What it means to be a Chief Medical Registrar. The power of small changes

“You need to get to the bottom of why they are so unhappy and start to cheer them up.” This was the debrief I was given when I was approached to take on the Chief Medical Registrar pilot scheme – led by the Royal College of Physicians with support from FMLM. My initial thought was hire a clown or a weekly stand-up comedian. How does one ‘cheer up’ people?

Why are trainee doctors unhappy at work (I dislike the word ‘Junior’)? Undervalued, feeling unloved at work, overworked, lack of time and space for training and education, rota gaps and the new contract. The low morale has been here for a while and it’s here to stay unless we change how we approach the situation. As we are aware since The King’s Fund report in 2012[1], low morale impacts on patient safety and this is why this is a worrying situation.

The Chief Medical Registrar (CMR) is part of the Future Hospital Programme and came out of the Future Hospital commission report[2], encouraging the importance of leadership at an earlier stage. This role allows you to promote the Future Hospital Programme with the support of the network team implementing a service that mirrors the future hospital sites. I have chosen to work with the acute medical team at my hospital, to expand our ambulatory care service.

The role of the CMR is to act as an advocate for trainee doctors and provide a two-way dialogue with senior management of the trust. This includes the medical and clinical director, chief medical officer and the chief executive. This has helped to create an open culture in the last three months, highlighting issues that contribute to low morale in the workplace. I am fortunate enough to have an open door and a ‘speed dial’ telephone relationship with both the medical and clinical directors. There are no barriers to open communication or addressing issues. For me, the role would be redundant without this. I am confident concerns will be listened to and action will be taken.

How have we worked on morale? We have a monthly trainee doctor forum meeting attended by the clinical director, director of medical education and lead coordinator for medicine. This is an open forum for doctors of all levels to discuss the issues they face. It is only by having this openness that we can get to the bottom of the real problems. I use the word openness repetitedly and I make no apologies for doing so. We want to create an environment where doctors feel like they are being listened to and are able to voice their opinions and concerns.

Every trainee doctor in medicine has completed a survey to decipher the issues and problems with their individual jobs. This has revealed several issues which had not been previously recognised. The results were presented at a trust wide consultant meeting. Again, open communication. I have sat down with the medical director and found solutions to the issues addressed in this survey. Not shying away from the issues, with the trainee doctors knowing that their concerns are addressed.

I am three months into a one-year post with a 60:40 split between clinical and the CMR role. The difference compared to the clinical fellows’ role is that you continue working on the ‘shop floor’; I am able to support trainee doctors, identify issues, promote quality improvement projects – and see these changes through.  

For example, one of the striking things I noticed when I started here was that very few doctors used the mess. Yet, it is a large space (40ft long) with Sky Sports (a godsend) and doctors paying £17 a month. Instead, doctors spend their lunch breaks in the ward office or staff room, on many occasions eating while working. Was this because they were too busy to leave? Our work load here is not too dissimilar to other places I’ve worked.

The issue with the mess was obvious. It was cold with old broken windows, a torn carpet and a dirty kitchen (if you can call it that) with overfilled bins. There was no food (tea and toast is a must) and it could be mistaken for a student rental, not a communal place for professionals. It saddened me to see this. I understand that the refurbishment of the mess had been an issue for several years, yet nothing had been done about this.

I arranged for senior management to visit the mess so they could see the reason I felt was a major contribution to low morale. I wanted the mess to be a hub where doctors could all sit, for the 10 mins before work, for breakfast or for the half-hour lunch. For many, working alone as the only doctor, this period of interaction with others is crucial. It allows you to vent and share your daily events with others (who are probably feeling the same). Also, as many doctors are new to the area, the mess is important to meet others and socialise. On a professional level it is the only place in the hospital where all disciplinees sit in one room, therefore making referrals easier. Personally, I have made many referrals to our surgical/orthopedic colleagues in the mess over lunch.

The response from the hospital management was commendable, and the level of investment was significant in this cash strapped climate. We installed new windows, floor, and kitchen along with regular cleaners and stocked the mess with food. The challenge going forward is to get people to visit regularly rather than sitting alone on the wards, which will be the focus for the new mess committee.

The neglect of the doctors’ mess is a reflection on the plight of how trainee doctors feel at the hospital. However, we all need to stop for a moment. How are we going to make this better? What small things can we do in our work place to make the lives of others better?

So far, getting in a few desks and two computers on a single ward has made a massive difference. Making the doctors’ mess more habitable is another. You do not need wholesale changes to make a difference. For those into football, Leicester City who were bottom of the league last year won the league this year. Their new manager, Claudio Ranieri, did not make big changes to improve their fortune. He made a few small changes and worked on team ethic and morale. They reaped the rewards and achieved the unachievable.

I’m not saying I’ve changed things around in three months; organisational change takes time. However, we have accepted there is an issue and we are working to improve it. My role is to find the little things that make the difference and I encourage everyone to take a step back and think of the one or two little things that will make the lives of everyone better. If you want to improve patient care and outcome, then value and invest in those that deliver this patient care – the trainee doctors. It is only then you will see the benefits to the organisation.

[1]^{West M, and Dawson J (2012). Employee Engagement and NHS Performance, The Kings Fund}

[2]^{Future Hospital Commission. Future hospital: caring for medical patients A report from the Future Hospital Commission to the Royal College of Physicians. London: Royal College of Physicians; 2013.}