Doctors who reported at least one major symptom of burnout reported more than twice as often in the past three months as a major medical doctor Report errors, says a study published online today Mayo Clinic Proceedings,
The study is based on a cross-sectional observational study that excludes causality or directionality of the association. But "it's conceptually likely that the two are reciprocal," write Daniel Tawfik, MD, MS, a pediatric intensive care instructor at Stanford University School of Medicine in Palo Alto, California, and colleagues.
They cite previous research that showed that "self-perceived medical errors could predict subsequent burnout, while burnout also predicted later perceived medical errors."
Tawfik tells Medscape medical news The most surprising finding from the new data is the strength of the relationship between burnout and errors after taking into account other factors, including OSH levels.
"It shows that these occupational safety grades do not tell the whole picture," he said. "They are an important reflection of practices in a unit, but they only tell a part of the story."
More burnout, more mistakes
The researchers used data from the American Medical Association Physicians Masterfile between August and October 2014 to connect with 94,032 physicians, including physicians of all disciplines. The invitation stated that the anonymous survey looked at factors that contributed to doctors' satisfaction and did not mention burnout. A total of 35,922 doctors opened an invitation and 6695 (19%) completed the survey. Two-thirds of respondents (67%) were male; the average age was 56 years. Respondents worked an average of 50 hours a week.
The 60-question poll asked about burnout; Well-being; fatigue; Depression; Suicidal thoughts; recent medical mistakes; and doctors worked age, gender, relationship status, specialty, practice setting and hours per week. Physicians were also asked to give their work area "an overall patient safety assessment" with one of the following: A (excellent), B (very good), C (acceptable), D (poor) or F (failed).
Standardized survey tools were used for burnout and wellness questions, and fatigue measured how the doctor felt on a 0-10 Likert scale last week (0 = worst); Values of 4 or lower were rated as excessive fatigue.
The medical question asked, "Are you worried that you have made major medical mistakes in the last 3 months?" This formulation, according to the authors, "is intended to identify recent internalized events as a significant medical error and it has been found that events identified in this manner are highly correlated with actual medical errors."
Just over half (54%) of respondents reported at least one major symptom of burnout. One-third (33%) reported excessive fatigue and 6.5% reported suicidal thoughts over the last 12 months.
Only 3.9% rated their area with a poor or failed safety standard, but 10.5% said they had made a major medical error within the last 3 months.
The most commonly reported errors were a misjudgment (39%), wrong diagnoses (20%) and technical errors (13%). Fatalities resulted in 4.5% of these errors and 5.3% resulted in severe long-term morbidity. More than half of the errors (55%) did not seem to affect the outcome of the patient. The most frequently reported errors were radiology, neurosurgery and emergency medicine. The perceived errors were lowest in pediatric specialties, psychiatry and anesthesiology.
Burnout, fatigue, and suicidal thoughts were significantly associated with medical errors: 78% of physicians reporting an error reported burnout symptoms compared to 52% of physicians reporting no errors (P <.001). After taking into account the demographic factors and hours worked per week, this difference led to a higher probability of 2.2 errors in people with burnout.
Similarly, nearly half (47%) of those who reported an error experienced fatigue, compared with 31% of physicians without error (P <.001). The likelihood of a perceived medical error increased by 4% for each additional night that a doctor was available each week.
Suicidal thoughts were twice as common among physicians reporting a major medical error than those who did not (13% versus 6%; P <.001). This finding fits data on the "second-victim syndrome," in which doctors who make a serious medical mistake feel traumatized by feelings of guilt, shame, and other negative emotions.
There are already data on stress caused by errors and burnout and errors that are likely to contribute to each other, Albert W. Wu, MD, director of the Center for Health Services and Outcome Research and a professor at the Armstrong Institute for Patient Safety and Quality at the United States Johns Hopkins School of Medicine, Baltimore, Maryland Medscape medical news, But underlying factors can contribute to both, said Wu, who coined the term "second victim."
"It is equally likely that working in an insecure environment, perhaps in a facility that does not give patient safety a sufficiently high priority, can be the cause of burnout problems and mistakes," he said. "Maybe structures work so that doctors are more prone to fatigue, and these things can cause mistakes, or these things can cause burnout, which can lead to mistakes."
After adjusting for age, gender, workload and specialization, the risk of medical errors increased as the level of safety of a work unit declined. Compared to A-grade units, the odds ratio for perceived severe medical errors was 1.70 among those with a B-grade, 1.9 with a C-grade, 3.1 with a D-grade, and 4.4 with one F-grade. But these results may illustrate an association similar to that implied by Wu.
"It's not really known if a low level of work unit security means many mistakes or bad results because people are aware of the mistakes," Tawfik said Medscape,
Not only not surprisingly, the results are pleasing to Michael Hicks, MD, executive vice president of clinical affairs at the University of North Texas Health Science Center in Fort Worth, because they provide quantitative data to support long-term observations.
"The problem we have with American health care, probably global health care, is often that the system is designed for optimal circumstances, the environment suggests that everything is going well and people are at the top of their game," said Hicks Medscape medical news,
"But often the workforce does not play at the top of their game" because they are human. "If you use someone who is ineffective because of emotional or physical limitations, in a system that is not meant to protect them from human frailty, I would be surprised if you get anything other than what they reported have, "he said.
Healthcare needs healthy providers
An estimated 100,000 to 200,000 patients die every year from medical errors, according to the National Academy of Medicine (formerly the Institute of Medicine), and fatal non-fatal errors occur 10 to 20 times more frequently than deadly ones.
Previous research has shown that about half of physicians feel burned and only a little less tired; Doctors also die from suicide at rates three to five times higher than the general population, the authors note.
"We have to face the fact that high-quality healthcare depends on healthy doctors and nurses," said Wu, referring to the Joint Commission's report last year, which recommends that health care facilities set up support structures for healthcare workers.
While the scientific community more values the relationships between these phenomena, it has not filtered sufficiently into clinical practice, Tawfik said Medscape medical news,
"So far, there seemed to have been no culture change in which preventing burnout and promoting one's resilience is really seen as an important part of your professionalism and improvement in patient care," he said. "There is still a culture in medicine that says you have to work harder, ignore your own needs in order to do the best for your patients without this contributing to your own burnout, which negatively affects your patients affect. "
He said that health workers should recognize and prioritize their own well-being, and the institutions must support them in this effort, including the provision of resources and training tools. But even larger systemic changes will be necessary.
"One of the biggest hypothetical predictors of burnout is just excessive documentation when doctors spend more time on computers to document what they do to the patient than they actually do with the patient," Tawfik said. He adds that such documentation usually only applies to billing or regulatory requirements that can be changed. "It will take a lot of work to change them, and that will allow doctors to spend more time with patients and restore some of that joy to medicine."
Another major change is the social perception of health care workers themselves, Hicks said, pointing to a "long-standing cultural bias" [that] Health workers are different than other people. "
"One of the things that really needs to be addressed is the idea that doctors and nurses are superhuman," he said. "We enable doctors and nurses to work hours in which we would never allow bus drivers or pilots to work, and the systems we work in actually encourage us to work at an unsafe level."
The doctors showed that they were unable to monitor themselves, Hicks continued. Therefore, external forces, including patients themselves, will require changes.
"I think that patients and their families have to ask their caregivers difficult questions about what kind of environment they care about," he said. "I think there are questions like: When I come to the surgery, how long have you been awake and how are you feeling and how are you working with the team?"
Change will then require changes along the entire supply chain, from individuals to systems, he said.
"When I think about the way in which these researchers are approaching this topic, the whole foundation of patient safety is based on developing better systems so that people can be human," said Hicks. "They need to build a system where we can do our job and be the best we can be, but catch us if we make a mistake or make a mistake."
The research was funded by the Eunice Kennedy Shriver National Children's Health and Human Development Institute and the Mayo Clinic Physician Welfare Program. The authors have disclosed no relevant financial relationships.
Mayo Clin Proc, Published online on July 9, 2018. Abstract
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