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Burnout in the NHS: what happens when doctors become patients?

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Dr Kevin Teoh, Lecturer in Organizational Psychology, discusses burnout and mental health trends in NHS consultants – which is the subject of a new paper, co-authored with Dr Atir Khan, Dr Juliet Hassard, and Dr Saiful Islam.

Not many days go by where there isn’t any discussion on the current state of our National Health Service (NHS) – whether it is increasing patient demands and numbers, concerns around funding, patient safety, or Brexit. However, as one of the largest employers in the world, the changes across the NHS can have significant ramifications for its workforce. In the press, there is increasing concern about how healthcare staff are coping in light of these changes.

One of the main topics of discussion is burnout, which consists of three components – emotional exhaustion, depersonalisation, and reduced personal accomplishment.

Emotional exhaustion refers to being emotionally drained and exhausted in the workplace, while depersonalisation is a psychological withdrawal from relationships and the development of negative and cynical feelings towards people. Reduced personal accomplishment represents a lack of work effectiveness due to emotional exhaustion and depersonalisation.

But why is burnout in the NHS so important? And what are the factors in the work environment that precede it? We sought to examine these questions in a sample of NHS consultants drawn from England, Scotland and Wales. Consultants represent the most senior and well-trained doctors in the healthcare workforce. Through their role as supervisors and educators, they are also pivotal in the development of the current and future healthcare workforce. Far less is also known about the working conditions of consultants, when compared to their junior doctor and nursing colleagues.

We focused on two aspects of work – work-related pressure and autonomy. The first reflects the workload and pressure that consultants are under, with considerable evidence from other sectors that link it with the health outcomes of workers. The latter actually reflects a potential positive work aspect as high-levels of job autonomy may be beneficial to consultants (and workers more generally). This is because job autonomy gives consultants the flexibility to manage their workload, work on tasks which they find more interesting and problem solve.

In addition to the working conditions and burnout relationship, we also wanted to see how these linked in with staff outcome measures, including the levels of depressive and anxiety symptoms that consultants were experiencing as well as their intention to retire early from the NHS.

The results paint a worrying picture. Out of the 593 consultants who took part, about a third of NHS consultants had poor-levels of psychological health, including emotional exhaustion (38.7%), depersonalisation (20.7%), anxiety symptoms (43.1%), and depressive symptoms (36.1%). These figures not only highlight that our consultants are struggling; they also suggest that poor mental health among consultants has increased in the years since they were last measured.

As expected, both aspects of work that we measured – (high) work related pressure and (low) job autonomy – predicted adverse psychological health. But what are the implications of poor working conditions and burnout among consultants in the NHS?

Our findings suggest that the impact on both severe mental health issues (i.e. symptoms of anxiety and depression) and an intention to retire early. This means that when consultants in the NHS experience high work-related pressure and job autonomy, the subsequent development of burnout could lead to more severe downstream issues.

From a psychological perspective, this does make sense. Consultants struggling in an environment where they have little autonomy and high work-related pressure requires energy and coping resources. Continual exposure then takes a toll on consultants’ psychological resources, which leads to burnout over time, as doctors feel exhausted and they depersonalise from the people around them. When doctors burn out, it exacerbates even further this demand on their psychological resources. What then happens is the manifestation of further mental and physical symptoms, such as the development of depressive and anxiety symptoms. Also, consultants may choose to leave that difficult work environment to protect their remaining psychological resources – which is why we see that when consultants report higher levels of burnout they are also more likely to intend to retire early.

While it is important to note that we did not diagnose actual anxiety and depression in our sample of consultants, the measurement of symptoms is strongly associated with it. Consultants struggling with such symptoms are more likely to be impaired in their performance, which is consistent with the growing research evidence base linking poor mental health among doctors with lower standards of patient care. Should the prevalence of depression and anxiety among consultants go up, it would inadvertently increase the demands on the NHS as doctors become patients themselves.

The intention to retire early is something that should be of concern to us all, especially as the NHS is currently facing a shortage of healthcare staff, including consultants. If consultants do go on to retire early, this would not only reduce the number of doctors in the NHS but would lead to a skills gap in the healthcare service. This might then generate a continuous downward spiral where consultants experiencing poor working conditions burnout, leading to the development of more severe mental health issues and/or early retirement from the NHS. In turn, this further increases the demands on the health service that impacts the remaining consultants, thereby continuing this cycle.

Managers and policymakers need to be aware of the current state of poor psychological health of NHS consultants. They also need to recognise that decisions and changes made to the working conditions of doctors (and healthcare staff in general) not only impact their burnout levels. Where it is not feasible to alleviate some of the work-related pressures, then ways to increase the level of consultants’ job autonomy should be considered.

These findings, along with some of our other research in this area, emphasise the need to address the systematic issues within the work environment that influence the working conditions of NHS consultants. Although more individual-focused interventions, such as resilience training, may have a role to play, on its own this is clearly insufficient. In the UK, there has been limited research looking at interventions to manage the working conditions of doctors. Nevertheless, growing research from elsewhere in the world provide some examples that may be relevant to the NHS here.

Ultimately, as potential users of the NHS, the mental health state of consultants and their working conditions really should be of concern to us all.

The full study, Psychosocial Work Characteristics, Burnout, Psychological Morbidity Symptoms And Early Retirement Intentions: A Cross-Sectional Study Of NHS Consultants In The UK, is published by BMJ Open.

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Using historical evidence to improve conservation science

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In a new paper, Dr Simon Pooley from the Department of Geography argues that moving beyond historical ecology to draw on methods from environmental history is crucial for the field and allied sub-disciplines of ecology like restoration ecology and invasion biology.

As researchers turn increasingly to history as a resource for understanding the trajectory of a planet under unprecedented human pressure, we need to be clear about the methodological challenges of finding and using historical data.

Mainstream ecology recognises the importance of recovering long-term ecological records by applying rigorous methods to the study of charcoal, ice cores, pollen and tree rings. The uses of historical textual and graphic sources are seldom accorded analogous rigour.

Ecologists use scientific methods to learn from the past, drawing on resources developed by historical ecologists to source data and assemble it into time series, predicting fluctuations and trends in variables over time.

Recently, interest in the impacts of human actions on earth systems has led scientists to aggregate data on generalised human perturbations like greenhouse gas emissions or the industrial manufacture of fertilizers. They then compare these with variables tracking impacts on related earth systems like earth surface temperatures and ocean acidification.

For environmental historians, the resulting framings of relationships between human agency and earth systems are often too linear and generalised. Further, historians urge analysts to pay closer attention to the contextual factors shaping data production, rather than dip uncritically into ‘the past’ as a ‘goody bag’ of useful facts.

This paper is aimed at ecologists rather than historians; it aims to communicate some of the major considerations they should be aware of when collecting and interpreting historical data. These can be handily divided into four themes, summarised as questions:

  • Why, how, and by whom were the data collected?
  • How were the data measured (relating to time periods and spatial units in particular)?
  • What conceptual filters shaped data collection and interpretation?
  • What anomalies, exceptional events and human influences shaped data collection?

The paper notes that the purposes for which data were initially collected, and by whom they were collected, using which methods and tools, all importantly shape what is (and is not) collected and in what form. Long time-series often combine datasets shaped in different ways in accordance with all these factors. A simple example is that, beginning in the late sixteenth century, the Gregorian calendar was adopted sporadically across Europe over several centuries, and then in parts of Asia and elsewhere in the late 1800s and early 1900s. In each instance, days were won or lost as regional or national calendars were adjusted accordingly.

The reporting periods used by institutions vary (and change) and researchers compiling time series must take these changes, and ‘longer’ and ‘shorter’ years used to adjust to new reporting cycles, into account when incorporating their data.

And of course datasets should never be taken at face value: whale catch data published by Russia and Japan in the postwar period, for instance, should be treated with due scepticism.

In the 1970s, mathematical models were devised to estimate historical (baseline) saltwater crocodile populations in northern Australia, as a means for judging when conservation measures introduced early in that decade had resulted in an adequate recovery to pre-exploitation levels. However, when a series of attacks followed an unexpectedly quick population recovery, public opinion demanded a rethink of models which calculated that these populations were will still at only 2% of their historical size.

Northern Territory researchers consulted historical records and interviewed former hunters, discovering that pre-exploitation crocodile population densities had varied significantly from river system to river system. According to their revised estimates, populations were at 30-50% of pre-exploitation levels, sufficient to allow controlled sustainable use of crocodiles. This resulted in a policy shift which has proven to be a successful long-term management approach in the region.

The ways in which underlying theories and conceptual frameworks shape data collection are challenging to work out. Examples include powerful narratives about desertification and deforestation which shaped how colonial foresters and agricultural experts interpreted landscape change and management in the colonies in which they worked. Ideas about fire, forests and rainfall long shaped expert thinking about landscape change in India, Madagascar and many parts of Africa, and arguably still influence management interventions aimed at changing or preventing traditional practices by local peoples. In India, ideas about degradation through burning still guide management of savannas, which are arguably misclassified as degraded woodlands.

The four themes identified in my paper are discussed in the text in relation to a schematic figure. Of course, any such visualisation conceals considerable complexity, but it provides a useful framework for exploring some of the challenges. The paper gestures to some of these further complexities through examples from my monograph Burning Table Mountain: an environmental history of fire on the Cape Peninsula (Palgrave 2014; UCT Press 2015) and a recent paper on fire and expertise in South Africa (Environmental History 23:1, 2018). These examples show some ways in which published theories don’t always match the authors’ recommendations for management in the field, or the results of experimental science are ignored in the face of powerful narratives about ecological phenomena like fire, soil erosion and drought. Finally, they demonstrate how complex factors – social, economic, cultural – combine in diverse ways to shape whether and how scientifically informed policies are implemented.

The paper concludes by arguing that the use of historical approaches as summarised in its accompanying figure can help improve the accuracy of the data we draw on to do important conservation work like estimate the conservation status of ecosystems or species, or prioritise conservation action. At a deeper level, historical methods allow us to tease apart the many interacting factors which shape policy and management and influence their interrelations with other narratives, knowledge systems and priorities in particular contexts, over time.

The paper is available (open access) with supporting figure and references in Conservation Letters.

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Eyes in the back of their heads?

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Is educational neuroscience all it’s cracked up to be? In a keynote speech at the London Festival of Learning, Professor Michael Thomas argues it can be used to provide simple techniques to benefit teaching and learning, and that in future machine learning could even give teachers eyes in the backs of their heads.

I could perhaps have been forgiven for viewing with some trepidation the invitation to address a gathering of artificial intelligence researchers at this week’s London Festival of Learning. At their last conference, they told me, they’d discussed my field – educational neuroscience – and come away sceptical.

They’d decided neuroscience was mainly good for dispelling myths – you know the kind of thing. Fish oil is the answer to all our problems. We all have different learning styles and should be taught accordingly. I’m not going to go into it again here, but if you want to know more you can visit my website.

The AI community sometimes sees education neuroscience mainly as a nice source of new algorithms – facial recognition, data mining and so on.

But I came to see this invitation as an opportunity. There are lots that are positive to say about neuroscience and what it can do for teachers – both now, and in the future.

Let’s start with now. There are already lots of basic neuroscience findings that can be translated into classroom practice. Already, research is helping us see the way particular characteristics of learning stem from how the brain works.

Here’s a simple one: we know the brain has to sleep consolidate knowledge. We know sleep is connected to the biology of the brain, and to the hippocampus, where episodic memories are stored. The hippocampus has a limited capacity – around 50,000 memories- and would fill up in about three months. During sleep, we gradually transfer these memories out of the hippocampus and store them more permanently. We extract key themes from memories to add to our existing knowledge. We firm up new skills we’ve learnt in the day. That’s why it’s important to sleep well, particularly when we’re learning a skill. This is a simple fact that can inform any teacher’s practice.

And here’s another: We forget some things and not others – why? Why might I forget the capital of Hungary, when I can’t forget that I’m frightened of spiders? We now know the answer – phobias involve the amygdala, a part of the brain which operates as a threat detector. It responds to emotional rather than factual experiences, and it doesn’t forget – that’s why we deal with phobias by gradual desensitisation, over-writing the ‘knowledge’ held in the amygdala. Factual learning is stored elsewhere, in the cortex, and operates more on a ‘use it or lose it’ basis. Again, teachers who know this can see and respond to the different ways that children learn and understand different things.

And nowadays, using neuroimaging techniques, we can actually see what’s going on in the brain when we’re doing certain tasks. So brain scans of people looking at pictures of faces, of animals, of tools and of buildings show different parts of the brain lighting up.

A figure representing human-rated similarity between pictures is available here:

The visual system is a hierarchy, with a sequence of higher levels of processing – so-called ‘deep’ neural networks. At the bottom level (an area called V1), brain activity responds to how similar the images are. It might respond similarly to a picture of a red car and a red flower, and differently to a picture of a blue car. Higher up the hierarchy, the brain activity responds to the different categories images are in (for example, in the inferior temporal region). Here, the patterns for a red car and a blue car will look more similar because both are cars, and different to the pattern for a red flower. This kind of hierarchical structure is now used in machine learning. It’s what Google’s software does – Is it a kitten or a puppy? Is John in this picture?

Again, teachers who know that different parts of the brain do different things can work with that knowledge. Brain science is already giving schools simple techniques – Paul Howard Jones at the University of Bristol has devised a simple three-step cycle to understand how the brain learns, based on what we now know: Engage; Build, Consolidate.

But there’s more – by bringing together neuroscience and artificial intelligence, we can actually build machines which can do things we can’t do. At a certain level, the machines become more accurate at doing things than humans are – and they can assimilate far greater amounts of information in a much shorter time.

I can foresee a day – and in research terms it isn’t far off – when teachers will be helped by virtual classroom assistants. They’ll use big data techniques – for example, collecting data anonymously from huge samples of pupils so that any teacher can see how his or her pupils’ progress matches up.

In future, teachers might wear smart glasses so they can receive real-time information – which child is having a problem learning a particular technique, and why? Is it because he’s struggling to overcome an apparent contradiction with something he already knows – or has his attention simply wandered? Just such a system has been showcased at the London Festival of Learning this week, in fact.

Of course, we have to think carefully about all this – particularly when it comes to data collection and privacy. But it’s possible that in future a machine will be able to read a child’s facial expression more accurately than a teacher can- is he anxious, puzzled, or just bored? Who’s being disruptive, who’s not applying certain rules in a group activity? Who’s a good leader?

This is not in any sense to replace teachers – it’s about giving them smarter information. Do you remember how you felt when your teacher turned to the blackboard with the words: ‘I’ve got eyes in the back of my head, you know?’ You didn’t believe it, did you? But in future, with a combination of neuroscience and computer science, we can make that fiction a reality.

This blog was first posted on the IOE London blog. 

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Histories of bioinvasions in the Mediterranean

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Dr Simon Pooley, Lambert Lecturer in Environment (Applied Herpetology) at Birkbeck discusses ‘bioinvasions’  – the phenomenon of plants, animals and microbes being introduced more frequently into new regions – which is the subject of his new book, co-edited with Ana Isabel Queiroz.

Bioinvasions, a global environmental problem of anthropogenic origin, have been studied mainly by the natural sciences. However, it is widely acknowledged that it is also important to understand the human dimensions of bioinvasions. The book brings together environmental historians and natural scientists to produce historical narratives of bioinvasions, drawing on a bricolage of sources and methods. Central to our endeavours is our recognition that temporal and spatial scales are crucial variables in all narratives which attempt to explain the movement of invasive species across ecosystems and landscapes.

This book has three overarching aims: first, to provoke natural scientists working on bioinvasions to think more historically; second, to convince environmental historians to engage with the science of bioinvasions; and third, through sharing the research presented in this book, to convince them all of the richness of the research materials and themes and the importance of the issues, and so stimulate interdisciplinary collaborations on bioinvasions.

So, why focus on the Mediterranean region? Primarily, it is because of the antiquity of human and ecological relations in the region, notably regional (and from the fifteenth century, global) maritime communications and trade. While historians have studied the impacts of European trade and invasive plants, animals and diseases elsewhere on the planet, they have paid less attention to the reverse flow. The introductions of some well-known naturalised (non-invasive) plants such as tomatoes, potatoes, tobacco and citrus, are better known.

Of course, as the eminent environmental historian J. Donald Hughes has remarked, the Mediterranean region is a somewhat fuzzy concept, and has been defined differently depending on whether scholars have chosen biophysical, political or cultural variables and definitions. In our usage, it includes the entirety of the Mediterranean Sea, and terrestrially, the Mediterranean-type climate (MTC) region surrounding this sea.

This biophysical framework should not obscure how this region has been transformed by human actions—from agriculture to herding, burning to hunting and deforestation. Such is the scale and diversity of such influences, over millennia, that the region represents an archetypal landscape where humans and their physical and biotic environments have coevolved.

Our book includes historical case studies which collectively contribute towards a history of bioinvasions in the Mediterranean region. The histories of marine invasions best fit this aspiration, in taking in the full sweep of the Mediterranean Sea. Some of the remaining chapters are perhaps more histories in than of the region, but they all offer insights into the histories and processes of invasion in the region which share commonalities across a diversity of ecological and cultural contexts. In addition to climatic and topographical factors, and longer-term geological processes, these include: seaborne exploration, colonisation, communication and trade; the impacts of agriculture, forestry and pastoralism; and the convergent evolution of the flora in response to human disturbances, notably land clearing and burning.

Histories of bioinvasions undermine notions of timeless continuities or geographical or environmental determinism. They feature an array of introduced species from across the globe’s oceans and shores, following diverse invasion pathways facilitated by unexpected vectors, imported for numerous purposes (or accidentally). Just possibly, in aggregate, bioinvasions herald a terminal disruption of the ecological coherence used to define a ‘Mediterranean basin’ region. So, this book offers both an argument for thinking in terms of a Mediterranean region, and offers a warning of its fragility, conceptually and physically.

Our book features nine case studies of bioinvasions from the plant and animal kingdoms, encompassing marine, freshwater and terrestrial environments. These include an overview of all marine bioinvasions, a chapter focussing on invasive marine and freshwater decapods (crayfish, crabs and prawns), terrestrial invasions by Argentine ants and waxbills, invasions of islands by reptiles, amphibians and Australian plants, invasions of coastal salt marshes by cord grasses, and of freshwater waterways by African clawed frogs. These invasive species have been transported from around the globe or internally within the Mediterranean region. My own chapter includes a section on the important role of fire coupled with invasive introduced plants in Mediterranean ecosystems. It also adds a comparative look at South Africa’s Mediterranean climate region, and the history of invasions of its unique fynbos biome, examining the reasons for introductions, and cultural, political and scientific responses to their social and environmental impacts. The chronological range of this collection extends from the Neolithic and the Bronze Ages through Classical times, the ages of European maritime discovery, to the present.

Ana Isabel Queiroz (NOVA-FCSH, Lisbon) and I (the editors) are grateful for the enthusiasm and patience of the scientists among our contributors in working through many exchanges and versions to steer their work towards more historical writing. The material reads unevenly as history, in parts, but we feel the gains are substantial. In the course of editing this book, we have noted some interesting gaps in historical knowledge. For example, our knowledge of the chronology of introductions and spread of species prior to the twentieth century is surprisingly imprecise. Awareness of most of these invasions has come surprisingly late, with most discoveries and interventions described here occurring in the late twentieth or early twenty-first centuries.

In our Introduction to the book, Ana and I highlight promising avenues for further research by environmental historians. For instance, too little is known about some major pathways of invasion (notably maritime) into Mediterranean Europe, and historians have paid scant attention to invasions from species moved around within the region. There is interesting work to be done on the role of empires and their collapses, and resulting movements of humans and biota, in the introduction of invasive species. Comparative histories of management interventions and their outcomes could provide important contextual information for attempts to control bioinvasions in the region. It seems that shrubs of the region survive or recover from anthropogenic disturbances, and on the whole resist invasions by plants introduced from the other Mediterranean climate regions, possibly (as ecologist Jon Keeley has argued) because of the long history of coevolution of humans with the local biota. An exception is the western Iberian region, and it would be useful to have environmental histories of the introduction and spread of Australian trees and shrubs in this region. Finally, there are fascinating opportunities to synthesise histories of the colonisation of the region by the terrestrial fauna after humans arrived on the scene.

Histories of Bioinvasions in the Mediterranean ed. Ana Isabel Queiroz and Simon Pooley, is available now from Springer.

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