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

The BMJ The firm: does it hold the answers to teamworking and morale? (BMJ 2019;365:l4105 )

Rotations and shift patterns mean that junior doctors often struggle to feel part of a team. Some want to bring back the “firm” way of working. But is this feasible, and was the firm really part of a golden age for trainees, asks Abi Rimmer

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……

Re: The firm: does it hold the answers to teamworking and morale? Reply 13th June 2019

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.

Today:

Re: Consequences of losing firm: true or false ?

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.

This entry was posted in Consultants, Medical Education, Professionals, Stories in the Media on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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