sBMJ | Making happy doctors

Making happy doctors

Medical students must receive regular, structured, and constructive appraisal to detect unhappiness and promote effective change, argue Ed Peile and Yvonne Carter

Unhappy doctors often underperform,¹ and by depressing morale in the workplace, they exert a negative influence on recruitment and retention, which are pressing problems in the NHS.² Everything we can do to promote contentedness at work is therefore a worthwhile endeavour in the interest of patients.

Much of the difference in the ways that doctors approach work and perceive the climate at the workplace is a reflection of stable long term individual differences in the doctors themselves.³ In a comprehensive questionnaire study, which included measures of approaches to work, workplace climate, stress (general health questionnaire), burnout (Maslach burnout inventory), and satisfaction with medicine as a career as well as the Big Five personality inventories, McManus et al obtained data on 1668 medical graduates, 12 years after they had entered medical school. They were able to relate doctors' present perceptions of the workplace climate to differences in measures of personality and learning style, which were already evident at medical school entry, and remained fairly stable when measured again in the final year at medical school and five years later in working doctors. Stress, burnout, and satisfaction also correlate with trait measures of personality taken five years earlier. Neuroticism for example, is a stable trait. It is unrelated to learning styles, but it is a predictor of a surface disordered approach to work, of a perceived high workload in the preregistration house officer year, and of stress. Traits such as extravertness, being open to experience, and agreeableness seem to confer advantages at work.³

We should not allow a cop-out for workplace environments where systemic conditions result in high levels of reported stress among doctors. But we should take note that it may be possible to partially predict which people will find the medical workplace particularly stressful, and we should be concerned that these people may be more prone to burnout as doctors.

The implications of these findings are far reaching. Should we be attempting to select happier doctors by routinely assessing personality profiles and learning styles at entry to medical school? Evidence shows that validated instruments such as Myers-Briggs profiles have predictive value for choice of specialty⁴ and learning styles inventories for success in a medical career. ⁵ But before we replace all admissions tutors by psychometricians, we should perhaps consider how far we can extrapolate from present evidence. Although the work by McManus et al has shown stability for predictive traits over time,³ can we be sure that we should be offering the same profiling tests to mature entrants as to school leavers? How do we rank the “right stuff” personality profiles against evidence of scientific ability or empathetic disposition? How do we ensure that potential entrants, assessed at a time when they have been “going through a bad patch” in respect of temporary problems in their personal lives affecting their mood and outlook, are not unfairly disadvantaged?

So if we lack the confidence in our social engineering skills to populate medical schools exclusively with easy going, contented students, what can we do to support those who struggle and those who encounter dips in their mood? Approaches that apply equally to the undergraduate in medical school as to the doctor already in the workplace would seem appropriate.

At the behest of the General Medical Council, procedures to ensure fitness to practise operate in all medical schools in the United Kingdom,⁶ where committees are given the task to decide whether health or conduct disorders are likely to interfere with safe effective practice. Because livelihoods are at stake, practitioners and students rarely report to such committees, and mental health problems are often concealed. This situation might be improved if fitness to practise committees were seen as more supportive, and earning a reputation for facilitating institutional help for students experiencing difficulties with mental or physical health. The need to debar from practice is rare and, like employers in the workplace, medical schools have responsibilities under the Special Educational Needs and Disabilities Act (SENDA) to support students with conditions that have substantial and long term adverse effects on the ability to carry out normal day to day activities; this includes mental health conditions such as depressive illnesses.⁷

The 2004 annual scientific meeting of the Association for the Study of Medical Education considered ways of assuring more equity across medical schools in fitness to practise procedures,⁸ a topic which is also being actively debated by the Council of Heads of Medical Schools and GMC. We could develop models of best practice, informed by reliable longitudinal evidence about the likelihood of students achieving a safe productive medical career and by evidence around effective support and rehabilitation for those who struggle.

Careers advice is also critical in this respect. Medical careers are disparate, and finding the right niche is obviously important for long term career satisfaction.²

University careers departments are rarely equipped to advise on medical careers, and as many postgraduate deaneries delegate careers advice to senior clinicians in the medical and surgical specialties, newly qualified doctors may be poorly supported in the initial decisions determining their career paths. The initiative, Modernising Medical Careers, places an emphasis on effective careers advice,⁹ and more work needs to be done on assessing the usefulness of psychological profiling.⁴

Perhaps the most important mechanisms for ensuring contended doctors are those of mentoring and appraisal. The NHS underlines that the explicit purpose of the appraisal system should be to support doctors,¹⁰ and likewise the GMC insists that students must receive regular, structured, and constructive appraisal.⁶ Effective appraisal can detect unhappiness early and promote effective change.¹¹ Likewise judicious admixtures of support and challenge from an experienced mentor can nurture the medical workforce.

Finally, realistic expectations of a modern career in medicine underpin contentedness in the medical workplace.¹² Medical schools must work closely with postgraduate deans responsible for junior doctors to ensure that undergraduate education encompasses not only the necessary subject material but also the appropriate processes to prepare doctors for the rapidly changing environment of medical practice. The messages about conditions for surviving and thriving in today's medical environment must be taken on board in medical schools and workplaces.

Ed Peile, associate dean,
Email: ed.peile@warwick.ac.uk

Yvonne Carter, dean, Warwick Medical School, University of Warwick, Coventry CV4 7AL

studentBMJ 2005;13:89-132 March ISSN 0966-6494

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Moss PJ, Lambert TW, Goldacre MJ, Lee P. Reasons for considering leaving UK medicine: questionnaire study of junior doctors' comments. BMJ 2004;329: 1263.
McManus IC, Keeling A, Paice E. Stress, burnout and doctors' attitudes to work are determined by personality and learning style: A twelve year longitudinal study of UK medical graduates BMC Med 2004;2: 29.
Clack, GB. Is personality related to doctors' specialty choice and job satisfaction? Unpublished PhD thesis. University of London, 2002.
McManus IC, Smithers E, Partridge P, Keeling A, Fleming PR. A levels and intelligence as predictors of medical careers in UK doctors: 20 year prospective study. BMJ 2003; 327: 139-42.
General Medical Council. Tomorrow's doctors: Recommendations on undergraduate medical education. London: GMC, 2003. Special Educational Needs and Disability Act 2001. www.hmso.gov.uk/acts/acts2001/20010010.htm (accessed 7 Dec 2004).
Cohen D, Hebert K. Training in undergraduate and postgraduate medicine for people with disabilities. BMJ Career Focus 2004;329:123-5. (http://careerfocus.bmjjournals.com/cgi/content/full/329/7468/123-9).
Association for the Study of Medical Education. ASME Annual Scientific Meeting. Fitness to practise. Liverpool: ASME, 2004. www.asme.org.uk/frames_meet.htm (accessed 2 Dec 2004).
Department of Health. Modernising medical careers; the response of the four UK health ministers to the consultation on unfinished business: proposals for reform of the senior house officer grade. London: DoH, 2003.
Department of Health. Guidance on appraisal for general practitioners working within the NHS. www.dh.gov.uk/assetRoot/04/03/47/23/04034723.pdf (accessed 2 Dec 2004).
Conlon M. Appraisal: the catalyst of personal development. BMJ 2003;327: 89-91.
Zuger A. Dissatisfaction with medical practice. N Engl J Med 2004;350: 69-75.

Responses published this month

Articles	Responses
EDITORIALS Making happy doctors Ed Peile, Yvonne Carter (March 2005)	Dr.Satheesha Nayak B (February 25, 2005) Read this response

EDITORIALS Making happy doctors Ed Peile, Yvonne Carter (March 2005)	Sarah Jones (March 03, 2005) Read this response

EDITORIALS Making happy doctors Ed Peile, Yvonne Carter (March 2005)	Catherine Jacqueline Yang (March 10, 2005) Read this response

	EDITORIALS Making happy doctors Ed Peile, Yvonne Carter (March 2005)
	Dr.Satheesha Nayak B (February 25, 2005) Selection Grade Lecturer, Melaka Manipal Medical College (Manipal Campus), Manipal, Udupi District, Karnataka State, INDIA. 576104 nayaksathish@yahoo.com
	Ed Peile and Yvonne Carter are so true in saying 'Medical students must receive regular, structured, and constructive appraisal to detect unhappiness and promote effective change'. Students do well in their studies when you encourage them and make them think positive. I have experience of mentoring the foreign students for ten years. I have changed the attitude of many students towards studies by giving regular and timely appraisals. The students, when they study, especially in a foreign country, they come across several difficulties like cultural difference, language problem and different educational settings. Even when a student enters the medical field in his own country, the medical subjects are like learning a different language all together. There will be a lot of stress and they often fail to cope up with the stress. They must be guided properly by giving timely advice. As a mentor, I have found many factors which hindered the learning process of medical students. Family problems, financial problems, health problems, friendship problems and bad habits like smoking and drinking are some of the things which resulted in negative thinking and failures in the examinations. The students like the teachers who go to the class with a smiling face and pass good comments about the class and make them think positive. If a student keeps himself happy, he will do much better in his examinations. Happiness is a highly subjective thing and different people get happiness by doing different things. The students become happy when the teachers appreciate their work and praise them in the class. This makes them work harder and they start believing in their strengths. Students hate the teachers who always criticize them. Many students lose interest in studies and give up if you criticize them always. Medical teachers must make their students happy by passing good comments and encouraging them. The teacher should be a facilitator, guide and a friend who shows the right path to a student by giving incentives when the students answer a question in the class or when he passes a test. The teacher has to act like a parent when the student does a mistake. He has to make the student realize the consequences of such mistakes and guide him to do the right thing. This makes the student happy and his performance will become better.

	EDITORIALS Making happy doctors Ed Peile, Yvonne Carter (March 2005)
	Sarah Jones (March 03, 2005) BM BS, BMedSci, 2nd yr, University of Nottingham mzyxslj@nottingham.ac.uk
	Having read this article I can't agree enough. The penultimate paragraph sums up the feeling of so many of my fellow students. Many of us have recently become disillusioned by the sheer volume of work and non-stop nature of the work. Having revised all of christmas, and then returned to exams, we have now worked a further 6 weeks and are realising that it is 10 weeks (including easter) until our summer exams week. Our lectures continue right upto 4pm on the friday before the exams, and after the exams we are expected to begin work towards our honours year projects (as we are doing an intercalated degree). There is little time currently allocated for feedback and tutorials in our timetable (2 this semester) and these sessions will probably last 10 minutes at most. Cant the GMC push for better feedback and appraisals for students? - as I believe that these would help my friends and I keep sight of the 'light at the end of the tunnel' and encourage us to keep working towards it, rather than purely finishing one set of exams and going straight back to work, with little feedback or constructive criticism. But who are we meer students to ask for such things? - what can one voice out of 260 do? Am i the only one who feels this way about the way our courses are run? Are other medical schools managing better, and if so what initiatives are they using? I look forward to hearing some answers

	EDITORIALS Making happy doctors Ed Peile, Yvonne Carter (March 2005)
	Catherine Jacqueline Yang (March 10, 2005) Medical Student, Representative New Zealand Medical Students’ Association, The University of Auckland cyan042@ec.auckland.ac.nz
	Editor, Peile and Carter ask whether we should be selecting happier doctors ‘by routinely assessing personality profiles and learning styles at entry to medical school’(1). This question highlights some major issues in entrance schemes to medical schools. Tests such as the UMAT (Undergraduate Medicine and Health Sciences Admissions Test) already attempt to put scores against traits such as empathy, generosity, and patience; a task equally as imprecise and haphazard as assessing the level of pain on a number scale. Even if standardised tests did work, we must look further than the matter immediately at hand; medical students will ultimately become clinicians working with patients. Although many will become specialists in fields where their neuroticism and other stress-coping mechanisms will be essential, others will choose to work in fields that do not require such personality traits. The danger here is that medical schools will be biased towards choosing candidates who fit a certain stereotype good for passing through basic training, and not those who will necessarily make good doctors. Furthermore, like the discrepancy between genotypes and phenotypes, we cannot ascertain who will have difficulty during medical school, based on their personality traits. Lifestyle changes, family, and other personal circumstances are more likely to affect performance and levels of stress felt, more than the type of pre-existing coping mechanisms at entry to medical school. Assessing suitability of candidates based on their perceived personalities on standardised tests carries many dangers, and should be avoided. This is not so much the actions of we who ‘lack the confidence in our social engineering skills’, but admitting to ourselves that even if we could put a figure to these, we would not want to.