I'd Won, But I Was Miserable

Almost constantly. And I kind of stuffed it down — I ignored it. I'd encourage people not to ignore it. You have to listen to what you want to do; there's a reason you feel passionate about the things that make you question whether you're in the right place. They're there for a reason, and they don't go away.

Medicine has been optimised over many centuries to be very efficient, because we have to do a lot, and to a very high quality. I suspect the speciation of doctors — going from generalist to specialist to subspecialist, these very clear tracks, these grooves — has emerged because how else can we hope to keep up with the demand and provide the care we're expected to? That's great, but it also leaves very little room for change. And the world changes. The pace of change has accelerated tremendously over the last couple of hundred years, and it seems to be getting faster all the time. Healthcare changes; the technology we use changes. I first became aware of the internet in the late eighties and early nineties, so I remember the time before and the time after — but a lot of what I do clinically is no different to pre-internet times, which seems absolutely crazy, because technology has flipped the rest of the world completely on its head.

So the world is changing, and medicine changes quite slowly, often for good reason. The things I'm interested in — the things I believe are important to providing care — there's no path for. Digital health is a great example. Technology doesn't only let us make current care more efficient; it lets us create whole new ways of caring for patients and treating populations. But there's no way in. There's no Royal College of Digital Doctors, no formal training path. So you're left creating your own path. It's the same for people with a passion for the arts or creative practice — you're working in the communication side of healthcare with your podcast, and there's no Royal College of Podcasting Doctors either, but it's a really key part of the public health function of medicine.

The first thing to say is just to recognise that there'll be a lot of people out there who feel that way. You're not alone. I felt that way — I still kind of feel that way. I'm happier, but I'm still trying to find my way. The trick, and the internet and social media have made this much easier, is to find that wider tribe: the people who think like you, who have that same spark, whatever it is. Give of your time, be humble, and learn from them, and everyone moves on together. In fact, within the NHS Clinical Entrepreneur Programme, I've known at least one clinical entrepreneur who got in on a podcasting ticket. So people are being more creative now. But yeah — reach out to other people. And it's okay. You're not alone. We're all weird. We're all finding our way.

With doctors, yes. Being honest about it — and when I say doctors, I generally mean healthcare professionals — doctors trust other doctors. If you're working in digital health and you want to convey something about the company you're working for, the people you're speaking to, particularly if they're doctors, will often want to speak to a doctor. There's an element of, I respect that person's opinion, because they've done a bit of practice, they've seen what the real world is like. So some of that is true.

But outside that, it falls off. The time you've spent as a doctor is very important to other doctors, but as you start speaking to data scientists, researchers, product people, user designers, the commercial side — they think, I recognise that's important, but genuinely, what are you bringing to this? At that point the credentials don't matter as much. What matters is what's uniquely yours — your clinical knowledge, your skills, your talent — but you hold it with humility, because you're often speaking with experts in other areas. This has been one of the great learnings I've had at Babylon: I get to work with some brilliant people, and I'm learning every single day. If I get stuck, I can go and find people who know it back to front, and their opinion, when you're working in this collaborative way, is as valuable as the clinician's. It doesn't diminish the clinician's opinion, but it's as valid.

We have a lot of doctors who aren't consultants working in the guild, and they're brilliant. Some absolutely phenomenal clinicians — some have stayed at Babylon, some have gone on to other things — and their ambition and vision is much brighter than mine at this point. They've got real creative energy, and they're very open to learning from product management, design, engineering, data science, AI. So you can get on board and be very valuable in digital health without becoming a consultant or a GP. What you want to do then is lean into your hybrid nature. You might go in as a junior doctor and end up, oh, I'm a product manager now — there are a lot of clinicians I know who've moved on to exclusively product management, because it's a wonderful and fascinating profession in its own right.

I won't deny there's value in seniority, or being at a certain credential level, for some things — but not all things. And remember, when you come into the commercial sector, it's never just about one person's effort. It's about the role you play in the team, and you can be tremendously good at that without picking up the credentials.

Sure. Virtual reality is a technology that's been around for decades. It's one end of a spectrum of technologies that use computer hardware and software to simulate an alternative space. Virtual reality is about immersing a person into that space — a computer representation of a room, say — and letting you interact with it: move your head and it moves as if you're in that space, you have hand controllers, and so on. Augmented reality is when that digital space is overlaid on the outside world, using things like smart glasses, phones and tablets. Mixed reality is when the digital data overlaid on the real world actually interacts with it. So in VR, I might stand at a simulated desk with a cup on it. In augmented reality, I'd just see that cup overlaid on the world, and it moves as I move my head. In mixed reality, the digital cup would sit on the real desk in front of me — and if I took it off the desk and dropped it, it would fall to the floor. That's the spectrum of immersive realities.

It's been around since the eighties and nineties. In the early nineties it was very popular — that's when I first got into it. It predates The Matrix, but there was a whole cyberpunk moment; Keanu Reeves was in Johnny Mnemonic, it got mixed into dance culture, and it was very popular. But the hardware was rubbish. I always describe it as VR writing cheques it couldn't cash — promising all these amazing things it couldn't deliver. So there was a winter afterwards where not much happened apart from in research. That's when investigators started realising VR could have a therapeutic use. It was used, for example, with people with severe burns during dressing changes: immersing them in virtual reality substantially reduced the distress and pain. That was with a technology called SnowWorld, and the kit was quite bulky.

Over time the technology got lighter and lighter, until by about the mid-teens we had things like the Oculus Rift — an entry-level headset giving very good performance at low cost — and we started using mobile phones for Google Cardboard, Samsung Gear VR and so on. So people could get a reasonable VR experience relatively cheaply. That was the next peak, and that's when I got onto it for the second time and started using it with my own patients. I had a Samsung Gear VR, and I used it with patients coming into my practice for dressing changes, because I knew the researchers' work. In primary care it's very difficult to control pain and distress for those patients — other than basically grin and bear it, or distract them. So I explored using VR and found it really helpful, and that got me excited about how it could be used.

Since then I've spent more time looking at it — this is a personal-interest side of things. It can be used in a number of ways. It can distract people experiencing pain, but it can also let people experience environments that might otherwise be problematic. So it's used for treating phobias — there's very good evidence that VR therapy simulating being up high, exposing people with a fear of heights and practising the techniques to manage it, is extremely effective. It works for fear of flying, for OCD, for a number of other mental health issues. It's also used for rehabilitation, and it can gamify that. A friend of mine, Farhan Amin, a GP from the north-west of England, and his company Concept Health use virtual reality to simulate an environment where people can do pulmonary rehab — and he's found it as effective as face-to-face pulmonary rehab.

So there are ways of making existing care more pleasant and less painful, but also novel ways of delivering care. And that's before you even get to using VR to train people — exposing them to simulated surgery, or difficult conversations with patients, in a way that's scalable. Experiencing things from the patient's perspective is really powerful. So VR already has much to promise, and that's not even going into AR and mixed reality. Just recently a company in the US called AppliedVR got FDA de novo breakthrough status, so they can use VR for treating acute and chronic pain — and in some cases it can be as effective as opiates for reducing pain. There's an effect that seems to go beyond simple distraction. I'm convinced, from personal experience and the emerging evidence, that it has an important role to play.

The difficult thing is how you get it in front of patients, and how you get doctors to know about it. Part of that is talking about it — opportunities like this. And the nice thing about VR is that you can spend a lot of time talking about it, or you can literally take a person, say "pop that headset on," and ten seconds later they go, oh yeah, totally get it. So a lot of a VR champion's job is just putting people into VR, because it saves so much time.

In terms of its growth, you're right that there have been peaks and troughs. What's been interesting is that everyone expected VR to explode like the iPhone, and it hasn't — it's taken a slower upward curve, which is actually reassuring for long-term adoption. Interestingly, this last Christmas one of the VR headsets, the Meta Quest — Facebook bought Oculus and rebranded it as Meta — the Quest, which is a standalone headset, was the top-selling console device, outselling the PS5, probably partly because no one could buy a PS5 or an Xbox. And when you look at companies like Microsoft and Meta, they're pitching towards something called the Metaverse. Briefly, for those who don't know: the Metaverse is a branding term based on Neal Stephenson's Snow Crash — or possibly Bruce Sterling; one of the two cyberpunk authors. When you go into virtual reality it's a simulated space, and social virtual reality is when you have multiple people in that space with their own avatars. The Metaverse, broadly, is when you link all these spaces together so you can move between them and take digital assets from one place to another — building this networked other place. And that's got interesting healthcare potential too.

There are definite barriers, but let's look at what some of them are. Take digital health and mHealth — mobile health, apps used for healthcare — and where we are now. The reason we can use apps for healthcare right now is because so many people have smartphones. If you wind back, the potential for creating apps on a handheld device was always there. But back in 2007, do you think the NHS would have built a mobile phone? On the basis of, well, why don't we build a piece of hardware that lets people interact with the internet remotely and take care of themselves? No one's going to do that. It took the commercial, consumer space — Apple and Android — to drive the penetration, so these became ubiquitous pieces of hardware that can then be used for multiple things, including healthcare.

That doesn't mean it's the sole way in. There are medical devices built case by case — pacemakers, for instance. Not everyone has a pacemaker you can download different rhythms to. So when it comes to VR, the question is whether enough people are going to have VR — or XR, extended reality, an immersive device — to make the case to build software to run on it. Is everyone going to have one, like a TV? Or is the use case powerful enough that we build things to run on the hardware and then loan out the hardware? That last approach is actually very successful right now. With Farhan Amin's pulmonary rehab work, part of the deal is that the healthcare provider posts out the headset — it's got a cellular link — and all the user has to do is put it on, use it, and send it back. So it's a prescribed device.

For that to work within the NHS, you have to make sure the device meets the hardware standards, the software meets the software standards, it's safe and regulated, and there's a reimbursement mechanism so companies can get a return and keep the lights on. The NHS needs companies to provide the hardware in a way that means doctors don't have to worry about keeping a cupboard full of VR headsets. And for it to work completely effortlessly — say I'm a GP and you're my patient with back pain, and we're in a world where I can prescribe VR for it — when I write the prescription, it's automatically fulfilled and delivered to your house if you don't have a device of your own. You use it, and the data comes back and updates me on your performance and your response, into your healthcare record. That's where we have to head, and we're making steps towards it, but we've still got a wee way to go.

Yep, all the time. And it really scares some of the GPs I speak to, because I come in going, this is fantastic, we can get enormous amounts of data, isn't this wonderful — and they go, oh my God, I can barely cope with what I've got right now, and you're going to pour all this important, or maybe not even important, information on me and make me responsible for it. So I understand that.

To dig into it: if you've got all this data coming off the device, some valuable for healthcare, some maybe not clinically valuable but helpful for improving the product, what you want to do is find a way for the clinically relevant insights to be presented at the right time to the right person. If at the end of every day I got four pages of PDF saying you'd used it and looked to your right three times and left four times — oh my God, I can't deal with that. But if I got a weekly update saying adherence appears good, progress is being made, pain rating is falling, and then at the end we discussed it — that's the kind of solution we'd want. I'd also like to know if things were going wrong, if you were having problems, so I was notified. So it's not about just dumping the data on you. It's about working out what's important, and to whom — not only the clinician, but other people in the healthcare system, and the patient themselves, because what you want to know as a patient might be different. That's where AI and the work of the data scientists come in: automating that huge flood of data and turning it into actionable intelligence.

I wasn't happy to be burnt out, but I'm very happy to talk about it, because I'd be very happy for other people not to have to go through it. And I burnt out really well.

Sometimes the story about what it's like to be a doctor is just: burnout is part of the expected story. It definitely needn't be that. But even when it happened to me, back in 2017 — this was pre-pandemic — I was having a hard time in the work I was doing, and God knows people in the health sector right now are really under the cosh. So what is burnout? It relates specifically to how a person's feelings affect their ability to work. If I remember correctly, it's a combination of tiredness and fatigue, an inability to work effectively or productively, and a negative take on — or a loss of emotional connection to — the work you're doing.

I had all of those symptoms. There are probably people listening thinking, yeah, this is medicine — but it genuinely doesn't have to be that way, and if you're feeling that way I'd encourage you to take steps to look after yourself. For me, I was working in a walk-in centre, really keen to pursue digital health but not knowing how to get into it, and I was in that groove I talked about. I'd got to that midlife point where I'd essentially won. I was an innovation leader at the CCG, a GP leading a practice — I'd won, there you go, I'd made it. That's exactly what I meant to do. But I was miserable. And that's not what you expect when you get what you're meant to get. You don't expect to be unhappy.

The practice was very busy — a walk-in centre, open seven days a week, twelve hours a day. I worked fixed shifts, so not insane hours, but when I was there it was hectic. I was working with a group of doctors who slowly left to do other things because they didn't like it, and I was left as the last man standing with locums. So I picked up a lot of the responsibility — QOF lead, prescribing lead — and it all started to stack up. I couldn't let go of work. I was thinking about it at night, waking up early, finding it difficult to connect emotionally with my patients, resenting the demands they put on me. I was still practising well, as far as I could tell, but I was struggling.

I described it in a blog post as being in a hot air balloon that's sinking towards the sea. I thought, I don't want to land in the sea — so what do I throw out to cope? And the weird thing about burnout is you decide the work is the important thing, so you throw out everything else. I stopped seeing my friends, stopped doing the things I enjoyed. I said, all I need to do is get rid of the non-important stuff and focus on work — and I just sank faster and faster, with nothing to protect me.

It got to the point — I think it was June the 22nd, 2017 — where I went in and saw a patient that morning asking for fairly simple advice about changing a hypertensive medication. It took me 45 minutes. My notes had references to online guidelines, CKS. I did my job, I saw the patient safely, but my God, I found it difficult to cope. I went home after a home visit and just said, I can't do this anymore. It felt like it happened just like that — but I'd been burning out up until that point.

I was fortunate that I'd made contact with the Practitioner Health Programme, which was set up by Clare Gerada and is available to most doctors in England now. So if you're hearing this and wondering about burnout, look online — it was extremely helpful for me in starting to address this. My GP was amazing. The irony is that I'm an arch technologist, but when I was unwell I couldn't pick up technology for toffee. I just wanted someone to talk to me. That was a really important lesson: whatever you do in digital health, people vary in their ability to use it — sometimes they're just less engaged. And of course there was my wife, family and friends. I required antidepressant medicines, took them for 18 months, and needed careful handling to get back into work. It was horrible. Depression, anxiety and burnout are truly hellish things — until you've gone through them you don't quite understand how horrible they are. I'd been treating people with these conditions for a long time, and while I'd never want to have gone through it, it helped me understand my patients' experience much better, and I believe it made me a better doctor. It shook me out of the comfort of lying in that groove and forced me to pursue what was important to me — being a digital doctor, whatever that means. Working that out is the rest of my life's job, but I knew I had to get into it. I'd be delighted if people listening could save themselves that pain.

In part, first of all, being able to talk about it. Part of the reason I burnt out, I think, is that I refused to talk about it — I wasn't talking about how I felt, I was just, all I need to do is buckle down and work harder and it'll be fine. So being open and honest, speaking to my wife and family, and publicly like this, helped. That was number one.

The next thing was recognising the triggers for when things are getting worse — because people will tell you when you're not coping, and you have to be open to listening rather than getting defensive. When someone says, Keith, you're quite stressed right now, it's very easy to push them away, and you mustn't. Listen to them.

For me, taking downtime is really important, and actually blocking it in. Over lockdown I did a lot more of this — getting out into nature and walking without headphones or a podcast, just being out with my dog. That empty space is so important that I've literally got it in my diary now, and if I don't do it, I miss it. For other people it might be mindfulness or swimming, but that's mine.

And then I pursue the things that give me happiness. Remember the balloon — I'd thrown out all the things I enjoyed: computer games, board games, swimming in the sea with my brothers, things I loved as a teenager. I'm now in my late forties and I'm not going to apologise for the things I enjoy. Reconnecting with a local board-gaming club, taking the time even when I was depressed and not enjoying them as much — doing the things I'd enjoyed brought me back. So making space for doing nothing, and space for doing the things you truly enjoy, are very important self-care practices you shouldn't minimise or apologise for.

I do think about that a wee bit. I blogged about it, and on the one-year anniversary of joining Babylon I gave a stand-up to the company and talked about my depression — I stood up in front of people and said, I am in recovery from depression and anxiety. I was nervous about it. But the benefit was that people came and spoke to me, and people still come to me and say it was important that someone in my position spoke honestly about it.

It's not going to be for everyone, and I'm not asking people who've gone through this to speak about it — hell no, it's not an easy thing. I'm just a bit of a show-off in that regard — a show-off in recovery. But the thing that kept driving me was this: when I was unwell, I was constantly looking for an example of someone who had been unwell and was no longer unwell, because depression absolutely robs you of hope. It's an obvious thing to say, but to be without hope is a terrible thing. I spent a lot of time online looking, and couldn't find anyone. So when I came across people who had been through it and come out the other side, I took a great deal of comfort from it. I remember thinking, when I get through this — and it was never guaranteed — I'll be sure to talk about it, because there will be people who feel this way and can't imagine there's a way back. So in part it was the hope that I might help someone in the position I'd been in. And the second thing was a kind of up-yours to depression — you've got to be careful saying that, because you never know, you're constantly trying to stay well — but it had taken so much from me that I was damned if I'd let it stop me taking something back.

I'm also very fortunate. Babylon is a wonderful environment in terms of diversity and support, so I felt comfortable that I'd be supported by my peers by talking this way — and I was. That's not always going to be the case for people out there, and if it isn't, I'm sorry. We all need to work together to make it okay to not be okay. If me talking about it can move the needle on that even a wee bit, then of course I'm going to do it.

A moment ago I talked about doing the things I enjoyed, and how moving away from them was a bad thing — so one habit that helped me stay well was persisting with those. In terms of my career, my interest in technology and gaming has informed how I practise medicine; it still infuses the ideas I have and how I solve problems. It's about keeping my thinking broad about how things that aren't technically medicine — my interest in comics, games, board games — can inform my practice as a clinician. I'm not unique in that, but I've found it very helpful, particularly in underlining me as a human being as well as a doctor.

The second thing is trying to stay open to different opinions and experiences. I'm quite a rationalist and atheist — I ran a Skeptics in the Pub organisation, and I used to be a bit of a card-carrying firebrand sceptic, shooting down people with alternative thoughts. I've mellowed since being unwell, because you do what it takes to get you through. Keeping your mind soft and open to new ideas is really important in your practice as a doctor. And if you transition out of medicine into a new role, you have to realise that within standard healthcare doctors assume a certain position in the hierarchy — that's not so much the case inside digital health. So stay humble and open to new experiences, because you're going to be learning a lot, and working with people has really helped me in my career.

The other habit is that when fortune smiles on you — when serendipity happens — you take advantage of it. I'd never say burnout was a fortunate thing, but it was the spark that let me make the change that's left me in a position where I'm very happy now. So it's a couple of things: keeping your mindset flexible, learning to be comfortable with who you are, and learning to manage yourself. You spend your twenties commanded by who you are, your thirties working out who you are, and your forties learning to live with it — and the fifties, who knows, we'll find out next. I realise I'm not going to change who I am. Some things about me are good, some are not so good, so learning how to manage that is really important. And having people you trust can help with that.

Thank you.