Physician burnout linked to major errors

The findings suggest that burnout should be a consideration in efforts to reduce errors, according to a study author.

The dangers of physician burnout may include major medical errors, a recent study found.

In a survey of 6,586 actively practicing physicians, 54.3% reported symptoms of burnout, 32.8% reported excessive fatigue, and 6.5% reported recent suicidal ideation. About 4% reported having received a poor or failing patient safety grade in their primary work area, and 10.5% said they had made a major medical error in the prior three months.

Photo courtesy of Dr Tawfik
Photo courtesy of Dr. Tawfik

Compared to physicians who did not report errors, those who did were significantly more likely to have symptoms of burnout (77.6% vs. 51.5%), fatigue (46.6% vs. 31.2%), and recent suicidal ideation (12.7% vs. 5.8%), according to results published online in July 2018 by Mayo Clinic Proceedings. Perceived errors were more common among physicians with poorer work unit safety grades, a measure of the patient safety practices of their primary work area.

ACP Hospitalist recently spoke about the findings with lead author Daniel Tawfik, MD, MS, an instructor of pediatric critical care medicine at Stanford University School of Medicine in California.

Q: What led you to study this particular issue?

A: Burnout is a growing epidemic among physicians of all specialties, but we still have an incomplete understanding of its causes and of its effects on physicians and patients. We wanted to better understand the relationship between physicians and the safety practices of their work environments, and how this relates to burnout and medical errors.

Q: You found substantial amounts of burnout, excessive fatigue, and recent suicidal ideation in the cohort. Were you surprised by these results?

A: Sadly, these results were not surprising. We know that physician burnout is highly prevalent and that physicians are at much higher risk of excessive fatigue and suicide than others in the general working population.

Q: Did you expect to find a link between these symptoms and medical errors?

A: We did expect to find a link when directly relating burnout and well-being to medical errors, as these relationships have been described in other studies. However, what surprised us was how strong this relationship remained, even after adjusting for the safety grades of the physicians' work areas.

Q: What are some potential implications of your findings in terms of the real-life practice environment?

A: Our findings suggest that physician burnout needs to be a key consideration when working toward reducing medical errors. Although [work] units with better safety grades did have fewer reported errors overall, within each safety grade we found much fewer errors among those physicians not experiencing burnout. If physicians notice a safety concern, we are taught to raise that concern to help it be addressed. Our results suggest that this type of practice is potentially even more important for concerns related to physician burnout.

Q: What are some possible reasons why burnout, fatigue, and work unit safety grades were associated with major medical errors?

A: As this study was not designed to evaluate the direction of the association, there are actually several potential explanations for our findings, and it is likely that a combination of factors is responsible for the observed relationships. Physicians experiencing burnout or excessive fatigue may be less able to concentrate on patient details, or may be less thorough in diagnostic or treatment plans. Burnout also may cause withdrawal or detachment from colleagues and patients, resulting in communication breakdowns. However, the relationship may also go the other way, with medical errors causing physicians to experience moral distress, emotional injury, or a reduced sense of personal accomplishment. Patient safety practices may be able to prevent some potential errors, but our findings show that even units with the best safety practices can't prevent all errors—and burnout still strongly associates with errors in those units.

Q: What can be done to address these interconnected areas of concern?

A: A multipronged approach will be needed. Of course, improving patient safety practices will continue to be important. However, physicians will also need to recognize that maintaining their own well-being is an important part of professionalism. Personal resilience training and mindfulness-based exercises can help foster well-being, but widespread lasting change will also require organizational improvements. Hospitals will need to find methods of improving efficiency of practice, which will vary from unit to unit, although reducing documentation and clerical burden have been nearly universally supported as necessary. Organizations also need to ensure that their physicians know that they care about their well-being, and take steps to foster a culture of wellness. These steps can include a variety of activities, such as soliciting physician input in decisions that affect their workflow, coordinating support groups or social outings, and offering protected time or other support for self-care.

Q: Is there anything you do in your own practice to prevent or treat burnout that you'd recommend to other hospital clinicians?

A: One intervention that I've found to be helpful is Three Good Things. It is a simple exercise of taking a few minutes each evening to write down a brief description of three things that went well that day. Although it may not seem like much, regularly doing this practice promotes positive psychology, helping you to find the positives rather than dwell on the negatives. Even getting into the habit of doing it for a week has been found to result in reduced depressive symptom scores as much as six months later.