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

The training of junior doctors is one of the priorities of the Royal College of Psychiatrists. An essential part of this training happens in multidisciplinary teams, and the ability to work effectively as a member of a clinical team is one of the core attributes of our professional identity as psychiatrists.

In this paper, I describe my experience of participating in a group which used a systemic framework to provide a space to reflect on our role as junior doctors. All the trainees were prompted to think about their clinical and professional dilemmas in relational terms, making links between themselves, the problem and the wider context, thereby gaining different perspectives and an awareness of power issues and the impact of context on everyday clinical issues.

Background

The advert of a popular campaign for recruitment in the National Health Service (NHS), ‘Join the team and make a difference’, is a powerful reminder of the fact that the delivery of care in the modern NHS is almost entirely based on the ability of individual members of staff to work effectively together as a team. Undoubtedly, the one-to-one relationship with the educational supervisor remains a primary source of learning for every junior doctor, and, as such, it has been a subject of interest over the years (Cottrell, 1999; King, 1999; Day & Brown, 2000; Sembhi & Livingston, 2000); however, the collaboration with other members of multidisciplinary teams can be an invaluable opportunity for professional and personal development.

Competence in management and service development is identified by the curriculum as one of the areas to be assessed by the MRCPsych examination (Royal College of Psychiatrists, 2001), but the opportunity to examine and critically reflect on the complex role of the psychiatric trainee in the context of a number of different interacting systems (multidisciplinary teams, in-patient units, peer groups, management structures, the College) is limited.

When working as part of a team, differences in roles, training and perspectives can be a stumbling block for the novice if not enough space is left to process experiences and deal with possible misunderstandings (Obholzer & Roberts, 1994). Some questions are often wide open in trainees’ minds (for example, How are we supposed to learn how to work with other people? When are we going to learn to think/talk/practise teamwork in our professional training?).

Context

The St George's/South Thames (West) Basic Specialist Training Scheme covers a wide geographical area. College tutors organise teaching programmes locally to cater for the training needs of trainees working in different areas. The scheme has an established tradition for psychotherapy training and offers trainees excellent opportunities for supervision of clinical work in individual psychodynamic psychotherapy, cognitive-behavioural therapy, group psychotherapy and family therapy. There are various possibilities for formal training, including a diploma course in cognitive-behavioural therapy, as well as foundation and intermediate courses in systemic therapy. Balint groups, encouraging case discussions focusing on the doctor-patient relationship, are routinely run in different parts of the scheme to ensure trainees’ participation.

Nature and purpose of the group

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

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

1. (a) the complexity of organisations;

2. (b) individuals’roles in relation to the wider professional network;

3. (c) the specific influences of the agency setting (team values, core beliefs, hierarchies, the history of service developments, etc.) on the way relationships with service users and between colleagues are shaped;

4. (d) the effect of their own training and professional development (including the possibility of competing demands on their time and loyalty) on relationships within their agency.

The group was run by a consultant psychiatrist and psychotherapist with 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 meetings in their 6-month placement, often the presence of colleagues who had worked in the area before and attended the meetings in their previous post was a valuable and significant adjunct to the process.

The range of skills and experiences in the group was very diverse: the junior doctors participating would be at different stages of their career (pre and post part 1 or preparing for the part 2 membership examination) and working in a variety of settings:

1. • four posts in a general community mental health team

2. • one post in a therapeutic community with a national catchment area

3. • one post in the local child and adolescent mental health service

4. • one post in a tier 4 specialist in-patient service for pre-adolescent children

5. • one post in the liaison psychiatry department of the local general hospital.

Systemic perspective

The first meeting for a new intake of junior doctors would include explaining the purpose and structure of the group. The facilitator would then encourage one of us to think about and present to the group a work-related issue, problem, theme - something that was creating difficulties or simply stimulating curiosity. As the only proviso was that the chosen situation could be described in relational terms, we found ourselves making use of the sessions to discuss a wide variety of topics. These included clinical cases, interpersonal problems, community team issues, ward issues, matters arising from particular referrals from general practitioners, the general hospital or the accident and emergency department. The chosen topic would normally be approached in different ways, including group discussion, role-play and small group consultation. A number of experiential exercises were used to develop a better description of the system ‘orbiting’ the problem, thereby allowing the person presenting to step back from the situation described (for example, What would the 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 the significance of the wider system to the development and presentation of ‘the problem’. They would then reflect on individual contributions to the coconstruction of that system, by considering the different positions (including their own) within the agency and 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 from a different perspective, finding appropriate channels of communication or pulling together different insights. During the time I attended the group we managed to solve some serious problems with our duty rota, address a malfunction in the paging system, which had given rise to a number of complaints, and give some creative ideas to a colleague who was working without office or desk in a crammed environment. At the same time, we experienced a sense of relief in identifying matters beyond our control (funding and staffing issues, office space, boundaries of catchment areas, lack of beds for acute admissions, etc.) and gained sympathy for those people in positions of authority, such as managers and senior clinicians, who deal with these matters all the time.

Value of the experience

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

During the period of training, a process of adaptation has to develop to maximise learning because the learning environment changes with every new placement. An appropriate space is needed to get acquainted with new structures, to make the interaction with new colleagues a fruitful process. I believe the group offered trainees just this opportunity and many more.

McFayden & Roberts (1994) reported on the benefits of formal systemic teaching for psychiatric registrars. Although formal teaching was not part of the agenda for the group, we learnt about core systemic concepts, such as context, perspective, feedback and circularity, power issues, self-reflection and curiosity, 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 process of consultation. The lively and interactive approach introduced by the facilitator was welcomed by all group members and ensured regular and enthusiastic participation, making our encounter with systemic ideas (for most of us it was the first encounter) an extremely valuable and worthwhile learning experience.