Welcome to the Firm

Barker, Janeway, Longcope, Thayer? Whichever uniquely Hopkins "firm" they join, new residents quickly find a family.

By MIKE FIELD

> The legendary Hopkins doctors who serve as namesakes for the firms: Barker, Janeway, Longcope and Thayer.

Susan MacDonald recalls a defining moment from the early 1980s, when she was a resident on Osler 3. It was always hectic. There was hardly time to sleep, much less eat properly. But she began noticing that one of the other woman residents was nonetheless eating a regular lunch, with a sandwich and milk and piece of fruit. Eventually, MacDonald’s curiosity got the better of her. “So I went over and asked how she managed every day to eat a decent meal,” recalls MacDonald.  With a slight look of embarrassment, the woman confided to her that she was, in fact, pregnant. “Oh, my God!” MacDonald exclaimed at once. “When did you find time to get pregnant?!”

Welcome to the marines—or more properly, the Osler Marines, as interns and residents back in the day grimly called themselves. Members of the corps endured years of grinding, grueling routine, yet decades later, they remember their experiences as being made bearable by an unusually close and collegial working relationship with their nurses, faculty, patients and the other residents on the service. This they attribute to the unique innovation the Hopkins residency program introduced in 1975: the firm system.

It was an idea borrowed from the British (and especially from Guys Hospital in London), adapted to fit the American medical training system, and championed by legendary Hopkins researcher and physician Victor McKusick, who in 1973 became Osler Professor and chairman of the Department of Medicine and physician in chief of  The Johns Hopkins Hospital. “This was just after the Osler and Marburg services had been combined,” recalls McKusick (M.D. 1946), “and the whole group was very large. There were nearly 80 house staff, almost four times the number there had been when I was chief resident under Dr. A. M. Harvey in 1951–52. We were very concerned that as a result we were going to lose the collegiality and compatibility that had always defined Hopkins training.”

The idea behind the firm system is very simple: Take a large group and break it into pieces, giving each of the smaller groups a sense of purpose, identity and place. Writing in The Johns Hopkins Medical Journal in April 1975, McKusick laid out his plan:

It is intended that on July 1, 1975, four services will be created and designated as firms. As inpatient facilities these will replace the four general medical nursing units in the Osler building. Each firm will be headed by a junior faculty member whose experience and competence are comparable to those of our current chief residents....The title will be Assistant Chief of Service (ACS).

Although McKusick proposed naming the services Osler A,B, C and D, somewhere along the way the decision was made to name each firm for one of the four seminal chiefs of medicine in line between Drs. Osler and Harvey: Lewellys F. Barker, Theodore C. Janeway, William Sydney Thayer and Warfield T. Longcope. By giving each firm a name, a sense of personality was imbued as well, and with it, a friendly, but not infrequently intense, sense of rivalry. “There was a sign that read ‘Barker: Firm of Choice’ just outside the team office when I was a member of the firm from 1989 to 1992,” says Landon King, now an associate professor of medicine and director of Pulmonary and Critical Care Medicine at Hopkins. “We would joke of course about the relative merits and demerits of the other firms. That’s just what teams naturally do.”

> McKusick, champion of the firm concept, on rounds.

Initially, each firm had an inpatient nursing unit of 27 beds and an outpatient clinic. Patients assigned to a firm would return to that firm on subsequent hospitalizations and would receive follow-up care in the outpatient section of that firm. The ACS would serve as physician of record for all the patients of that firm, countersigning orders, reviewing patients’ records, and writing progress notes for a period of two years. However, the workload required by that role soon made the two-year requirement impractical. “We tried it, but two years was just too strenuous an undertaking,” McKusick says. “Otherwise the firms exist today very much as we envisioned them more than 30 years ago.”

An important impetus behind the reorganization of the medical service came from new government rules covering medical reimbursements. Now every patient needed a physician of record to sign off on all treatment orders. Change was in the air, and the firm system was designed with an eye to the future organization of hospital-based medical practice. In his 1975 article, McKusick noted optimistically that “one consideration prompting change is that National Health Insurance or its equivalent is expected to provide professional fee capability for all participants in the next few years.” Hope, it seems, springs eternal.

“There was some concern at first that the new rules would somehow diminish the responsibility of the residents, and the ACS would become the only decision-maker,” says Craig Smith, one of the first four ACSs and one of only a handful to have held the post for two years. “It was tough getting people to accept the new approach, but it didn’t affect the independence of the house staff. I think what it did was improve the teaching. Now as ACS I had to go and see every patient. We were spending much more time at the patient bedside with the house staff instead of sitting in an office.” 

Smith later went on to help found the Division of General Internal Medicine at Hopkins and subsequently entered the biotechnology industry, rising to become CEO of Guilford Pharmaceuticals.  “It was incredibly grueling, and very intense,” he now says of those two long years from 1975 to 1977. “But there isn’t a better way to be more intimately involved in medicine. It was an incredibly rich experience.”

The firms help build a strong sense of identity, which can make all the difference during the frantic, difficult, sleep-deprived years of residency. “The firm was like your family,” says Susan MacDonald, today the associate chair of the Department of Medicine at Hopkins. “It was where you lived, and if you rotated off for a while as part of your training, when you came back it was like coming home.” It was, says one former resident from the early days, “like taking a city and breaking it down into villages,” each with its own strong character and sense of purpose.

And there is something uniquely Hopkins to the way the firm system works, says Landon King, which may explain why few other American medical schools have adopted similar programs. “We have a particularly rich history, and we pay more attention to history here than at other schools,” he says. “The idea that we organize teaching around the names of people who were prominent in the past is another way in which we respect that history. It’s reflective of the fact that we have a lot of pride in the achievements and contributions of this place.”

And is that sign declaring Barker the firm of choice still hanging outside the team office today? “I’m not really sure,” he replies, and pauses. “But I sure hope so.”