Katherine Hurst, David O’Regan
Have you been told during a weekend ward round or night shift.. ‘In our day we worked a one in two’, ‘In our day we lived in the hospital.’ These statements are impressively true, but along with this our now consultant body had meals provided, a bar in the Mess… an actual mess!, accommodation on site, a single ward of patients and most importantly a team. Ten years down the line; we have shift work, multiple handovers, are rarely able to work with the same junior doctors and consultants in a rotation, and daily piles of paperwork. To add to this, our on call rooms are slowly being removed or charged for, restaurants close at 7pm and inpatient numbers are significantly higher. All during the time of heightened awareness of a 24/7 NHS. Where has the fun in Surgical Training gone?
Socialisation is implicit in all the models of knowledge transfer. The original SECI model of Nonaka started and finished with socialization, and ‘tacit knowledge’ – knowledge which cannot easily be articulated, but is vital or organizational constructs, acts as one of the key pillars to this.
The importance of enabling people to meet and chat was an underlying principle in the design of the modern science institute behind the British library. Architects, sociologists and psychologists understood the need to enable people to ‘bump’ into each other on a regular basis and designed buildings like ‘large hadron people colliders’. Many an innovative thought has originated from a chance encounter.
The anthropometric value of our very being is underlined in the fact that work is a social construct. We need formal and more importantly informal social contact to realise our ‘relatedness’ needs (as described by Aldefers modification of Maslow hierarchy of needs). We need other people to communicate with, build relationships and thereby foster trust. We cannot work in isolation as individuals. The world of health care is very complex and complex systems depend on good relationships.
Sadly, this opportunity is being removed from medical staff. The doctors mess, dining room and residents have been consigned to stories of a bygone era. In less than a quarter of a decade we have gone from starched white table cloths and sit down lunches breaking a full theatre day, to grabbing an anonymous sandwich on the run. Of course this has had to change for many reasons; as we have moved to a more egalitarian and multi disciplinary way of working, but why can’t we recognise the fun and camaraderie that it engendered and build it into today working environment.
This is certainly not to say our consultant staff did not have a hard time; they were largely unsupported, learned from mistakes, and worked 100+ hour weeks… but there was an obvious emphasis on teamwork and fun in training. At present increasing number of trainees are taking time out of training, moving abroad or leaving the profession. Causes for this are wide, but certainly include burnout, lack of support and/ or value, and increasing work demands due to lack of staff.
Due to unforeseen circumstances, the senior author was left resident without a foundation doctor or registrar one Sunday. Although a pleasant day, as night closed in, it became more apparent that he was seeing fewer and fewer colleagues. There was no ‘chit chat’. The hospital divested itself of all visitors and the number of people seen in the corridors dribbled away. The place became desolate and void of any human interaction. The lack of relatedness needs was troubling and further exacerbated by the fact that basic needs of food, hydration and a place to put you feet up were not met in any form or fashion. The experience was soul destroying and appropriately described by the encounters of Harry Potter with the dementors. The scattering of poorly maintained vending machines could not provide enough chocolate to mitigate the effect. This led to a reflection that the conditions under which we expect junior staff to work are appalling.
In contrast, on a trip to the USA, Mr O’Regan visited John Hopkins hospital that colloquilised the term ‘rounding’ due to the fact that wards were arranged around each other. The day started early at 0600 having breakfast in a food / dining emporium not to dissimilar to those found in shopping malls. Staff and whole teams were noted to be taking breakfast together at round tables. The meet and greet was generous and genuine. The work of the day was shared and discussed. The SECI model of knowledge transfer was alive in a purpose built and dedicated food court that was clearly bringing out the best in everyone. Excuse the pun but this offered food for thought!
One or the senior cardiac surgeons provided a coffee machine in their department at his own expense of six thousand dollars a year. The offices were organised around a central administration hub and the coffee machine was in the middle. He noted and valued the fact that the cardiac team met in this informal hub at the beginning of the day to share experiences, exchange knowledge and conduct the business of the day. This simple and generous act paid for itself many times over as the team reached and aspired to do better. It is well recognised that happy staff make for happy patients.
It was not surprising to learn that a well known coffee outlet in the foyer of the hospital was doing a roaring trade and has now elected to be open 24/7 including Christmas Day. Could this not be a lesson for all leaders and managers in the NHS. Look after your staff and the staff will look after you and the patient. It is all there in the theories of anthropology, sociology and psychology- after all doctors are human too.
Only 6 years ago as a foundation doctor, I thought life could not get any better. As part of a medical/surgical team we would see and treat patients, learn skills as an apprentice, and at the end of the list (or week) regroup in a local public house with time to reflect, relax and even laugh. Although shifts were busy and we often finished several hours late, there were still opportunities for a team coffee or evening dinner when rotas allowed. These events not only provided opportunities for guilt free ‘down time’, but also encouraged the development of bonds within teams, scientifically proven to improve patient outcomes. I cannot believe the difference in only six years. At present we are fighting a demoralised NHS system, where paperwork and overwhelming numbers of patients are leaving doctors tired and stressed at the end of the day.
The last thing colleagues wish to do is stay around the hospital for longer periods of time. Even if possible – who do they stay with; the foundation doctor they have met once before or the boss who is only their boss for a week. There is no will or time for social and team bonding events, which has knock on effects including; colleagues being less willing to swap shifts or stay late to help a ‘friend’, fewer ‘corridor conversations’ which would benefit patients, and juniors struggling to sign off even the commonest of daily tasks. Rotas have inflicted ‘shifts’ rather than vocational jobs, and time spent in the hospital is becoming a chore, not a commitment to patient care. I remember a time when the whole department attended our National Conference. This was the perfect setting for tacit knowledge. Socialisation, building of trust and rapport, and discussing future projects outside a busy NHS working day. This year one consultant and one trainee attended.
How can we change this – it is difficult to say. Trusts simply do not have the money to improve staff facilities, or provide the amenities which had been available to our predecessors; but these factors are vital for staff morale and retention and more importantly patient care.
We need to stop the rot around surgical training which is demoralising current trainees, inhibiting the uptake to surgical training numbers, increasing our drop out rates and most importantly affecting trainees mental health. Lets put the fun back into working for the NHS!