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……
Firms would wither in this age of individualism.
Firms that thrived in past had a wise head leading it; collective responsibility was cherished and self sacrifice was applauded not derided.
In firms, good and bad decisions had ownership and learning from mistakes is encouraged without a sword hanging over the head.
But the firms of the past would not survive the current “age of individualism”. Now individual rights reign supreme without even a symbolic nod to group responsibility. Good firms place patient needs first and hence is incompatible with a clock watching culture.