Archive and Study Centre Publications: Series 2 Essay 3
by David Clark
Although there are papers describing some of the things that we did at Fulbourn Hospital, many experiments were never published. Notable amongst those were the meetings for the doctors that were held every Friday morning from 1966 to 1979. Some of us regarded these as our most important meeting of the week, and a setting in which we had valuable growth experiences. Certainly all visiting doctors found them surprising, and many made enthusiastic comments. The first Royal College Accreditation team spoke very highly of what they thought the doctors were learning from them; though subsequent teams became critical as they became more academic and training orientated.
In 2002 Ross Mitchell and I attempted to put together something of what we had learned from this wonderful experience, and I attach these papers in an attempt to give some flavour of how it was. The first paper is a history of the meeting as given in extracts from my book "The Story of a Mental Hospital; Fulbourn 1858-1983. The second is an explanatory letter for newcomers to the meeting (and the hospital) drafted in 1974. The next two are personal reminiscences of the meeting, by myself and Ross Mitchell.
The average number of members present was usually about twenty: Five Consultants, four Senior Registrars, and a dozen Registrars and Senior House Officers. No record was kept of attendance over the thirteen years, but some sixty-five doctors - ten Consultants, fifteen Senior Registrars and forty Registrar and SHOs - spent a substantial time in these meetings.
D. H. Clark
1. Fulbourn Hospital Doctors’ Friday Meeting: From “The Story of a Mental Hospital”
2. "An explanatory note to new doctors about the doctors' meeting" (1974)
3. "Personal Reminiscences of the Friday morning meeting"
by David H Clark
4. The Friday Morning Meeting at Fulbourn (memories of the Doctors' Meeting),
by Dr Ross Mitchell, Consultant Psychiatrist (retired)
There are a number of records available about the meeting. In "The Story of a Mental Hospital; Fulbourn 1858-1983. I make several references to it:
Pages 115-116. (1956)
“My general pattern of government was fairly settled by 1956. The morning meeting with the doctors was my main instrument of medical policy; all new plans and projects were discussed here and many minor difficulties sorted out. After the early turmoils new doctors accepted that the senior nurses had legitimate comment to make on any matter............
“The doctors' morning meetings had many functions. There was the obvious one of exchanging information. The doctors told me and the others about major happenings; the night duty doctor reported on any overnight turmoils. I distributed letters which had been addressed to me but which really concerned others, especially those about particular patients. There was also the more important function of clearing misunderstandings and ventilating conflicts. Sometimes this failed, particularly where differences arose from personal antipathies; at times I would feel surges of irritation run through the meeting without being able to discern the cause, though sometimes I heard months later what lay behind a blow up............
“It was also in these meetings that the new doctors learned how the hospital worked and what their powers and responsibilities were - toward their patients, the other doctors, the Consultants and the nurses. I found that all the new doctors would make a few mistakes which could be corrected in the meeting but more important, that they learned from the comments they heard about others' mistakes, and they saw how decisions were made. I also came to hope that they learned my approach to a problem and gradually gave up the traditional model of decision-making (in which the doctor gathers the facts, decides the diagnosis and prescribes the treatment, largely unaided) for a method of group discussion. In these discussions all involved in the problem had their say and the summing up, formulating and implementing of the group decision often fell to some other member of the group than the doctor.”...........
Pages 190-192. (1966)
“In 1966 both Leslie Buttle and Christopher Scott, the psychotherapist at Addenbrooke's, retired and we made two excellent new Consultant appointments - Ross Mitchell at Fulbourn and Malcolm Heron at Addenbrooke's. Both men were to make major contributions to Fulbourn Hospital in the coming years. Products of post war psychiatry, both were deeply committed to a social view of work with the mentally ill............
“Malcolm Heron was appointed as psychotherapist to the Outpatient Department of Addenbrooke's, but he took a keen interest in what was going on at Fulbourn and was fully committed to group and social therapy. He went to a number of ward meetings, and then began to attend the doctors' meetings in my office. At first he observed and said little, but then began to comment on process. He pointed out how the setting (my office) inhibited the group, so we moved the meeting to a seminar room downstairs. Gradually the meeting became a sensitivity group for the medical staff. The discussion became less structured and more spontaneous, with Malcolm offering facilitative interpretations on the group process. We stopped bringing administrative problems to it, and Jack Long, now Chief Nursing Officer, stopped attending. When the Postgraduate Medical Centre was opened in 1970 we moved there. This "doctors' meeting" was held every Friday morning from 9.00 until 10.30 am and became a key part of the programme of social therapy of Fulbourn Hospital.”
Pages 215-217. (Review 1966-1979)
“One of the more unusual learning developments of the "Culture of Change" at Fulbourn was the "Doctors' Friday Meeting" mentioned earlier; this was a unique experiment in egalitarian sharing between doctors of all grades. This started from the meetings in the Medical Superintendent's office which I had begun shortly after I arrived. Through the fifties I met every morning with all the hospital doctors and the Nursing Officers. We focused on day-to-day affairs, sorting out the mail, arranging patient transfers, and so on, and getting to know and trust one another. The style of the meeting was open and saw a good deal of plain speaking. By the mid-sixties we were meeting three times a week and spending more time on major differences, policies and medical staff training. Then came a number of changes in the hospital. Oliver Hodgson was appointed Consultant in 1959 and in 1962 took over as deputy Medical Superintendent; in 1966 Ross Mitchell was appointed Consultant. Both attended the meetings regularly and worked with me and challenged me as issues arose. The meetings began to concern themselves more with relationships between the doctors, especially doctors of different grades. In 1966 Malcolm Heron a Consultant Psychotherapist began to attend the doctors' meetings at Fulbourn and to move the group towards examining its own structure and function. The meeting moved out of the Medical Superintendent's office and settled on meeting once a week, every Friday morning for an hour and a half.
“This continued for about ten years and is remembered by many doctors who worked in those years as one of the most interesting parts of their psychiatric training. The meeting had no agenda and no Chairman. The discussion was free-floating and spontaneous with an emphasis on open expression. The focus was on our medical work within the hospital, on particular the stresses and problems we could not talk about elsewhere - the struggles and rivalries between doctors, the pressures on us from other hospital staff and people outside (general practitioners, social workers and general hospital Consultants), the drives which brought us into psychiatry in the first place and the pains of becoming a psychiatrist. We often became very personal and talked of our own private problems. Although it was not compulsory, nearly all the medical staff working in the hospital attended regularly. The Fulbourn Hospital Consultants, Oliver Hodgson, Ross Mitchell and I attended every week, the Addenbrooke's Hospital Consultants less often. Malcolm Heron came consistently and was the chief facilitator until his untimely death from cancer in 1974. The meetings varied greatly - sometimes being passionate confrontations or bitter personal rows, at other times quiet relaxed discussions of current medical political happenings. Sometimes they were flat, boring and repetitive, but not often - for the stresses of psychiatric hospital life meant that there was always some doctor distressed or enraged by recent challenges for his work. Doctors starting in psychiatry were often able to share their distresses with those of us who had lived through similar turmoils, and could begin to come to terms with our stressful speciality.
“People used the meetings differently at different times. I found it helpful to share with them the pressures that came on me, as Superintendent (and later as Chairman of the Division of Psychiatry) from Management Committee, police and Magistrates. I also valued being challenged over my mistakes and ineptitudes in my way of working. Both Oliver Hodgson and Ross Mitchell used the meeting as a sounding board during their periods as Chairmen of the Division of Psychiatry. Sometimes the meetings were painful but often very warn and supportive. Few of us will forget how Malcolm shared with us the knowledge that he was soon going to die, and allowed us to express some of our despair, grief and anger at this news.
“Oliver, Ross, Malcolm and I saw these meetings as an essential part of the psychiatric trainees ' introduction to their chosen speciality and spent a lot of time attending to the reactions of newcomers. Some young doctors welcomed this atmosphere and took to it with glee, revelling in the chance to challenge Senior Registrars and Consultants openly and to leam more about themselves. Others found the departure from traditional medical relationships disturbing and distasteful. It was particularly stressful to more senior doctors, Senior Registrars and Consultants who had come from other hospitals and more traditional ways of working and who could not tolerate being challenged or confronted by their juniors. The Friday meeting continued through the early 1970s, but ran into difficulties in the mid 1970s, after several new Consultants joined the staff. Some of them found the meetings intolerable; one even cried out in fury "It's a Communist attempt to brainwash me!" as he left the meeting for ever.
“The arrival of the university academics in 1977 brought a major change. They made it clear that they disliked this meeting and thought it of no value. They believed that psychiatric training should consist of instruction given by the skilled and experienced to the unskilled and inexperienced, and that egalitarian discussions were of little value. After a few visits to the Friday meeting they stayed away and advised other doctors to do so too. As the academic model became dominant in Cambridge psychiatry during the late 1970s, the Fulbourn doctors' meeting withered. The numbers at the Friday meetings dwindled; the discussions became flatter and the meetings finally stopped in 1979.”
For many years the doctors at Fulbourn Hospital have been meeting on Friday mornings. The siting, the structure, the function and the work task of the meeting have changed and evolved during that time. We were originally a working group, assembling in the Superintendent's office with the senior nurses as members. We moved out of the Superintendent's office in 1967. The last nurse left in 1970. From 1968 until about 1971 the meeting began with an "administrative" period when the Superintendent, the Clinical Tutor and the others made announcements ("the talking notice board"). From 1966 onwards there was an explicit pressure to become a "sensitivity group", although no conductor was ever recognised.
The meeting is part of the educational work of Fulbourn Hospital and an integral part of "The Fulbourn experience" for doctors in training. It plays a part in the communication structure of the adult psychiatry service in Cambridge.
The value and necessity of the meeting has often been questioned and the answers that emerged have varied. The following reasons for holding the meeting seem fairly constant.
1. Many members find it a valuable (though at times painful) experience which enables them to do their work better and to understand and modify their own ways of functioning.
2. Psychiatric work, being concerned with distress and suffering, creates strain in all of us. Other strains arise from the conflicts and tensions of the widespread and constantly altering organisation of the Cambridge Psychiatric Service and Fulbourn Hospital. An informal forum where these can be shared is valuable both for us and for the organisation.
3. By looking early at stresses and conflicts amongst the doctors here we can prevent them building up into the crises and chronic feuds which mar many psychiatric groups.
4. Many doctors in training have found the "Friday morning meeting" not only unique but one of the most valuable parts of their Fulbourn experience - an occasion where they can share some feelings with some of their seniors, can see group and organisational dynamics in action and can try out styles of making their own contributions to group discussions.
Newcomers are sometimes puzzled as to what the purpose of the group is, and what its basic contract can be. Although the topics of the group change from week to week and the pattern of interaction changes (and develops) over the months, the basic contract remains much the same.
The following seem to be basic "ground rules" for the group, which could be formally communicated to newcomers.
1. Every Friday morning from 9am to 10.30am a sensitivity group for Fulbourn Hospital Medical Staff meets in the Postgraduate Medical Education Centre. There is no formal work task and the use of the meeting for disseminating information or making arrangements is discouraged. The main task is to examine tensions and feelings amongst the group, both within the meeting and throughout the activity which we have in common, namely the medical work of Fulbourn Hospital.
2. Membership of the group is open to all doctors working at Fulbourn Hospital, and there is an expectation that all doctors in training will take part.
3. As in all sensitivity groups there is an expectation that those who come will participate, that they will attend regularly and will explain absences or withdrawals.
David H Clark
Perhaps I find it difficult to reminisce about the Friday morning meeting because it meant so much to me. For ten years it was the most important meeting of the week, and the one from which I gained most emotional support. I gradually came to see that it was a unique gathering, and the years since have confirmed for me that this was one of the most exciting of the many experiments in social psychiatry which we carried out at Fulbourn during the great years, and also a unique experiment in medical education.
Although egalitarian relations between senior and junior doctors were quite common in therapeutic communities and also developed in some small units such as the Henderson Hospital, as far as I know nothing like this had happened in any mental hospital with its full complement of Consultants, Senior Registrars, Registrars, Senior House Officers etc. Of course the old mental hospitals with two or three medical staff (such as Fulbourn Hospital in the 1930s) close social relationships between the doctors such as we had at Fulbourn was very different.
Every Friday morning all doctors at Fulbourn gathered for an hour and a half in an unstructured meeting without anybody formally acting as chairman. The agenda was the experience we were all sharing - the tasks of being a doctor in a mental hospital, the pressures and the strains that this brought on us from the disturbances of the patients, the tensions amongst the doctors, and the pressures from the outside world - in particular, GPs and Addenbrooke’s Consultants.
The meeting evolved from the Medical Superintendent’s morning meeting (1953-66), when the doctors working in the hospital met with the Senior Nursing Officers and the Superintendent to deal with any medical matters that had arisen in the previous 24 hours. I had started this in 1953 when I first came to Fulbourn, and it had run vigorously for over ten years as the size and complexity of the medical staff gradually increased. At first, in 1953, there were only two or three junior doctors. In 1959 Oliver Hodgson joined me, and in 1966 Ross Mitchell. The number of doctors in training increased steadily, and in 1964 when Kent House was opened we had an increase in Senior Registrars so that there were three of them working as well as half a dozen Registrars so that there were three of them attending as well as half a dozen Registrars and Senior House Officers.
In 1966 Malcolm Heron came as psychotherapist at Addenbrooke’s, and because of his experience at Claybury expressed a wish to play a part in the life of Fulbourn Hospital. He began attending the meeting. He pointed out that it was rather burdened with formal administrative matters and perhaps oppressed by its setting in the Medical Superintendent’s office. We therefore moved the meeting to a neutral place (the nurses’ library in the basement) and began to concentrate on our relationships with one another. About this time Jack Long, the Senior Nursing Officer and the only remaining non-medical member, withdrew from the group.
Two years later, when Ross Mitchell as postgraduate tutor persuaded the authorities to create a postgraduate education centre with a library, lecture room and meeting room in the shell of an old dormitory, we removed to there and held our meetings there for the next ten years. To begin with Malcolm was the facilitator of the group, leading it to greater openness, though he refused the title. The fact that he did not have any clinical responsibility within Fulbourn Hospital itself was important. Key figures were the three Senior Registrars who by this time were running the three admission units - Friends, Street and Adrian -, and carrying considerable clinical responsibility as well as authority over the work of the Registrars with them. They were often critical of the weakness or failure of Consultants to back them in their battles with GPs, Mental Welfare Officers and in particular Addenbrooke’s Consultants, such as the Professor of Medicine; and they did not hesitate to attack us for our personal failings and inadequacies, particularly my over-talkativeness.
In due course several other Consultants joined us. Brian Davey came regularly, Bernard Zeitlyn came occasionally, Beresford Davies hardly at all. On their appointment, Graham Petrie and Jean Werner attended regularly and contributed vigorously. Ramon Gardiner and Peter Brook, on the other hand, found the meeting distasteful and left after a few occasions.
The meeting broke up when coffee was delivered. The Senior Registrars and Registrars stayed to discuss their business, and the Consultants went off to another meeting place. The Consultants’ Meeting served both as a “staff review session”, where we looked at some of the issues which had risen and some of our reactions to them, and also as a place where we could deal with issues that involved us alone.
A turning point came when Malcolm Heron fell ill and was found to have an inoperable cancer of the liver. He came back to work, rejoined the meeting, and told us of his diagnosis. Shocked and dismayed, we attempted to digest the news. He helped us in this, and even got us to acknowledge that amongst all our compassion was some irritation and hostility that he would be leaving us to face the problems on our own.
Several of the junior doctors went through difficult periods which they worked on in the meetings. Some denounced psychiatry and left it; others struggled with the erosion of their medical self image but came to see themselves in a new light; one had a breakdown, went away, was treated with ECT and came back to join the group again. Different groups dominated. At one stage we had four Greeks, all rebellious refugees from the dictatorial regime in their country, and very willing to challenge the failings of Fulbourn.
The end of the Friday morning meeting began when the academics were appointed. In 1977 German Berius was, for a time, an active member of the Friday meeting, but Martin Roth rapidly made it clear that he wanted no part of it. He was particularly incensed by the assumption of the meeting that any doctor, any member of the group, had the right to challenge and question any other. He disliked, too, the underlying therapeutic community assumption that any member of the team might have a relevant contribution to make which might be more important and effective than the opinions of the Consultant. Martin’s attitude seemed to be that knowledge flowed downward and that as Professor he knew more about everything than anyone else. His task was to teach; the duty of others, particularly Senior Registrars, was to learn from him and not to ask questions or challenge him. The idea that he might learn something from a newly joined Senior House Officer was to him inconceivable. As he built up his department and attracted new staff to his power, the vigour went out of the Friday meeting and it finally quietly closed in 1979.
What did I get out of it? My early years as Superintendent of Fulbourn had been lonely. There was no one within the hospital with whom I could share my views, ideas and anxieties. When they came, Oliver Hodgson and then Ross Mitchell were a great help to me; but I found the Friday meeting even more valuable, and I would share with the group many of the pressures which came on me from Regional Board, Addenbrooke’s Consultants, the police, the magistrates and judges and other outside bodies. When my marriage broke up in 1975 I shared this with the group at the Friday morning meeting before I told any other group in the hospital.
The main things I valued in the Friday meeting was direct criticism of my actions and attitudes. When I first came to Cambridge I had many critics, particularly amongst the Management Committee, but as things went well and became more successful there was less criticism. I came to miss it as a valuable check on my exuberance and optimism. I was glad to find it again in the doctors’ meeting. Amongst those who criticised me trenchantly I recall with affection some of the Senior Registrars - Junichi Suzuki, Geoffrey Pullen, Jane McEwen -, and some of the Registrars - Steve Wilson, George Vitzas, Julia Wilkinson. This called for a bold and confrontational style, and there were some doctors who worked with me and whom I greatly valued who could not bring themselves to do that. Ilham Raafat for instance, a gentle, courteous Copt would never confront anyone, far less a Consultant. Khedar Dwived, Registrar and Buddhist teacher who made his points by quiet, soft comment: not confrontation.
One particularly difficult time came when some of our Senior Registrars applied for a Consultant post at Fulbourn, facing an appointments committee on which some of the Consultants sat. It was difficult enough beforehand; but afterwards, when he was not appointed, the pain and bitterness were hard to bear. However, we struggled through it and we Consultants managed to share some of our difficulty in being part of a body that turned down someone with whom we were on friendly and egalitarian terms. It was a painful reminder of the power structure of the NHS; but in most cases the pain was resolved, with everyone respecting the roles which others had to carry.
It was for me my primary support group within Cambridge psychiatry for the ten most important years of my work, when I developed therapeutic communities in both Hereward House and in Friends Ward, and faced the excitements, the challenges, the difficulties and the grief that came from that. During the 1970s the Rehabilitation Service gradually became the centre of my activities, and after I ceased to have admission ward responsibilities (in 1977) I had less in common with the Doctors’ group as a whole. I found my personal support group among the senior members of the Rehabilitation Service, particularly the nursing officers such as Ruby Mungovan and John Wise, people of my own age who shared long years of asylum experience. By the time I retired in 1983 I did not know many of the younger doctors working in the hospital, and had no working contact with the Senior Registrars. It was a changing world with constant emphasis on didactic teaching and fault finding over everything that happened, in which I felt increasingly uncomfortable.
Dr Ross Mitchell, Consultant Psychiatrist (retired)
When I first came to Fulbourn as a new Consultant in May 1966, I found that every Friday morning a meeting of the medical, nursing and administrative staff was held in the office of Dr David Clark, then Medical Superintendent. We all sat round his large desk to review the progress of patients, and in particular to discuss any crises in patient care that might arise over the weekend, and which the duty staff would have to deal with. In other words, this was an administrative and business meeting which served that purpose well. However, gradually, over time, business gave way to more personal matters, concerning the pattern of working of specific doctors and differences in approach between different staff which could give rise to conflict. It was decided, therefore, to change the focus of the meeting from business to "personal explorations"; and to symbolise this change, the meeting moved from Dr Clark's office into the recently opened Post Graduate Medical Education Centre, and membership was confined to all doctors who were currently working at Fulbourn.
Such a meeting had to have certain ground rules if it was going to work, and these were clarified over succeeding weeks. This would be a closed group for medical peers without a specific leader or facilitator. This would allow leadership to be shared and moved round the group as appropriate. The focus would be on the exploration of feelings and attitudes in a peer sharing context, and as such would be different from typical therapy groups popular at the time. There would be no set agenda, and members would contribute as the feeling moved them. In this the meeting could be seen as similar to the Quaker ideal. The hierarchical divide of Senior Doctor/Junior Doctor would be replaced by the more experienced/ the less experienced. The content of all meetings would be confidential, and there would be real learning from each other.
Initially, there were doubts about the validity of spending this hour and a half each week. One member calculated the cost in terms of staff salaries! Others were unsure how useful or safe self-disclosure might be, and thought the whole exercise could be seen as self-indulgent or even fulfilling neurotic needs! The proof of the value of these meetings was not a theoretical one, but could only be found through commitment and personal experience.
This was an important time for me, as we looked at what it meant to be a doctor during the 70s and 80s, and particularly what it meant to be a psychiatrist at a time when an assessment should be made of what was going on inside the mental health team in dynamic terms, as well as the conflicts in our patients. At times genuine differences gave rise to powerful feelings which could be defused before they broke through into the clinical arena. I remember vividly how we worked through really traumatic events in the personal as well as professional lives of group members - there were failures to gain expected promotions, divorces, and the distressing deaths of two of us. One colleague died after a road traffic accident and was deeply mourned by the group; but what was even more incredible was the way another member diagnosed with advanced terminal cancer stayed with the group and helped us to anticipate his death, and to go on the journey through his darkness with him. I have not been involved in such a deeply moving learning experience since.
At a more mundane level, being a member of the group helped me personally cope with the responsibilities of being Consultant, for a time, of our Psychogeriatric Unit, when the demand for services for the disturbed elderly was very high: More than we could provide, with the resulting painful conflict with aggrieved general practitioners and angry family members. It was also instructive for younger doctors to hear their older colleagues confess to their anxieties of dealing with violent patients, or of being on call, and, despite years of experience, being stressed by the various demands which being on call made on us. The matters dealt with in the group were as varied as the membership of the group itself.
As new members of staff were appointed - particularly with the advent of the new undergraduate medical school in Cambridge -, a new culture began to emerge. An identification with the therapeutic community movement and a commitment to psychodynamic and psychotherapeutic approaches gave way to a more "scientific" philosophy predicated on the so called "medical" or "organic" view of psychiatry, in which events at the molecular level replaced our emphasis on intrapersonal or even interpersonal events. New members of staff declined to take part, and this meant that the group no longer represented a true corporate view of medical thinking and values among those working at Fulbourn. The potential damaging effect of schisms were recognised by the remaining members of the group, and the decision was taken to disband, however painful and disappointing that was.
However, in retrospect, many of the young trainees at Fulbourn, who are now senior psychiatrists in their own right, will on occasion recall fondly their membership of the Doctors’ Friday Meeting; and they say, among very many things they recall of their time at Fulbourn, how formative of their own views of themselves and of psychiatry in general those meetings were.
Now that I am retired myself from clinical practice in the NHS based at Fulbourn, I have many things and many people to look back on. But standing clear of all the memories, like an Everest towering over lower mountains, I see the Friday Morning Meeting, and consider how much I owe in my own personal development to having been a regular member over some 13 years.