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
In the discontinued “firm” system—a model of medical apprenticeship—groups of doctors worked together to provide patient care.
Firms generally had at least one permanent member, a consultant, who led the firm and after whom it was named. Some four of five trainees of varying seniority weren’t permanent members of this firm, but they belonged to it, and for many it was a consistent source of professional and emotional support.1 The quality of education and training that trainees received, however, varied.2
The firm’s demise came after 2005 when trainees began rotating more frequently under the Modernising Medical Careers programme. From 2009 European working time regulations shortened doctors’ working hours. Junior doctors spent less time on the wards and their involvement in teams became far more transitory.
But many doctors would like to see the firm reinstated, seeing it as an answer to today’s problems of disenfranchisement and low morale among junior staff.
The cause of all the mayhem
When the firm functioned well, says the Royal College of Physicians (RCP), it provided “a structured development process, role modelling of professional behaviour, mentoring, and a good balance of challenge and support.”2
Harold Ellis, a retired professor of surgery who qualified in 1948, describes his firm as being like a family. In a firm, Ellis tells The BMJ, there would be one or two consultants known as “the chiefs,” a senior trainee known as “the registrar,” a junior trainee known as the “house physician” or “house surgeon” who lived in the hospital, and medical students.
“The firms were wonderful,” he says. “A lot of people think that the breakup of the firm is one of the causes of all the mayhem in the health service now.”
In 2016 junior doctors throughout England took industrial action over contract changes, and the then health secretary Jeremy Hunt expressed regret at the loss of the firm.
By dismantling the system, Hunt said, “We may have thrown the baby out with the bathwater. Can we bring back the firm or at least the best bits of it?”3 Also in 2016, research from the RCP concluded that the fragmentation of medical teams from frequent junior doctor rotations, rota gaps, and limited induction was central to trainees’ disengagement.4
An answer to junior doctors’ wellbeing?
Junior doctors’ displeasure about their contract and working conditions has pushed their wellbeing up the agenda.5 And the narrative persists that the firm provided yesterday’s medical trainees with something that is missing today.
In a recent letter to The BMJ, the locum Niak-Puei Koh lamented the loss of the firm as “a key cause of disconnect between junior and senior staff, where the feeling of being unsupported seems to be rampant.”6
He added, “The loss of the doctors’ mess, the sitting room for nursing staff, and a specific canteen (away from the public eye) have eroded this sense of community. Bringing some of these back—and even enabling teams to sit down with a cup of tea to discuss the daily chores—might foster a better working relationship and help team members feel less isolated.”
The anaesthetic registrar Joanna Poole laments the lack of a supportive team structure in medicine. “I love medicine, and my colleagues are smart, funny, caring, and inspiring,” she wrote. “But none of my seniors, who I get on well with, knew about my engagement or the death of my dad and my grandad, either because of the rota pattern, busy shifts, or we aren’t designed to ask. We all get asked how our shifts were but not the viscera of our lives.
“In the old days you had a firm or ability to socialise outside of work. We rotate so far geographically now this is difficult. Longer placements would be more humane, with secondment for tertiary specialties,” she said.7
Ellis is not surprised that today’s trainees are struggling. “Eleven hour shifts without a break is inhuman,” he says. Although he worked very long hours as a trainee in the late 1940s and ’50s, the work was less intense and he lived on site.
“If things were quiet you would take some time off: you could go and sit in the garden or pop out to get your hair cut,” he says. “There’s nowhere now for trainees to sit down and read the newspaper and have a cup of tea. We had our own mess but that’s been taken away.”
Without the close team working of the firm, Ellis says, consultants can no longer judge their trainees’ skills or learning needs. “My boss would say, ‘Come on Harold, you’ve seen me do this 10 times. Swap round: you stitch him up, and I’ll cut the knots for you,’” he says.
Autonomy within boundaries
James Morrow, a Cambridge GP, says that the firm built trust that gave trainees more freedom to learn.
“You were given a great deal of autonomy—within boundaries,” he says. “You could push yourself to achieve new things, knowing that there was support, in a non-judgmental way, available from someone who viewed you as part of the core team. And that is incredibly powerful.”
The firm also gave trainees a feeling of stability because they knew who they would be working with, Morrow says. “You looked out for each other, and backed each other up.”
However, the firm also came with disadvantages, Morrow remembers. “Some of the worst times of my life, as well as some of the best times, were working on a firm. The unrealistic expectations to be there all the time, to know everything, were not conducive to a happy life outside the hospital ward,” he says.
“We have improved working hours to a large extent, and that should be retained,” he says, but he’d like to see “if we can bring back some of the magic that made being junior doctor such great fun” by “working as part of a consistent, coherent, collective team.”
Health Education England (HEE) wants to do just that, Sheona Macleod, deputy medical director for education reform, told The BMJ.
Bringing back the best
“It’s not possible to bring the firm back the way it was but HEE is asking, ‘What was good about the firm? What do people miss about it? And how do we provide these things in the current training and working environment?’” she says.
Could a modern firm improve surgical training?
In 2016, Jeremy Hunt announced that Health Education England would work with the Royal College of Surgeons, teaching hospitals, and education providers to explore whether a modern firm structure could improve team working and make junior doctors feel more valued.3
The college started recruitment to the Improving Surgical Training (IST) pilot scheme throughout England, Scotland, and Wales in 2017. At the time Ian Eardley, senior vice president of the college, explained that the modern firm would omit the long hours and frequent on-calls but would re-create the best aspects of the old model.
He said, “The nice things about the firm were that you had a support structure in place; if you had a problem, no matter what hour of the day or night, you always had a person who you knew could help you, who could give you some advice.”8
In August 2017, 48 general surgery trainees in England and 31 core surgical trainees in Scotland took up their posts in the pilot.
Daniel Beral is a consultant colorectal and general surgeon and trainer on the IST programme who is involved in training the trainers in the pilot.
Trainees taking part have longer placements, of up to 12 months, which he hopes will foster stronger relationships with their consultants.
This relationship is key, and the scheme promotes regular meetings between trainees and supervisors. “In the firm structure you often worked for one, two, or three consultants but somebody actually got to know you,” Beral says.
The pilot focuses on the whole clinical team. “In some of the sites, newer team members such as surgical care practitioners or advanced care practitioners contribute to the on-call rota,” Beral says. “This means that there are more people on the rota and the trainees can work more in daylight hours.”RETURN TO TEXT
Maximising learning in the modern workplace
In its Never Too Busy to Learn guidance the Royal College of Physicians sets out how doctors working in modern teams can find the same kind of education and peer support that the firm offered.2
Medicine and patient care have changed substantially since the days of the firm, says Emma Vaux, senior censor at the college and one of the authors of the guidance.
“The team is no longer just doctors. As many as 18 different professionals look after a patient on a medical ward, and they are all contributing something,” she tells The BMJ. “We are working together, so why can’t we learn together?”
The guidance aims to look at “how we can capture the essence of what was really good about the medical firm,” she says, but without rose tinted glasses.
Recommendations from Never Too Busy to Learn for creating and maximising learning opportunities in the modern workplace are:
1 Target your time—make inter-professional board rounds more efficient
2 Use brief learning moments—take a break in the day to teach and have a cup of tea
3 Learn while with patients—make ward rounds and outpatient clinics educational
4 Learn by caring—listen to the experiences and emotions of staff
5 Practice makes progress—integrate simulation into the working day
6 Share professional experiences—role modelling and mentoring can support learning
7 Share learning experiences—use quality improvement projects and grand rounds to increase learning
8 Embrace technology—consider how it can improve doctors’ education
The guidance recognises some of the advantages of the firm but also that learning was “inevitably variable, accounting for considerable inconsistency in educational quality and outcomes for trainees, and in the resultant standards of patient care.”2
But it also gave consultants time to give trainees individualised careers advice, Macleod says. In its ongoing review of foundation training, HEE will “recommend that foundation doctors should have non-clinical training so that they can think about different career options,” Macleod says.
Other HEE projects have re-created other positive aspects of the firm. “In the past, your consultant might have suggested that you do research, or follow up on something,” Macleod says. “The flexible portfolio careers work we are doing in Enhancing Junior Doctors’ Working Lives allows people to pursue an interest while they are working.”
Macleod also recognises that not everyone had good experiences of the firm and some people’s careers were cut short by bullying. “It’s not an easy story to tell, ‘I was going to be a surgeon but this man in my firm made fun of me for six months so I gave up and became something else.’”
Jeeves Wijesuriya, chair of the BMA Junior Doctors Committee, says that nostalgia for the firm often ignores that when it operated lots of other things worked differently too. “There was less regulation, less oversight and measurement of performance, for example,” he says.
However, through the ongoing work that the BMA is doing with the government to improve the 2016 junior doctors’ contract, Wijesuriya is hoping that some of the positive aspects of the firm can be brought back.
For example, he is hopeful that improved job planning for trainees will give them greater autonomy over their work schedules and more quality time with their educational supervisors.
“At the nub of it is community and a relationship with your boss. The feeling that your educational supervisor isn’t just ticking off the required items without ever taking an interest in you,” Wijesuriya says.
“What we are trying to develop for junior doctors is relationships with supervisors who are interested in their career and in what they want to do next. That will not just keep trainees in the profession but will also bring the profession together.”
Provenance and peer review: Commissioned; not externally peer reviewed.
Competing interests: I have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.