British Medical Association Research Articles

Mental wellbeing in doctors: the measure matters! development of a core outcome set for measuring wellbeing in doctors

AimsTo achieve a consensus Core Outcome Set for measuring mental wellbeing in doctors.Hypothesis: A minimum set of valid, reliable and practical wellbeing measures is needed for doctors.BackgroundThe importance of doctors’ mental wellbeing to everyone using Health Care is highlighted by the levels of burnout reported in doctors around the world. In 2019 a number of UK policy documents made recommendations for the wellbeing of doctors, but how those wellbeing interventions are evaluated needs to be defined. Core Outcome Sets are increasingly being used in medicine to prevent waste in research, by recommending the inclusion of a minimum set of valid, reliable and practical measures. An operational definition and Core Outcome Set for wellbeing in doctors is needed to meaningfully progress the work in this field.MethodThe Centre for Workforce Wellbeing (C4WW), a collaboration between the University of Southampton and Health Education England, was created to support research into the nature, assessment and enhancement of wellbeing in physicians. A Systematic Review of wellbeing measures used in doctors and the robustness of those measures, along with surveys of 250 UK doctors of all grades and specialities and patient and public involvement is informing what a core outcome set could be. A Delphi Study among 37 UK experts has been initiated to establish the consensus Core Outcome Set.ResultPublication of research into doctors’ wellbeing is growing internationally. In the UK alone data are being captured by multiple national organisations including: the Care Quality Commission, General Medical Council, British Medical Association and the Royal Colleges. Health and Social Care Organisations are, therefore, keen to “do something” and are spending money on wellbeing interventions with little, or no, evidence base and a lack of appropriate, comparable evaluation. A Core Outcome Set for measuring wellbeing in doctors is ethically required to reduce waste, to replace burnout measures and to refine wellbeing interventions.ConclusionWellbeing measures that actually measure wellbeing, and not burnout, which are validated, reliable and practical, are needed to inform local organisational, national government and international research policy. An absence of burnout does not equate to wellbeing. The focus of measurement needs to shift to capture in what contexts we thrive, not just survive. If everyone used the same Core Outcome Set to measure mental wellbeing, direct comparisons could be made, and money invested, in creating infrastructure, processes and cultures that really work.Health Education England funded PhD.

A national cross-sectional survey and interviews exploring the relationship between well-being and burnout in doctors

AimsDoctors’ mental health is a national concern – the General Medical Council, British Medical Association and Health Education England pledge to improve their well-being. Well-being has no common definition, instead pathogenic measures such as burnout are published as a demonstration of doctors’ wellbeing. Yet, the relationship between burnout and wel-being has not been explored.Aimto investigate the relationship between burnout and well-being.Hypothesisthey are negatively associated, but not opposites.MethodAn online cross-sectional national survey was distributed to doctors of all grades and specialties via the Royal Colleges and doctor organisations. The Oldenburg Burnout Inventory (OLBI) measured burnout, and the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) measured well-being. Correlation coefficients between total scores of these measures estimated the relationship. Additionally, semi-structured interviews explored personal definitions of wellbeing and its relationship with burnout. Thematic analysis was carried out.Result64 doctors completed the OLBI and WEMWBS. Comparing the total scores for the questionnaires with Spearman's rho indicates a moderate negative correlation (rs= –0.658, p = 0.00, n = 64). Total scores were made into binary variables, a Chi-square test showed that a low WEMWBS score (<40) and a very high risk OLBI score (≥2.85 exhaustion and ≥2.6 disengagement) were statistically significantly associated (X 2 (1, N = 64) = 4.232, p = 0.04). Three themes emerged from the 10 interviews conducted: the importance of networks/relationships outside work; scepticism towards the proposal of an NHS wellbeing check-in; and how participants do not strive to improve their wellbeing until its decline.ConclusionThis research demonstrates that wellbeing and burnout have only a moderate negative correlation when using commonly employed measurement tools. Therefore, measures of burnout are not a surrogate for wellbeing. Further research could adopt a salutogenic approach by using the WEMWBS to monitor doctors’ wellbeing and could explore interventions to increase well-being, rather than waiting for its decline.

Survive and thrive wellbeing programme: an innovative experiential wellbeing programme for trainees in Health Education England- Thames Valley (HEE-TV)

AimsThe aim of this project was to develop an experiential programme which encouraged trainees to develop their own processes for mental resilience acting to mitigate difficult work and life environments.BackgroundDoctors are at considerable risk of work-related stress, burnout and mental health problems, particularly trainees, many of whom are experiencing symptoms earlier in their career. The Thriving at Work Review, the British Medical Association and HEE all call for cultural and organizational change that works to prioritise, promote and enhance wellbeing by providing good working conditions and an atmosphere that encourages open discussion about mental health with access to appropriate support that destigmatises mental health.MethodAcross HEE-TV we identified that there were no regular wellbeing initiatives for trainees, and specifically no psychologist-facilitated Cognitive Behavioural Therapy-style sessions to enhance resilience. Six schools identified a specific need for HETV-targeted resources focused on enhancing trainee mental wellbeing.The current course has morning sessions that cover self-awareness, and afternoons are psychologist-facilitated sessions. The initial pilot was run for the School of Anaesthetics, and later offered to specialties with a General Medical Council-survey identified need. Multiple improved iterations of the course have been driven by detailed trainee feedback, including adding the psychology sessions to give trainees tools for self-help.ResultWe triangulated feedback from attendees at the sessions, nominated trainee representatives from all specialties across Thames Valley via the Trainee Advisory Committee (TAC), and HEE-TV quality assessors. Feedback from trainees who attended was almost universally positive. The Quality Committee noted improvement of trainee morale in Anaesthetics and direct improvement in aspects of the learner environment that would not have happened without this intervention. The TAC endorsed this as one of the measures to support trainees in difficult learner environments. They also recommended it be rolled out for all as a preventative measure as there can be a time lag before items appear on the Risk Registers and are officially recognized as requiring support. The biggest measure of success is that HEE-TV have agreed to fund these sessions ongoing.ConclusionWe learned that an iterative response to trainee feedback and careful co-ordination is key to successful engagement via the training programme directors who arrange regional training programmes. This, and making the SAT course free at the point of use, makes it easier for trainees to access this programme. In addition we will be including the trainee voice is shaping bespoke aspects of the day for each specialty.

Waiting list eradication in serious mental illness (SMI) “secondary care” psychology: addressing an NHS blind spot

AimsThe poster focuses on the reduction, and eventual eradication, of waiting times within a community-based NHS psychology service in the North East of England. The poster aims to demonstrate the effectiveness of strategies implemented within a secondary care psychology service whilst examining patterns of help-seeking behaviour and treatment compliance in those waiting for therapy, and also the care needs of this cohort following a wait for services.BackgroundSecondary care waiting lists for psychological therapy, as highlighted by a recent British Medical Association audit, remain a so-called ‘blind-spot’ in mental health care provision and a national problem. Tackling waiting lists within this sector has been stated as a priority within the Five Year Forward View, however “core ingredients” of waiting list eradication methodologies and the components leading to such, have yet to be disseminated.MethodA historical audit and follow-up of clinical data were utilised to gather and analyse data of 208 individuals who were seen by the psychology service between October 2014 and March 2016.ResultNo significant differences were found between individuals who successfully completed therapy compared to those who disengaged in regard to demographic or epidemiological variables, or mental health service input. Despite lengthy waiting times of up to 3.69 years, waiting time did not significantly impact whether someone engaged with psychological services. Any form of input from psychological services led to a significant reduction in distress, as measured by the CORE-OM. No individuals who completed therapy were re-referred for psychological input at 12-month follow-up.ConclusionIf imposed appropriately over a suitable time-frame evidence-based, effective and efficient needs-led psychological input can be provided whilst eradicating a waiting list and still remaining flexible, formulation-based and person-centred.

A survey on psychiatry trainees’ experiences of racism

AimsTo measure rates of racism experienced and witnessed by trainees training in Derbyshire.BackgroundDerbyshire Healthcare Psychiatry trainee workforce comprises 39.1% white, 52.2% ‘Black, Asian and Minority Ethnic’ (BAME) and 8.7% undisclosed ethnicity. Racism can affect trainees by increasing risk of poor mental health and psychological distress leading to worse health outcomes. Discrimination, marginalisation and segregation is related to poorer quality education and employment opportunities.MethodElectronic surveys were sent out via e-mail to trainees in the North and South Derbyshire Hospital sites, accessible online from 11th to 31st December 2020.Questions asked about personal experiences of racism, witnessing racism from patients and/or staff whilst training in Derbyshire. Trainees were asked if they know how to report incidents and if routinely reported. Trainee ethnicity was recorded.ResultA total of 56 trainees received a survey request. Response uptake rate 25% (14 out of 56). Respondents comprised of 36% white and 64% BAME doctors. Over one third (36%) of trainees reported experiencing racism from staff. 64% of trainees reported experience of racism from patients. There was no report of racism witnessed by staff towards patients. 29% of trainees reported witnessing both staff on staff racism and patient on staff racism. 93% of trainees reported witnessing racism from patients to staff. 29% BAME trainees reported experiencing racism from both staff and patients. 7% BAME trainees said they experienced racism from staff alone. 36% of trainees reported experiencing racism from patients only (4 BAME and 1 white trainee). 57% of trainees do not know how to report racism. 50% of trainees said they would report racism if they knew how.ConclusionRacism remains a barrier affecting the lives of trainees requiring attention. BAME trainees are disproportionately affected by racism, and report witnessing more incidents, from staff and patients in the workplace. There remains an apprehension by doctors to report racism. A departmental presentation has been delivered on racism, unconscious bias, incident reporting process and sources of support. A workshop with the ‘Equality Diversity Inclusion’ team has been delivered to all trainees with the presence of the Freedom to Speak Up Guardian. Our British Medical Association Local Negotiating Committee Representative has also been informed.

COVID-19 survey burden for health care workers: literature review and audit

ObjectivesConcerns have been raised about the quantity and quality of research conducted during the COVID-19 pandemic, particularly related to the mental health and wellbeing of health care workers (HCWs). For understanding the volume, source, methodological rigour and degree of overlap in COVID-19, studies were conducted among HCWs in the United Kingdom (UK). Study designMixed methods approach, literature review and audit. MethodsFirst, a literature review of published research studies and second, an audit of studies HCWs have been invited to complete. For the literature review, we searched Medline, PsycINFO and Nexis, webpages of three medical organisations (Royal Society of Medicine, Royal College of Nursing and British Medical Association), and the YouGov website. For the audit, a non-random purposive sample of six HCWs from different London NHS Trusts reviewed email, WhatsApp and SMS messages they received for study invitations. ResultsThe literature review identified 27 studies; the audit identified 70 study invitations. Studies identified by the literature review were largely of poor methodological rigour: only eight studies (30%) provided response rate, one study (4%) reported having ethical approval, and one study (4%) reported funding details. There was substantial overlap in the topics measured. In the audit, volunteers received a median of 12 invitations. The largest number of study invitations were for national surveys (n = 23), followed by local surveys (n = 16) and research surveys (n = 8). ConclusionHCWs have been asked to complete numerous surveys that frequently have methodological shortcomings and overlapping aims. Many studies do not follow scientific good-practice and generate questionable, non-generalisable results.

299 Implementing A Formal Surgical Handover Tool for Junior Doctors – A QI Approach

Abstract Introduction An informative medical handover facilitates safe patient care. It was recognized that insufficient clinical information at handover resulted in unsafe communication in the general surgical department at Pinderfields General Hospital (PGH). We aim to utilise the Royal College of Surgeons’ (RCS) and British Medical Association’s (BMA) guidelines to improve the existing handover system, facilitate an efficient and relevant handover, and furthermore improve patient safety. Method General surgical foundation doctors (FDs) (n = 15) at PGH were surveyed to establish their perspectives of existing handover documentation. Subsequently a handover tool was iteratively designed, using tests of change, combining RCS and BMA guidelines with FDs’ suggestions of patient information required for safe handover. At two time points, FDs in the department were re-surveyed to measure improvement. Results Prior to implementation of a formal document, only 20% of FDs reported sufficient patient identifiers of the handover. This improved to 67% post intervention. Pre-intervention, 0% perceived the handover as ‘Excellent’, 20% as ‘good’. Post-intervention, these improved to 34% and 60% respectively. Conclusions Over six months, we improved the FD’s handover document, resulting in positive feedback of perceived safety of surgical patient handovers. However, recognised time constraints have highlighted the need for more efficient handover documentation.

Absence of monitoring in withdrawal of clinically-assisted nutrition and hydration (CANH) and other treatments: a cause for concern?

Since 2018, there has been no requirement to bring decisions about the withdrawal of clinically-assisted nutrition and hydration (CANH) in patients with persistent disorders of consciousness before the courts, providing that the requirements of the Mental Capacity Act 2005 (MCA) are fulfilled. Subsequent British Medical Association and Royal College of Physicians guidance on CANH withdrawal recommended standards of record keeping and internal and external audit to ensure local decision making was compliant with the MCA to safeguard patients. The scope of the guidance also included patients with stroke and neurodegenerative disorders.Freedom of Information requests made 2 years after the introduction of this guidance have shown that none of the NHS trusts or clinical commissioning groups who responded were undertaking any systematic monitoring of these decisions. Neither is the Care Quality Commission reviewing these decisions, as there is 'no statutory requirement' to do so. It appears there is a lack of organised scrutiny of these highly complex life-ending treatment decisions. This omission must surely be a cause for concern.

Terms of engagement

Terms of engagement

Doctors support switch for contraceptive pills from POM to P medicine

The British Medical Association (BMA) has backed proposals to permit the supply of two progestogen-only contraceptive pills in community pharmacies, but said “some issues” need to be addressed before the change is agreed. In February 2021, the Medicines and Healthcare products Regulatory Agency (MHRA) launched consultations on the reclassification of two progestogen-only contraceptive pills — Lovima 75 […]

RPS maintains support for up to 12-week dosing interval between COVID-19 vaccines

The Royal Pharmaceutical Society (RPS) has said it maintains its support for leaving up to 12 weeks between administering doses of COVID-19 vaccines, despite pressure from some quarters to reduce the gap. The British Medical Association (BMA) has called for “a dialogue” with the government over halving the maximum interval between doses of the Pfizer/BioNTech […]

In Their “Best Interests”

This essay criticizes the subjective understanding of “best interests” adopted by the United Kingdom’s Mental Capacity Act 2005 and by the 2018 guidance of the British Medical Association and the Royal College of Physicians on the provision of clinically assisted nutrition and hydration to incapacitous adults. The key criticism is that such an understanding wrongly values people’s preferences above their lives.

The Norwegian Medical Association should continue to oppose assisted dying.

The Norwegian Medical Association has long taken a clear stance against the legalisation of assisted dying. Recently, the British Medical Association moved to a neutral stance. Is it now time for the Norwegian Medical Association to change its course?

COVID-19 risk tools should incorporate assessment of working environment risk and its mitigation.

COVID-19 risk tools should incorporate assessment of working environment risk and its mitigation.

Ten minutes with Dr Joseph Home, Medical Directors Leadership Fellow at Pennine Acute NHS Trust

### Biographies Dr Christopher Waugh is a Junior Doctor in Greater Manchester. With an interest in medical education and clinical research he is currently involved in several collaborative studies including...

Commémoration des connections neurologiques franco-britanniques entre 1860 et 1920

We review interactions between British and French Neurologists from the birth of this discipline in the 1860s to the early 20th century. First connections include Robert Bentley Todd and Thomas Clifford Albutt in England and Armand Trousseau and Guillaume Benjamin Amand Duchenne in France. During the 1860–80 years, Jean-Martin Charcot in Paris created the Salpetriere school of neurology. In London, the National Hospital for the Paralysed and Epileptic was founded in Queen's Square in 1860 with Charles Brown-Sequard as a first physician. Hughlings Jackson (1862), Russell Reynolds (1863), later William Gowers (1873) and David Ferrier (1880), all influenced French Neurology. Charcot investigated paralysis agitans and named it Parkinson's disease. He emphasized the contribution of Jackson to aphasia and epilepsy. Charcot travelled frequently to Great-Britain, especially to the annual meetings of the British Medical Association. He and other French physicians interacted with British colleagues at the International Congress in London in 1881. In the late 19th century, a number of articles were published by Charcot and other French authors in Brain, and by British neurologists in Nouvelle Iconographie de la Salpetriere and Revue Neurologique. Brown-Sequard and Charcot became corresponding members of the Royal Society of Medicine in 1887, as later did Jules Dejerine, Joseph Grasset and Theodule Ribot. The creation in 1999 of the Societe de Neurologie de Paris included among the foreign corresponding members Jackson and Ferrier. Dejerine, Fulgence Raymond and Pierre Marie developed Charcot's work and received in Paris foreign neurologists, among which Samuel Alexander Kinnier Wilson who spent one year in Paris in 1903 with Pierre Marie. He returned to Queen Square and King's College Hospital and remained in contact with French neurology. Wilson presented in Paris in 1912 a new disease he called progressive lenticular degeneration with cirrhosis of the liver (Wilson's disease). During the early 20th century, Anglo-French connections were emphasized in international congresses, notably in 1900 in Paris and in 1913 in London, where Joseph Babinski made his lecture on the cerebellar syndrome. In 1914, the Societe de Neurologie de Paris elected 10 new foreign corresponding members from Great Britain. Since then, Anglo-French links have continued with other young promising neurologists travelling from France to the United Kingdom and vice-versa.

Assessment and improvement of junior doctor handover in the emergency department

IntroductionEffective handover between junior doctors is widely accepted as essential for patient safety. The British Medical Association in association with the National Health Service (NHS) National Patient Safety Agency and...

Bedside handover at the change of nursing shift: A mixed-methods study.

To describe the structures, processes and content of bedside handover at the change of nursing shift in an acute-care context. The handover of patient information and care at the change of nursing shift is an essential, albeit risk-laden, time-consuming activity in clinical practice. A convergent parallel mixed-methods design was used. Thirty episodes of bedside handover were concurrently audio-recorded and observed using a researcher-developed tool modelled on the five domains of the British Medical Association's Safe Handover-Safe Patients framework. The audio recordings were analysed using content analysis. Quantitative and qualitative data generated were then triangulated to develop a more complete interpretation of the structure, process and content of information transferred at the patient's bedside during the change of nursing shift. This study followed Good Reporting of Mixed Methods Study guidelines. Bedside handover was observed to be mainly conducted at a fast pace. However, within these timeframe large volumes of complex information were shared and important nurse-patient interactions occurred. Analysis of the audio recordings provided evidence that the dialogue during handover was nurse-dominated and the outgoing nurse appeared to influence the degree of patient participation. Bedside handover at the change of nursing shift involves three key stakeholders: outgoing nurse, incoming nurse and the patient. A combination of intricate communication skills both verbal and nonverbal facilitates the rapid sharing of large volumes of complex information which is necessary for the continuity and safety of patient care across nursing shifts. The comprehensive description of the complexities of bedside handover in this study provides an insight into this frequently occurring, important nursing practice and can be used to support nurse education and practice development.

An Australian reflects on the Collings report 70 years on.

The publication of ‘General Practice in England Today — a Reconnaissance’ in the Lancet of 25 March 1950 made its Australian author, Dr Joseph Silver Collings, the National Health Scheme’s first whistleblower.1 It also ruined any chance of an academic or administrative career in the UK. Its unflattering description of English general practice angered the medical profession, particularly the British Medical Association (BMA). The Nuffield Provincial Hospital Trust who had funded it were not prepared to have their name associated with it. The Ministry of Health and the Chief Medical Officer who had directed the research underlying it remained silent. Joe Collings, as he preferred to be called, conducted the first evaluative research on general practice published in the English world.2 Challenging the smugness of British medicine, Collings was denied due recognition with his approach labelled unorthodox, and his sampling of English general practice considered fatally skewed. Joe was portrayed as a brash, inexperienced Australian influenced by American concepts with limited experience of British medicine. All those with direct knowledge of those times are now dead, so we must rely on records to ascertain what happened. Joe was a meticulous archivist and his wife Bett preserved his papers in the National Library of Australia.3 Extensive Rockefeller Foundation archive documents add to our knowledge of his activities.4 Joe had experienced general practice in two pioneering universal healthcare insurance systems, New Zealand and Manitoba, Canada, where the reformers sought his opinions. The Rockefeller Foundation funded him for 3 months in 1948 to explore medical educational developments in …

Governance system of the British Medical Association

It is regrettable that in recent years, the Korean Medical Association (KMA) has held special meetings of the house of delegates almost annually, purely for the removal of the president of the KMA from his/her office. There could be several reasons for this, but the failure of communication caused by the fragmentation of the KMA’s governance structure may be a major contributing factor. It may therefore be helpful to benchmark the governance of other professional organizations like the British Medical Association (BMA) to identify differences in the practice of consensus building, which leads to policy making. Due to the unexpected COVID-19 (coronavirus disease 2019) outbreak, this study was limited to internet resources. It was impossible for the author to conduct participant observation or direct face-toface interviews to get essential information about the governance of the BMA. Nevertheless, the findings provide valuable lessons for the KMA. There seem to be chasms among the house of delegates, the regional association and the board of directors in the KMA; better integration among major bodies within the KMA is required. Furthemore, the time spent by these bodies on generating policies and strategies is not sufficient. The BMA is a union with its professional activities secured by labor laws, whereas major players of the KMA do not have a protected time for their professional trade association. The KMA needs to remodel the current governance which is characterized by inadequate communication and subsequent fragmentation among the acting bodies of the Association. Continuous professional development for the leaders and members of the KMA might enable this change in governance.