Making medical errors because of fatigue


The study linked doctors' burnout rate to factors including a “chaotic work environment or lack of control over that work environment”. — TNS

Physicians experience extremely high levels of burnout, and that’s contributing to medical errors.

That’s the conclusion of a new Mayo Clinic study (in August 2018) that found more than half of the physicians in the United States experience burnout, defined as either emotional exhaustion or a feeling of distance from a one’s job and colleagues, said Dr Christine Sinsky, the vice president of professional satisfaction at the American Medical Association and a researcher on the study.

Those findings resonate with Dr Albert Chan, chief of digital patient experience for Sutter Health, California, and a family medicine doctor.

“Our physician culture (is) very much a culture of: put the patients first, which we always do and still do,” he said. “But sometimes, it’s at the expense of ourselves. And increasingly we understand that that’s not a healthy thing.”

The study, published in Mayo Clinic Proceedings, compiled survey results from 6,695 physicians in the US responding to topics like fatigue, burnout, thoughts of suicide and workplace safety.

Thirty-two percent of respondents reported feeling excessive fatigue and more than 10% said they had committed what they considered to be a major medical error in the three months prior to taking the survey.

The physicians who reported major medical errors also acknowledged higher levels of burnout.

Of the 663 physicians who reported medical errors, nearly 40% said the mistakes were caused by errors in judgment and 20% attributed them to an incorrect diagnosis.

“The study found that there’s two times the rate of perceived error when physicians are burned out,” Dr Sinsky said.

The survey asked physicians to give their work areas a grade based on patient safety.

Burnout was found to be more likely in areas with low safety grades, but it also occurred in areas with high safety grades.

“High burnout, even in an excellent safety environment, is nearly as risky as no burnout in a unit that had a poor safety grade,” she said.

Medical errors are responsible for 100,000 to 200,000 patient deaths every year in the US, according to the study.

The study linked burnout rate to factors including a “chaotic work environment or lack of control over that work environment”, said Dr Sinsky.

Another factor is work that takes physicians away from direct patient care.

“(There is) a great increase in the amount of administrative and clerical work,” she said. “That disconnects physicians from the reason why they went into the profession in the first place and that’s a source of burnout.”

Physicians can be slow to seek out personal help, sometimes resorting to self care and end up committing suicide at a rate that exceeds national averages, the study reports.

Dr Peter Yellowlees, a professor of psychiatry and the vice-chair for faculty development in the University of California (UC), Davis, Department of Psychiatry, has researched the suicide issue.

“It’s estimated there’s something like 400 physicians a year in American suicide – that’s the equivalent of two large medical school classes,” said Dr Yellowlees, who recently published a book titled Physician Suicide Cases and Commentary.

As a practising psychiatrist, he sees physicians as clients. These physicians come from a variety of health groups, including UC Davis, Sutter Health, Kaiser Permanente and Mercy General Hospital, as well as private practice.

Burnout is a minor psychiatric problem that can have more severe implications, he said.

“I think it’s pretty clear burnout can act as a trigger,” he said. “We know that there are lots of causes of depression. If you are then in a situation where you’re feeling very burnt out through your work, it can be a trigger.”

In addition to its effect on physicians, burnout also hurts physicians’ families and their patients in various ways.

“We know that patients are less adherent to our treatment recommendations when physicians are burned out, physicians show less empathy to their patients when burned out, and physicians are less satisfied with their care,” Dr Sinsky said.

“Physicians and other clinicians who are burned out are at higher risk of divorce, diseases such as coronary artery disease, drug and alcohol abuse.”

In the 16 years Dr Chan has been in practice, he said he’s never experienced burnout. But he’s seen the impact on his colleagues.

“At a minimum, we spend 11-plus years to get where we’re at and to reach the end of your training, which is really just the beginning of your career, and you wonder if you should continue to be a physician and you’re fatigued – that’s a concern,” he said.

Californian health providers like Sutter and Kaiser are aware of these issues and are actively working to reduce the number of stressors affecting physicians.

A feature story published by Kaiser in 2017 addressed the health group’s active and ongoing focus on improving the mental health and well-being of its medical students and staff.

Efforts by Kaiser include providing wellness services like nutrition counselling and teaching students “resilience and coping skills”.

In the summer of 2016, Sutter encouraged its providers to engage in acts of gratitude during a two-month campaign aimed at reducing burnout.

And the Sierra Sacramento Valley Medical Society hosts the annual Joy of Medicine summit, which looks to connect local physicians and help them bring joy back into their profession.

Some researchers looking into physician burnout have criticised similar efforts, saying they blame physicians instead of broader issues and employers for burnout.

“It’s more nuanced, I think,” Dr Yellowlees said. “It’s absolutely true that you can’t resilience yourself out of burnout. It’s undoubtedly the organisational issues that cause burnout and that need changing.

“That’s why most groups... are trying to change the organisational culture. And you’ve got to avoid blaming physicians.”

But because physicians tend not to seek out care, it can be important for health systems or organisations to encourage physicians to do so, he said.

Dr Sinsky said she thinks change on a systemic level will yield more long-term results.

“It’s my observation that 80% of burnout is driven by system factors and only 20% is driven by individual factors,” she said. “We really get more for our investments if we invest in system factors that reduce burnout.”

The American Medical Association and Sutter Health are looking into regulatory issues that can add to the administrative load on physicians.

Maintenance of electronic health records is one time-consuming area both groups mentioned.

Dr Chan mentioned research published by Health Affairs, which found physicians spend around 3.08 hours in face-to-face interactions with patients and 3.17 hours interacting with electronic health records and other virtual tasks every day.

Sutter is one of several healthcare systems that use a system developed by Augmedix Inc. that connects physicians with a remote, trained scribe.

Physicians wear Google Glass during appointments with patients and the technology allows the remote scribes, who take notes and provide medics with information, to sit in on the appointment.

Sutter patients are made aware of the remote digital assistant beforehand and there is a 98% patient acceptance rating for the service, used in doctors’ offices in areas including Sacramento and the Central Valley, said a Sutter spokesperson.

This service allows providers more time doing the face-to-face work they most enjoy.

Reducing burnout among physicians is important both to ensure quality of care and because burnout is one of the reasons behind the nationwide physician shortage, Dr Sinsky said.

The Association of American Medical Colleges projects a shortage of up to 100,000 doctors by the year 2030.

Dr Sinsky referenced data from surveys completed in 2007 and 2014 that predict 2% of physicians are highly likely to leave the medical profession. That can be reduced if the job is made more fulfilling.

“Anything that gets in the way of physicians being able to provide that high quality care is likely a contributor to burnout,” she said. “This is a solvable problem. I believe that we can work more productively together to begin to solve these problems.” – The Sacramento Bee/Tribune News Service

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