David Oliver: Has the term “front line” had its day?

The March issue of the London Royal College of Physicians’ Commentary included an excellent essay by Derek Macallan, an infectious diseases specialist, arguing that it was time to stop using the term “front line” in a medical context. The piece finished by asking what, if anything, could replace it.1

Macallan made his case in the context of the pandemic medicine many of us have practised for a year or so. He was concerned that battle metaphors mis-described our roles in caring professions, that they gave an inadvertent message that self-sacrifice and acceptance of personal risk were part of our professional identity, and that being “on the front line” of a “battle” could be used to legitimise an unacceptable drop in standards of conduct, care, or communication.

Similarly, in discussions of burnout or moral distress23 in healthcare professionals who can’t deliver the desired standard of care because of workload, resource, and staffing constraints, some have argued against using the term “moral injury.”45 It originally referred to people in military combat or emergency service roles who sometimes have to kill or harm others and are at risk of death or serious injury in the course of their work.6 Short of working in war zones, doctors and other clinical staff are mostly not in that group. And, Macallan argued, while clinical staff have been at higher personal risk of catching or dying from covid than other groups, the mentality should be one of adequate precautions and equipment to minimise risk, rather than reckless bravery and self-sacrifice.

Another common term, “coalface,” is also problematic. Traditional mining is a dangerous and physically demanding job, done in hostile conditions, that puts employees at significant risk of work related diseases. You could argue that this term is an insult to miners, although my description doesn’t sound a million miles away from aspects of NHS work.

I do have great sympathy with Macallan’s reasoning, but I’ll offer some friendly counterarguments. First, there should be a way to differentiate those who do hands-on, patient facing clinical work from the rest of the workforce. This is not to disparage other important groups. But the core business of healthcare—the one most visible to patients and the public, with the greatest emotional burden for staff—is direct clinical care for people who are sick, frightened, distressed, or dying, and for whom our actions and omissions have direct and palpable consequences. Similarly, combat troops, firefighters, police officers, and fishermen rely on people in other support jobs, but the exposure to personal risk is theirs.

Second, in pandemic medicine, data clearly show that staff in clinical areas caring for patients with covid-19 have had a much higher risk of contracting covid-19, being admitted as patients, or even dying than other healthcare staff.78

Third, these clinical and caring roles can’t be carried out remotely. They require physical presence in the room with the patient. Even if we can minimise personal risk—much like the firefighters, police, or armed forces, with the right equipment and procedures—we stand to be traumatised. We see at first hand the distress, death, fear, and grief of patients and families, and we were overwhelmed by the sheer volume of very sick patients at the peak of the pandemic, especially in services that went well beyond normal capacity, such as intensive care.

Fourth, a “them and us” divide persists, as seen in endless stories of staff failed by inadequate access to personal protective equipment or testing, by staffing gaps, by unsupportive management cultures, or by incompetence and mendacity higher up the NHS management chain.910

The public and press understand that there’s something different about staff who put their physical and psychological welfare on the line and take on the unique responsibilities of clinical and care staff. We shouldn’t be ashamed of this. “Front line” is snappy, effective shorthand. I share the reservations about it but, like Macallan, I’m not sure that another term works better.