Systemic thinking in practice: a remedy for trainees' team-working dilemmas?

The training of junior doctors is one of the priorities of theRoyal College of Psychiatrists. An essential part of this traininghappens in multidisciplinary teams, and the ability to workeffectively as a member of a clinical team is one of the coreattributes of our professional identity as psychiatrists.

In this paper, I describe my experience of participating ina group which used a systemic framework to provide a spaceto reflect on our role as junior doctors. All the traineeswere prompted to think about their clinical and professionaldilemmas in relational terms, making links between themselves, the problem and the wider context, thereby gaining differentperspectives and an awareness of power issues and the impactof context on everyday clinical issues.

Background

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Background

The advert of a popular campaign for recruitment in the NationalHealth Service (NHS), ‘Join the team and make a difference’,is a powerful reminder of the fact that the delivery of carein the modern NHS is almost entirely based on the ability ofindividual members of staff to work effectively together asa team. Undoubtedly, the one-to-one relationship with the educationalsupervisor remains a primary source of learning for every juniordoctor, and, as such, it has been a subject of interest overthe years (Cottrell, 1999; King, 1999; Day & Brown, 2000; Sembhi & Livingston, 2000); however, the collaborationwith other members of multidisciplinary teams can be an invaluableopportunity for professional and personal development.

Competence in management and service development is identifiedby the curriculum as one of the areas to be assessed by theMRCPsych examination (Royal College of Psychiatrists, 2001),but the opportunity to examine and critically reflect on thecomplex role of the psychiatric trainee in the context of anumber of different interacting systems (multidisciplinaryteams, in-patient units, peer groups, management structures,the College) is limited.

When working as part of a team, differences in roles, trainingand perspectives can be a stumbling block for the novice ifnot enough space is left to process experiences and deal withpossible misunderstandings (Obholzer & Roberts, 1994). Some questions are often wide open in trainees’ minds(for example, How are we supposed to learn how to work withother people? When are we going to learn to think/talk/practiseteamwork in our professional training?).

Context

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Context

The St George’s/South Thames (West) Basic Specialist TrainingScheme covers a wide geographical area. College tutors organiseteaching programmes locally to cater for the training needsof trainees working in different areas. The scheme has an establishedtradition for psychotherapy training and offers trainees excellentopportunities for supervision of clinical work in individualpsychodynamic psychotherapy, cognitive-behavioural therapy,group psychotherapy and family therapy. There are various possibilitiesfor formal training, including a diploma course in cognitive-behaviouraltherapy, as well as foundation and intermediate courses insystemic therapy. Balint groups, encouraging case discussionsfocusing on the doctor-patient relationship, are routinelyrun in different parts of the scheme to ensure trainees’ participation.

Nature and purpose of the group

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Nature and purpose of...

As part of the teaching programme, all senior house officersworking in the proximity of Sutton Hospital were invited toparticipate in a group meeting scheduled at monthly intervals.

The group aimed to create a context in which trainees couldreflect on the specific work with their current agency andapply a systemic approach to gain a better understanding of:

the complexity of organisations;
individuals’roles inrelation to the wider professionalnetwork;
the specific influencesof the agency setting (team values,core beliefs, hierarchies,the history of service developments,etc.) on the way relationshipswith service users and betweencolleagues are shaped;
theeffect of their own training and professional development(including the possibility of competing demands on their timeand loyalty)on relationships within their agency.

The group was run by a consultant psychiatrist and psychotherapistwith experience and training in family and systemic therapy,working in one of the trust’s psychotherapy departments.Although most junior doctors would only attend six meetingsin their 6-month placement, often the presence of colleagueswho had worked in the area before and attended the meetingsin their previous post was a valuable and significant adjunctto the process.

The range of skills and experiences in the group was very diverse:the junior doctors participating would be at different stagesof their career (pre and post part 1 or preparing for the part2 membership examination) and working in a variety of settings:

four posts in a general community mental health team
one postin a therapeutic community with a national catchmentarea
onepost in the local child and adolescent mental health service
one post in a tier 4 specialist in-patient service for pre-adolescent children
one post in the liaison psychiatry department ofthe local general hospital.

Systemic perspective

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Systemic perspective

The first meeting for a new intake of junior doctors would include explaining the purpose and structure of the group. The facilitatorwould then encourage one of us to think about and present tothe group a work-related issue, problem, theme - somethingthat was creating difficulties or simply stimulating curiosity.As the only proviso was that the chosen situation could bedescribed in relational terms, we found ourselves making useof the sessions to discuss a wide variety of topics. Theseincluded clinical cases, interpersonal problems, communityteam issues, ward issues, matters arising from particular referralsfrom general practitioners, the general hospital or the accidentand emergency department. The chosen topic would normally be approached in different ways, including group discussion, role-playand small group consultation. A number of experiential exerciseswere used to develop a better description of the system ‘orbiting’the problem, thereby allowing the person presenting to stepback from the situation described (for example, What wouldthe situation look like if you were to see it from a helicopter?What would a map of this situation look like and how would you position yourself in it? etc.).

The group members would first be encouraged to recognise thesignificance of the wider system to the development and presentationof ‘the problem’. They would then reflect on individualcontributions to the coconstruction of that system, by consideringthe different positions (including their own) within the agencyand the influences of contextual issues, such as gender, race,culture, power differentials etc., in determining those positions.

Although solutions were not prescribed, some were ‘accidentally’found at the end of the process by looking at problems froma different perspective, finding appropriate channels of communicationor pulling together different insights. During the time I attendedthe group we managed to solve some serious problems with ourduty rota, address a malfunction in the paging system, whichhad given rise to a number of complaints, and give some creativeideas to a colleague who was working without office or deskin a crammed environment. At the same time, we experienceda sense of relief in identifying matters beyond our control (funding and staffing issues, office space, boundaries of catchmentareas, lack of beds for acute admissions, etc.) and gainedsympathy for those people in positions of authority, such asmanagers and senior clinicians, who deal with these mattersall the time.

Value of the experience

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Value of the experience

The job of a junior psychiatrist can be quite demanding, anissue that is possibly highlighted by the difficulties withrecruitment and retention (Storer, 1997). Out-of-hours duties,daily management of suicidal and potentially violent patients,dealing with difficult relatives and recent changes in theNHS, are only a few of the areas frequently mentioned as potentialsources of stress (Guthrie et al, 1999; Rathod et al, 2000).

During the period of training, a process of adaptation has todevelop to maximise learning because the learning environmentchanges with every new placement. An appropriate space is neededto get acquainted with new structures, to make the interactionwith new colleagues a fruitful process. I believe the groupoffered trainees just this opportunity and many more.

McFayden & Roberts (1994) reported on the benefits offormal systemic teaching for psychiatric registrars. Althoughformal teaching was not part of the agenda for the group, welearnt about core systemic concepts, such as context, perspective,feedback and circularity, power issues, self-reflection andcuriosity, by applying them to our own work settings.

The group provided both a different forum to reflect on potentially difficult situations and a direct experience of the processof consultation. The lively and interactive approach introducedby the facilitator was welcomed by all group members and ensuredregular and enthusiastic participation, making our encounterwith systemic ideas (for most of us it was the first encounter)an extremely valuable and worthwhile learning experience.

Acknowledgments

I am particularly grateful to Dr Sophie Thomson who so skilfully facilitated our meetings and to Dr Sam Reeve with whom I firstdiscussed the ideas in this paper as ourfinal presentationfor the Foundation Course in Family Therapy.

References

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