The firm: does it hold the answers to teamworking and morale?

In her article “The firm: could it fix team-working and morale?” Abi Rimmer (BMJ 15 June 2019) draws on the past experiences of Professor Harold Ellis, whose description of the firm is well recognized by many now towards the end of their career. The allocation as both a medical student and a trainee to a firm was met with mixed emotions reflecting the reputation of the consultants who led it. There was the old school style , sometimes endured rather than enjoyed , or the opportunity for an interesting and stimulating experience, which could inspire career choices. Although we can look back with a degree of nostalgia there is recall bias here , and the working conditions of that time are no longer tenable.

However the team-working ethic experienced in the traditional firm laid the foundations for modern practice. There is a significant body of evidence suggesting that working in a multidisciplinary team improves patient experience, safety, productivity and the working lives of all involved. Such a team approach allows quality improvement in working practices, which can be regularly reviewed and revised to improve patient outcomes. It also develops a sense of belonging, which not only includes all clinicians but also the support staff including medical secretaries. This forms the basis of the “modern’ firm.

In 2016 the RCS England assessed the contribution of the extended surgical team (EST) 1, which includes both medically and non-medically qualified members of the workforce. It was clear that not only did this team enhance training, but it also increased continuity of care to the benefit of patients. The implementation of the EST is a challenge both in terms of workforce but also financial resources. There are however popular postgraduate training opportunities for the different members of the EST with increasing numbers graduating over the next few years.

The Improving Surgical Training (IST ) 2 project was set up not only to consider the implications of the Shape of Training 3 recommendations on surgical training but also to determine whether enhancing trainer / trainee relationships could reverse the dissatisfaction of foundation and core surgical trainees. As a pilot the IST project is on-going and awaiting formal evaluation. There is early evidence that where time for training is in trainer job plans, the trainee experience is improved . Unfortunately the inclusion of formal training time in many trainers’ job plans is variable across the country. It requires employer support which is not always forthcoming.

There is clear evidence that good surgical training is provided by Trusts delivering high quality services. Trainees are able to develop their clinical and technical skills in an enthusiastic, supportive environment and in the context of modern conditions of service. The traditional surgical apprentice model is not possible in the 21st century but working within a team of multidisciplinary colleagues led by trainers with time for training is the approach which the RCS England believes will not only enhance training but also improve patient outcomes.

Bill Allum, Council Member, Royal College of Surgeons of England
Ian Eardley, Council Member, Royal College of Surgeons of England
Derek Alderson, President, Royal College of Surgeons of England
Neil Mortensen, Vice President, Royal College of Surgeons of England

References
1. A Question of Balance – The Extended Surgical Team. Royal College of Surgeons of England 2016
2. Improving Surgical Training – Proposal for a Pilot Surgical Training Programme Royal College of Surgeons of England 2015
3. Shape of training. Securing the future of excellent patient care. Greenaway, D. 2013.

Having graduated only in 2015, I have never experienced 'the firm'. I would, however, like to suggest that smaller hospitals and DGHs may be closer to a happy medium.

From my experience as a foundation trainee my initial year was based in a rural DHG. All the FY1s lived on site in hospital accommodation as well as some of the rotating registrars and FY2s. No long commute! We knew each others rotas so if you'd been on a long shift someone else would make you dinner or run an errand for you. We still had a mess fully stocked with snacks and a fund for tea, coffee and a few nights out, we also put on a biannual dinner and dance. Consultants and senior registrars took a keen interest in our training and well being and would notice when things weren't quite right, possibly because there was a weekly pub quiz in which to socialise after work.

This system was not perfect but it felt cohesive and fun and supportive. When I moved on to a bigger city hospital I felt much more of a transient cog in a big machine where you could just turn up do the list of jobs handed over and leave. It felt lonely and isolating.

My experience of some specialties, such as psychiatry, do largely maintain a consultant led team with a junior and senior trainee (this experience is limited) where, as a junior I did feel more valued, included and a more fulfilling sense of continuity. Is it possible in the more pressured specialties integrate more of this within the working time directive constraints? I suppose that is the million pound question.

The experience of ‘firm’ attachments was key to maintaining my enthusiasm throughout my career. As a junior, the support of colleagues, who often became lifelong friends, compensated for long hours and sleep deprivation. Over a dozen consultant ‘bosses’ led by example. Sometimes one learns that what not to do is as valuable as what to do. Professor Ellis, quoted in the text, was renowned as a hard taskmaster but many of his trainees delight in recounting their beneficial apprenticeship. The sharing of confidential clinical experiences requires intimate confidence amongst colleagues which the companionship of firm continuity permits.

As a consultant, I delighted in the support and skill of many trainees. I hope that in return they felt confident in trusting my advice and guidance. The abolition of the ‘firm’ structure, the anonymity of attached visitor trainees and the consequent uncertainty as to who was caring for ‘my’ patients was a key catalyst to my retirement.

Having had surgical training between mid - 80s and early 90s in traditional firms led by a consultant and supported by senior registrar, registrar and house surgeons (senior and junior) and following completion of the training , worked as a consultant till date, has given me an opportunity to appreciate the gains and losses incurred under both schemes. In all honesty, both systems have their inherent advantages and disadvantages, and both are not perfect. When one speaks to trainees of current system, they favour the present system of training with shift system as this is thought to be more humane and safe in comparison to the past system which included long hours of on calls (24 hours on week days and 72 hours on the weekends) with potential risks to the patients and doctors from lack of rest and exhaustion. Lack of continuity of patients care and incomplete connection with the patients and team are the major barriers to comprehensive training in the current system. However, eight years of structured current surgical training programme (core and specialist training) with well described curriculum and objective examinations (MRCS and FRCS) on completion of stipulated training, is at par with surgical training schemes internationally, including USA and Australia, as far as I am aware. It must be acknowledged that NHS in UK is under financial constraints and its repercussion as reflected by the reduced number of staffs (doctors and nurses) has significant implications on the workload of doctors, particularly the consultants, and the quality of training. It is important to assess issues surrounding the current training scheme and address them commensurate with the rapidly advancing science and technology in medicine.