Intended for healthcare professionals

Rapid response to:

Feature Medical Training

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

BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l4105 (Published 10 June 2019) Cite this as: BMJ 2019;365:l4105

Rapid Response:

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

Rimmer's article on the firm made me pause for reflection on changes during my medical career. Having grown up with the firm, for me it seems extraordinary that the structure of a firm should need to be explained, before going on to discuss its strengths and weaknesses. Rimmer does well in identifying many of the key suportive elements of the firm, which was an organic social structure within which work and learning could take place; and which therefore provided emotional as well as technical support. This I am sure was beneficial to teamworking and morale as the article makes clear.

I think there are additional factors to consider. Rimmer suggests that itensity now is greater than in past days. Intensity varies by post, but I don't think in general this is true, certainly at the most junior levels. In my first post my normal working day was 11 hours, with up to 52 patients to care for. This incuded carrying out all pleural procedures for the chest firm. In addition, I worked every second night and every second weekend. In my third 6 month SHO post I was on call with one pre-registration house officer covering the acute take, medical wards, coronary care and medical patients on HDU/ITU. My responsbility was continuous from Friday morning until the start of the normal working week on Monday. Over the weekend no more senior staff particpated in review of patients. I placed central lines and temporaroy pacing wires, and enrolled patients with acute myocardial infarction into mulit-centre trials. I really do not think that current shifts are longer or more intense than this, and I could expand still further. At the same time what does seem to me to be very clearly true is that junior doctors now do have significantly poorer morale than my peers did, and feel demotivated compared to the raw enthusiasm of the medical students that we recruit.

Rimmer rightly identifies the support and educational aspects of the firm structure. I think though one important aspect of the firm structure is missed. With the firm strucutre, we admitted a patient, cared for them and discharged them. If things went well we shared the happiness of the patient and their family. If things failed to go well, one naturally carried out a real time audit in one's head; should I have done better? Did I make mistakes? Each of these served as powerful motivators. Positive feedback from successes encouraged good behaviour, negative experiences were powerful incentives to learn and do better next time. Either way we knew what we did personally made a difference and invested heavily in the outcomes.

Now, patients will tend to be passed on from admitting team to specialist teams, to cover teams, and an individual doctor has much less sense of ownerhsip. My own pet hate is the clerking plan that includes the phrase 'for senior review' which is code for I have now done my bit and take no further responsbility for the ongoing care of this patient. Particularly on call, the junior doctors role has ceased being ongoing care and review, but has fragmented into a list of tasks to be ticked off when completed, each of which is rather meaningless in isolation.

The solution here is difficult. The desire to limit working hours to ones that might be regarded as reasonable, and to afford consistently good care round the clock with appropriate access to various specialities means that the same level of continuenty of care formerly achieved can never be fully reinvented. Rimmer reproduces bulleted points from the RCPs 'never too busy to learn' document. These are all excellent points but to me they revolve around the system doing what it can to get the most out of the trainee; doing things to or with them. I think we also need to acknowledge the key role to be played in helping the trainee get the most out of themselves. Continuity gives ownership, responsbility and feedback, all of which are key in producing good morale and internal motivation and continues the practice of medicine as a vocation rather than a series of tasks. The practice of medicine will always be difficult technically and emotionally; success in practice will mean the doctor must get ongoing rewards and feedback that are intrinsic to carrying out their practice, not simply additions and supplements to it.

Competing interests: No competing interests

20 June 2019
Roderick Lawson
Consultant in Respiratory and GIM
Sheffield Teaching Hospitals
Sheffield