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Aequanimitas - The Firms at 40: Successes, Challenges
Aequanimitas Spring 2015
The Firms at 40: Successes, Challenges
Date: March 30, 2015
He didn’t know it then, but while serving as chief resident in medicine, Steve Achuff was about to participate in transforming Johns Hopkins’ renowned internal medicine residency training program into a new model that divided the growing medical service into four group practices.
The firm system, now in its 40th year, was one of Victor McKusick’s “most enduring innovations, of which he was justifiably proud,” says Achuff, retired director of adult cardiology clinical programs.
But why did McKusick, then the newly appointed director of medicine, feel an urgency to revamp the residency program? And does the model still work in the face of increasingly complex medical scenarios and regulations?
First, some context: Back in 1973, recalls Achuff, he, fellow chief resident Tom Inui and general internal medicine division founder Philip Tumulty would meet every morning in McKusick’s office to discuss patients.
It was during those informal meetings, says Achuff, that McKusick lamented how much had changed since his own training in the early 1950s. The number of housestaff had grown from 28 to 80, and McKusick was concerned about losing Johns Hopkins’ legendary collegiality and being able to ensure continuity of care. Also, pressure was mounting for hospitals to shorten lengths of stay and contain costs.
So McKusick proposed dividing the medical service into four units—dubbed firms, for the British term for a unit of caregivers. He named them Barker, Janeway, Longcope and Thayer, after the four men who headed the Department of Medicine between the original director, William Osler, and McKusick’s immediate predecessor, A. McGehee Harvey. Giving each firm a name, he hoped, would instill a strong identity and friendly rivalry.
Debuting in 1975, each of the firms had its own head (a junior faculty member called an assistant chief of service, or ACS), housestaff, nurses and hospital space. The ACS served as physician of record for each firm—initially for two years but later reduced to one.
“Those first years were trial and error,” recalls Achuff, and there was some initial resistance from residents. But as an attending physician on the Longcope firm for 25 years, Achuff says, the program not only improved continuity of patient care but fostered strong personal bonds among the physicians that span generations.
Yet Achuff worries about new challenges. In 1975, for example, a hospital stay for a myocardial infarction lasted 12 to 14 days. Now it lasts two to three days, giving residents much less time with each patient. Each firm has also grown—from eight interns per firm in 1975 to 13 per firm in 2014.
Even dividing patient care among four services, says Achuff, may not adequately address increasingly high patient volumes and residents’ time constraints that endanger handoffs. He also worries about the potential for more reliance on technology and lab data “versus what the patient tells you.”
Sanjay Desai, director of the internal medicine residency program and former Barker ACS (2004–2005), acknowledges Achuff’s concerns. Even so, Desai says, the firm system remains conducive to building trust and improving care. As evidence, Desai cites bedside rounds and patients presented at Grand Rounds.
Cardiologist Lorrel Brown, who served as a Janeway ACS (2011–2012), says the firm system works because it challenges chief residents to assume more responsibility for empowering trainees. “The heart of our teaching method,” says Brown, “is making inexperienced people capable and unafraid—unperturbable—the meaning of aequanimitas.”
For Desai, the most rewarding part “is having the opportunity to participate in the development and mentorship of unbelievably passionate people who want to change medicine.” On that, Achuff concurs. “The people going into medicine today,” he says, “are the same motivated, bright people we thought we were.”
Watch a video on the firm system, “Chief Rounds: An Oral History of the Firm System,” at bit.ly/FIRMSYSTEM.
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