Myers and medicine
C HARLES Myers (1873–1946) had a formidable range of talents. After
a double first in natural sciences at Cambridge, and then graduating as
a doctor at Bart’s, he went on an expedition to the Torres Straits
where he was one of the first practitioners of ethnomusicology
(Clayton, 2000). He wrote one of the first textbooks of experimental
psychology, helped found the British Journal of Psychology and the
Experimental Psychology Laboratory in Cambridge, described the syndrome
of ‘shell shock’ while working as a psychiatrist in the First World
War, and afterwards set up and directed the National Institute of
Industrial Psychology. As T.H. Pear, the founding Professor of
Psychology in Manchester, said so eloquently:
Myers was unusually many-sided: doctor, anthropologist, musician,
Alpinist, traveller. Few psychologists had seen so many places. Though
a fine experimentalist, he never believed that the most important
things in life could be experimentally investigated or measured. There
would never have been any need to remind him that all human psychology
is social psychology or that society is made up of individual persons.
(cited in Costall, 2001, p.191)
I cannot help but feel an affinity with Myers. Like Myers I originally
studied medicine and qualified as a doctor, although an intercalated
psychology degree (in the Cambridge department which Myers had founded)
moved my primary interest from medicine to psychology. With him I share
an interest in experimental aesthetics, in left-handedness, and in
statistical methods, and we have both been presidents of the Psychology
Section of the British Association. Although I also share his love of
travel, I do regret not having his ‘ready acquisition of foreign
languages’.
After the First World War, when Myers could readily have continued in
academia for the rest of his life, he instead chose to leave Cambridge
and the university to set up the National Institute for Industrial
Psychology in London, which was devoted to addressing psychological
problems arising from work and employment. Myers would have seen rich
research pickings in modern medicine, and he would have well
appreciated that this would not only benefit psychology as a scientific
discipline, but would also have beneficial, practical aspects for
medicine itself, and through medical practice, for patients. Myers did
not believe in an artificial distinction between pure and applied
science, and wrote: ‘I came to share Pasteur’s view –
“Il n’y a pas des sciences appliqués; il y a les sciences et les
applications des sciences” [There are not applied sciences; there are
only sciences and the application of sciences]’ (Costall, 1998).
In 1933 Myers gave the distinguished Bradshaw Lecture at the Royal College
of Physicians in London with the title ‘A psychological regard of
medical education’, and I have taken this as my inspiration. Much of my
own professional life has been spent using the techniques of psychology
to study medicine, and in particular to study medical students and
medical practitioners themselves. The work has covered many areas, from
student selection, undergraduate training, career choice, and
postgraduate assessment, to the effect of the stress and anxiety
experienced by junior doctors on duty in the night on operative
performance. I hope to give you an overview here.
A neglected practice
If this article has a single, clear message I hope it is the
realisation that medical practice has been neglected by psychologists.
By that I am not referring to any lack of work or interest in clinical
psychology or health psychology, for both disciplines have made superb
progress in the past three decades, to the great benefit of patients.
Instead I mean a neglect of the study of medical practitioners
themselves. The doctor–patient relationship is at the core of much
medicine, but while patients are studied in depth there is little study
of the other half of the equation. And yet doctors and medical students
are potentially a wonderful group for eliciting and answering a wide
and rich range of issues for psychology: not only clinical questions,
but also educational, social and cognitive issues.
Each year in the UK about 6000 medical students enter universities.
They have remarkably similar entry qualifications, they have a
remarkably homogeneous course (overseen by the General Medical
Council), they mostly practise for a monopolistic employer, the
National Health Service, they have their postgraduate and continuing
education overseen by Royal Colleges (who administer carefully
standardised examinations), and most doctors stay within the NHS for
their entire working lives. Doctors’ jobs within the NHS are complex
and varied, with wide-ranging technical skills, as in surgery or
interventional radiology. Roles involve complex, multidisciplinary
teamwork, and complex cognitive tasks, such as diagnosis, often coupled
with extensive research skills. Doctors’ jobs also require subtle and
empathic communication with patients, sometimes in difficult,
life-threatening situations, which inevitably impose stresses upon the
doctors themselves. Doctors, in other words, are the perfect model for
studying professions and professionalism in all their manifestations,
from tyro through to expert.
Almost everything in which psychologists are interested – social,
cognitive, educational and occupational – can be found happening in
medicine at a high level of performance and on a daily basis. For an
educational psychologist there are rich pickings indeed, allowing
assessment of the nature of student selection, the short- and long-term
impact of education, differences in attitude towards learning, the
validity of examinations, and the effects of different universities, of
different departments, of different courses, and indeed of different
teachers upon students. Compare that with the problems of studying
psychology students (which I have sometimes been asked to do).
Psychology students enter university with many different qualifications
and for many different reasons, they study different modules throughout
their much shorter courses, the majority do no postgraduate study,
there are no common examinations, and at the end of their courses they
scatter to the four winds into a myriad different employments where it
is nigh on impossible to follow them up.
Studying stress and burnout
A growing research interest for me in recent years has been the
effectiveness and the happiness of doctors. Everyone, patients and
doctors alike, wants doctors to be effective and happy. However some
doctors are ineffective, some are unhappy, and a few are both
ineffective and unhappy. The question is why, and what can be done
about it. My emphasis here will be almost entirely on the issue of
happiness, and its obverse of stress and burnout. Perhaps the only
important thing to say about effectiveness is that the main predictor
of effectiveness – at least conceptualised as the ability to pass
examinations and acquire a high level knowledge of modern clinical
medicine – is A-level grades. But A-level grades in particular and
academic performance in general do not predict stress, burnout or
happiness in doctors. There is simply no support for the idea that some
doctors are unhappy because they are too clever, too able or too
thoughtful for the sometimes mundane realities of daily life as a
physician (McManus et al., 2003). The brightest, the best and the most
knowledgeable of doctors can always find much to learn from patients,
even in the seemingly most routine of cases.
Understanding the careers of doctors requires longitudinal data if it
is to be successful; and such longitudinal data can only be acquired
over long periods of time. Needless to say, it is not easy to persuade
funding bodies to commit large sums of money over long periods of time,
when their primary interests are short term, and their financial base
insecure. Over the past 25 years we have carried out the only three
large-scale, prospective studies of medical student selection and
training in the UK (McManus & Richards, 1984; McManus et al., 1989;
McManus et al., 1995). The most recent started in autumn 1990 and
provided data on thousands of people throughout the subsequent 12 years
of their medical careers, including data from nearly 40 per cent of our
cohort on their performance in the exam for membership of the Royal
Colleges of Physicians in the UK.
The scope for linking in other data sources as this cohort progresses
through their careers is enormous. Like any cohort study, the dataset
is complex, with not all individuals completing all assessments at all
occasions. But the potential for answering difficult, important and
interesting psychological questions is unparalleled, not least because
it is only longitudinal data that ultimately can provide answers to
questions about causality.
Consider the issue of stress and burnout. In our study we measured
stress levels using the GHQ-12, and burnout with an abbreviated version
of the Maslach Burnout Inventory, at the end of the pre-registration
house-officer (PRHO) year.
All doctors know that PRHO posts are a gruelling, hard year (and one of
my first medical education studies – McManus et al. (1977) – looked at
it using a mixture of quantitative and qualitative techniques), yet it
was clear that there was a wide range of responses. Some doctors were
indeed very stressed, very emotionally exhausted, very depersonalised,
and had little sense of personal accomplishment; but many were not.
Why?
If asked, most doctors will say that it is the workload of the PRHO
posts that is stressful. And yet in our study we had asked about
working hours, the number of patients admitted, the hours of sleep
obtained when on call, and so on. None of those measures of workload
correlated with stress levels. That result was so surprising that a
major medical journal rejected our study on the basis of, as an editor
asked, ‘How can it not be the case that stress is related to working
conditions?’.
The fact that stress was not related to working conditions in our data
was confirmed using multilevel modelling, for data such as these are
inherently multilevel. PRHOs work for a particular team of consultants;
the consultants are grouped together in hospitals; the hospitals are
grouped together into trusts; and the trusts are overseen by
postgraduate deaneries. Because of the large number of doctors in our
study, many had done the same PRHO posts, and we could therefore
partition the variance in levels of stress between doctors, consultant
firms, hospitals, trusts and deaneries. The result was very clear:
there was simply no variance in reported stress or burnout due to
consultant firms, hospitals, trusts or deaneries. That was not because
of a lack of statistical power (and indeed we readily found effects of
consultant firms and hospitals for many other aspects of the posts),
but those levels of variance simply did not affect stress or burnout.
To put it at its simplest, two doctors doing exactly the same PRHO post
were no more similar in their stress levels than two doctors working
for different consultants, in different hospitals, in different trusts
and under different deaneries. The variation in stress is mainly a
function of differences between doctors and not in differences in
working conditions (McManus, Winder & Paice, 2002).
Stress has long been known to be related to personality, and in
particular to the personality dimension of Neuroticism. We soon found
that the same was true of our PRHOs. An abbreviated Big Five
personality measure showed that those
with the highest stress and burnout measures had higher neuroticism
scores, were more introverted, were less conscientious and were less
agreeable. Exactly the same correlations were found when we looked at
the stress levels of the same group of doctors, five or six years later
in 2002/3 (and we had also found it
in an entirely different set of more mature doctors – McManus et al.,
2003). Of particular interest was a high correlation between stress
levels as PRHOs and the stress levels in 2002/3, when the doctors were
in entirely different jobs. Unless one wishes to believe that stressed
doctors keep choosing unsatisfactory jobs, then the most reasonable
interpretation is that stress is primarily a characteristic of doctors
rather than of jobs.
What comes after stress?
Stress and burnout are not merely outcome measures in longitudinal
studies such as these. They are input measures too – being stressed or
burned out today will affect how an individual does things tomorrow.
Although the terms stress and burnout are mostly used interchangeably
(and there is little doubt that they are highly correlated
statistically), they are separable conceptually, with the main thrust
of burnout being that it relates specifically
to the job itself. Stress is a more generic condition in which
individuals have a higher risk of depressive or anxiety disorders,
conditions which influence the whole of mental life. The causal
relation between stress and burnout is not easy to tease apart in
cross-sectional studies, but longitudinal studies allow causality to be
inferred. Path analysis of longitudinal data from our study suggests
that the main engine driving stress is emotional exhaustion; emotional
exhaustion makes doctors stressed and stress makes doctors emotionally
exhausted. More controversial are the effects of depersonalisation.
Depersonalisation, the treating of patients as objects rather than
people, seems to decrease subsequent stress. Depersonalisation, while
bad for the patient, can nevertheless be seen as a response that for
the doctor is adaptive, reducing the immediate likelihood of stress
responses. Likewise, a sense of personal accomplishment, while
correlated with lower stress in cross-sectional studies, in
longitudinal data is correlated with higher stress. A sense of
achievement is good for a doctor but it is potentially bought at the
price of greater risk of emotional exhaustion and stress (McManus,
Winder & Gordon, 2002).
Although stressed doctors are unhappy (and also, as we will see later,
regret having become doctors, get little personal pleasure from being
doctors, and frequently think of leaving medicine for another career),
they also continue to work as doctors. We need to know how their
approach to work, to learning through work, and to working with
colleagues is affected by stress and by other variables. The full
complexity of the longitudinal data is presented elsewhere (McManus et
al., 2004 – see weblinks), but here I want to describe the relationship
between stress, the Big Five personality measures mentioned earlier,
and the learning and working styles of doctors.
Approaches to learning matter for doctors, as they do for all
professionals who must continue to develop themselves professionally
throughout long and busy working lives. Much learning occurs on the
job, and doctors differ in their approaches to work, and how they
perceive their working environment. Recent work by Dianne Delva and her
colleagues in Canada (Delva et al., 2002) has developed effective
questionnaires for assessing both approaches to work and learning, and
the workplace environment. Learning styles have also been much studied
in undergraduates, and our work has adapted the typology of Biggs (Fox
et al., 2001), with its measures of surface, deep and strategic
learning.
The interrelations between these measures are complex; but then to
expect that social phenomena would be simple would be simplistic. We
have developed
a path model for the relationships between personality, learning
styles, stress, approaches to work and the work environment (McManus et
al., 2004).
Here is a summary of the key relationships.
l Extraversion, and particularly Openness to
Experience, drive a deep learning style at university, which drives a
deep approach to work – integrating different areas and new ideas,
seeking personal understanding. That results in choice and independence
in the working environment – control over what one does and how one
does it.
l The effect of Conscientiousness is
to encourage a strategic approach to learning at university – using
whatever methods are successful, even if this results in patchy
understanding.
A surface approach to learning at university (which in part is a
maladaptive strategy to examination failure – Tooth et al., 1989) can
result
in either a surface-rational approach
(a liking for order, detail and routine)
in the workplace in those with high conscientiousness, or a
surface-disorganised approach (overwhelmed, with poor time management
and little understanding) if conscientiousness is low, with the latter
then driving a perceived high workload.
l Neuroticism’s effect is to drive stress, which then
goes on to produce a surface-disorganised approach to work, a high
perceived workload, less choice-independence, and a less
supportive-receptive work environment.
l The effect of Agreeableness is simple: agreeable
individuals report that they find their working environment more
supportive and receptive than those
who are less agreeable. That is hardly unexpected, but it makes much sense.
Room for all
I like to think that Myers, some time a doctor and always a
psychologist, would have found much to excite and stimulate him in
studies such as these, but he would also have found much about which to
be careful. In particular, he would not have jumped to the easy
conclusion that some have taken from our results, that medical school
selectors should merely choose doctors with low N and high E, C, A and
O. Medicine is a broad church, and needs many personality types. A
better response to data such as ours is probably to help individuals to
be aware of their own personality strengths and weaknesses, and to have
careers which develop those strengths and avoid the weaknesses.
Physician, know thyself!
- Chris McManus is Professor of Psychology and Medical Education at University College London. E-mail: [email protected].
Weblink
McManus et al. (2004) BMC Medical article: www.biomedcentral.com/1741-7015/2/29
Discuss and debate
Should personality measures be used in the selection of medical students?
How important is diversity of personality in a profession such as medicine?
How well can different personalities learn to respond better to stressful environments?
Have your say on these or other issues this article raises. Send
letters to [email protected] or contribute to our online
discussion forum via www.thepsychologist.org.uk.
References
Clayton, M. (2000, June/July). Charles Samuel Myers: Forgotten
pioneer of ethnomusicology. International Conference on
Nineteenth-century music, Royal Holloway, University of London.
Costall, A. (1998). From the ‘pure’ to the ‘applied’: C.S. Myers and
British psychology. Revista de Historia de la Psicologia, 19, 143–163.
Costall, A. (2001). Pear and his peers. In G.C. Bunn, A.D. Lovie &
G.D. Richards (Eds.) Psychology in Britain: Historical essays and
personal reflections (pp.188–204). Leicester: BPS Books.
Delva, M.D., Kirby, J.R., Knapper, C.K. & Birtwhistle, R.V. (2002).
Postal survey of approaches to learning among Ontario physicians:
Implications for continuing medical education. British Medical Journal,
325, 1218.
Fox, R.A., McManus, I.C. & Winder, B.C. (2001). The shortened Study
Process Questionnaire: An investigation of its structure and
longitudinal stability using confirmatory factor analysis. British
Journal of Educational Psychology, 71, 511–530.
McManus, I.C., Keeling, A. & Paice, E. (2004). Stress, burnout and
doctors’ attitudes to work are determined by personality and learning
style: A twelve year longitudinal study of UK medical graduates. BMC
Medicine, 2, 29.
McManus, I.C., Lockwood, D.N.J. & Cruickshank, J.K. (1977). The
pre-registration year: Chaos by consensus. The Lancet, i, 413–417.
McManus, I.C. & Richards, P. (1984). An audit of admission to
medical school: 1. Acceptances and rejects. British Medical Journal,
289, 1201–1204.
McManus, I.C., Richards, P. & Maitlis, S.L. (1989). Prospective
study of the disadvantage of people from ethnic minority groups
applying to medical schools in the United Kingdom. British Medical
Journal, 298, 723–726.
McManus, I.C., Richards, P., Winder, B.C., Sproston, K.A. & Styles,
V. (1995). Medical school applicants from ethnic minorities:
identifying if and when they are disadvantaged. British Medical
Journal, 310, 496–500.
McManus, I.C., Smithers, E., Partridge, P., Keeling, A. & Fleming,
P.R. (2003). A levels and intelligence as predictors of medical careers
in UK doctors: 20 year prospective study. British Medical Journal, 327,
139–142.
McManus, I.C., Winder, B.C. & Gordon, D. (2002). The causal links
between stress and burnout in a longitudinal study of UK doctors. The
Lancet, 359, 2089–2090.
McManus, I.C., Winder, B.C. & Paice, E. (2002). How consultants,
hospitals, trusts and deaneries affect pre-registration house officer
posts: A multilevel model. Medical Education, 36, 35–44.
Tooth, D., Tonge, K. & McManus, I.C. (1989). Anxiety and study
methods in pre-clinical students: causal relation to examination
performance. Medical Education, 23, 416–421.
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