower our peers to develop their skills to be the best they can wherever in the rankings they may fall. Horrifyingly, it has been noted that revising with friends is a questionable idea as it may be detrimental towards your own rank [2]!
The nature of the FPAS (Foundation Programme Application System) process further fuels rivalry. It seems that individuals are obsessed with gaining points, especially for publications. We feel that research, expressing opinions and the process of peer review should be enjoyable exchanges amongst peers. However, these are often periods when individuals become secretive about their work and seclude themselves. We feel this is not a sustainable approach. By definition, research is about disseminating knowledge, critically appraising each other’s work and promoting collaboration. The basis of a multidisciplinary team (MDT) is reliant upon this, surely it should be encouraged at an earlier stage.
Soon after FPAS application has gone through and we are thrust into the world of ‘real’ Medicine - with overwhelming shift patterns, there is barely enough time to eat let alone discuss our fears, and insecurities of day to day life. Often it feels as if our friends are scattered across the globe, there is no cake and no safe environment to have such discussions. Virtual environments, in the form of Facebook groups, such as Tea and Empathy have received a lot of public attention. They have connected individuals and enabled them to discuss topics from day-to-day life, mental health struggles and career planning. Luckily in Wales, hospital accommodation is free. This is useful as it offers a sense of community amongst junior doctors and reminds us that perhaps we are all in the same boat.
We recommend improved strategies to build openness and discussion amongst colleagues. An example of this could be increased awareness of the benefits of attending Grand rounds and Schwartz rounds. These may enable junior doctors to develop their confidence in presenting cases and voicing concerns.
References:
1. Gerada Clare. Clare Gerada: Dissecting resilience. BMJ 2018; 363 :k4974
2. Nowbar and Francis. A friend in need. Student BMJ 2014;23:g7345
Competing interests: No competing interests
Clare Gerada is correct that the lack of opportunity to make friendships with colleagues damages a doctor’s ability to develop resilience. The loss of hospital accommodation has been a big loss. It allowed junior doctors of various grades to live alongside other healthcare professionals and meet up and support each other after work. The accommodation was also cheaper and meant that doctors were based near the hospital, reducing travel time which adds to the stress of work.
Competing interests: No competing interests
Clare Gerada's piece goes to the heart of the sad loss of the team spirit we once enjoyed from "traditional" training. I am very concerned to discover that the GMC is unable to tell me how many non-Consultant doctors have committed suicide in the last 5 and the last 10 years. They are supposed to look after us. Such stats are so very basic.
The strain on Juniors today is severe, and no longer supported by the "Firm" system, is it surprising that so many Juniors are voting with their feet? I personally knew two Juniors who killed themselves, unsupported in their time of need. Neither were mentally ill.
Competing interests: No competing interests
Dr. Gerada is absolutely correct that friendship is the special dimension of social capital that nurtures our resilience. I used to teach Anatomy and can confirm that the longterm cooperative learning some student groups had then, led to bonds that have lasted over 30 years. Not all medical students can be acculturated to their profession (some from overseas found UK higher education especially challenging). However, I observed a number of traditional extra-curricular Medical School groups (rowing crews, local charity volunteers, choral singers) did promote social resilience. The ability to laugh at oneself safely is a lifelong asset. Of all the medical traditions, the hospital Christmas pantomime seemed to have the most lasting impact. As a 'participant observer' of acculturation, I was especially touched when invited to be a last-minute replacement for the Rear End of an Elephant in the Jungle Book, one Christmas.
Competing interests: No competing interests
The Beauty of a Doctors' Mess
Doctors coming from different backgrounds and medical schools converge on their next phase of life to work together, mostly in District General Hospitals/ teaching university hospitals. This phase of education and training is the real-life opportunity for doctors to grapple and grab what may come naturally their way for learning, say, by osmosis by being with seniors of varying degrees of skills and aptitudes from bedside manners, conversation skills to medical updates.
Having spent most of the morning, preparing for the ward rounds, presenting at rounds is quite a demanding formal activity. Having a break time after the busy morning is a very refreshing time to spend informal moments with colleagues, where doubts, queries arising and pouring of updated knowledge promptly for the decisions made earlier may offer an opportunity to refine decisions. It is unfair and unrealistic to expect clinicians in training, or even mature clinicians to be hot on all aspects at all times. Informal chats on the topics are hugely beneficial for learning and patient care.
Such informal gathering offers a great opportunity to iron-out minor difficulties of clinical decisions, with conflicts between colleagues being mutually resolved rather than escalating to formal complaints and creating bickering and leading to damage to the team spirit or worse even to higher degrees of issues such as referring to the GMC, making complaints, etc.
I recall with great fondness my time in 1982-3 at an infectious diseases hospital, King’s Cross Hospital, Dundee, working as rotating Paediatric registrar. The lead Consultant for the hospital, a non-paediatrician, was very well informed about all aspects, hot on current topics and very good with kids, full of energy and with a delightful personality--she would bring life into any mundane situation. Mid-day lunch break, with her sitting down in the middle of the fairly large doctors' mess often kneeling down in the middle, in a room furnished with a sofa, coffee table and TV, south facing large windows of the Victorian building, she would be surrounded by juniors. Calling everyone by their first names, how ever difficult those foreign names may be to pronounce, she would make any one so comfortable and welcome. Learning would become fun! One may take these as non-clinical times, but to be honest those were the best moments for learning and understandably beneficial for patient care!
Going over all the lab results bedside, urine microscopy and blood ESR and film examination, recognising atypical lymphocytes of Infectious Mononucleosis, X-ray reports and scan results together would infuse confidence, and generate a very conducive learning environment. I have no data to back up the claims I am making, but from what I recall, we know those were excellent ways to learn and to support juniors, making lasting relationships to cherish.
I feel sorry for the current generation of doctors in training who are missing out on such mode of learning and enhanced patient care.
Dr Neel Kamal
Rtd Consultant Paediatrician
Competing interests: No competing interests