In the interest of protecting life, limb, and pocketbook, I've sometimes harped on the ugly statistics concerning physician error. For instance, I've written about how mistakes made by doctors cause as many as 98,000 deaths each year in the United States alone -- more than traffic accidents, breast cancer, or AIDS. I've mentioned that medical error ranks as the fifth leading cause of death, trailing right behind death by prescription drugs at 106,000 deaths per year. Protecting patients from becoming victims has been a primary concern for me, but several new studies just published in the Journal of the American Medical Association (JAMA) now turn the lens away from vulnerable patients and allow me to take a sympathetic look at some of the factors that may make doctors too frayed to do a good job. Unfortunately, though, these factors give you even more reasons to be concerned for your own health and safety.
The first study examines how fatigue and mental strain affect physician performance. It doesn't take a neurosurgeon to figure out that falling asleep on the job may lead to problems. Earlier studies, in fact, have shown a startling correspondence between doctors who work long hours and big errors. In 2006, a study out of Harvard University and Brigham and Women's Hospital in Boston reviewed monthly reports of 2307 medical residents and found that doctors who worked even one extended, 24-hour shift during the month increased the odds of reporting a "significant medical error" by 300 percent. Those who completed five extended shifts reported 700 percent more significant errors and a 300 percent increase in errors that resulted in patient death.
Similarly, earlier research identifies burnout as a risk factor. Once doctors make a serious mistake, their chances of burning out skyrocket according to a 2006 study out of the Mayo Clinic. And once the doctor burns out, his or her chances of making subsequent mistakes increases exponentially. "In addition to the obvious negative effects of errors on patients, studies have shown that the physicians involved often experience guilt, shame, distress and depression," said Tait Shanafelt, M.D., the director of that study.
Now this new study builds on previous knowledge by not only looking at the impact of fatigue and burnout, but also evaluating the impact of psychological distress on doctor performance. Distress, according to the study criteria, includes factors such as depression, financial issues, family concerns, and emotional issues. Subjects, who included 430 medical residents, underwent standardized testing to measure their emotional state and level of exhaustion every three months between 2003 and 2009. Big surprise: the results show that the most distressed and tired physicians made the most mistakes (39 percent of the subjects reported making a significant error during the study period). The next time you go to a hospital, you might want to think of Clint Eastwood's line from Dirty Harry, "Well punk, do you feel lucky?" Interestingly, depression seemed to have more of an impact on performance than even exhaustion did.
"While changes have been made to reduce fatigue and sleepiness during residency training, other changes may be necessary to more specifically address distress and burnout," said Dr. Shanafelt. "Changes to the process of physician training should address both resident fatigue and distress in an effort to improve resident and patient safety."
Of course, one man's vinegar is another man's wine. What changes are we talking about here? Medical students used to work 120 hour weeks during their residencies. Now, thanks to the changes Dr. Shanafelt refers to, some hospitals are "trying" to enforce an 80 hour per week maximum. But expecting doctors to work even 80 hours a week -- and under stressful conditions -- is still completely insane and guaranteed to leave hospital physicians exhausted and depressed.
Which brings us to the second study, also published in JAMA. That research involved 70 primary care physicians from Rochester, New York, who attended a continuing education program in "Mindful Communication." The program specifically aimed to address psychological distress, burnout, and communication skills among doctors. During the year-long program, doctors submitted to regular testing on standardized scales for mindfulness, burnout, empathy, psychosocial orientation, personality, and mood. At follow-up several months after completing the program, the doctors showed improvements in all areas, with a 17 percent reduction in mood disturbance, a nine percent increase in mindfulness and an almost seven percent reduction in burnout. Good for them…and their patients.
The fact is that medical doctors experience burnout and depression at alarming rates. Doctors commit suicide at six times the rate found in the general population, with even modest estimates assuming that 30 percent of doctors suffer from depression. Studies of physicians in private practice have found burnout rates exceeding 60 percent. The reasons for physician distress may include factors such as debt, pressures exerted by the HMO system, easy access to drugs, and the aforementioned lack of sleep and guilt over mistakes made in providing care to patients.
So back to the idea of protecting life, limb, and pocketbook. What all the previous adds up to is the fact that the health care system depends on sleep-deprived, depressed, burned out healers with free actions to an entire world of pharmaceutical drugs. Without doubt, this is a recipe for disaster.
Assuming that at least some of those healers started their careers with good intent, plenty of brains and a fair amount of expertise, it seems that a key component in healthcare reform needs to address how physicians get trained and treated so that they can thrive and perform optimally. Certainly, communication skills need to be taught before doctors have scalpel in hand, rather than long afterwards. And certainly, doctors need as much sleep as auto mechanics and chefs and even patients so that the scalpel doesn't go haywire as the physician nods off.
Finally, physicians need psychological support to deal with the extraordinary pressures they face. Insurance companies could probably reduce malpractice payouts if they demanded that their covered doctors undergo regular psychological screening. And those doctors also would benefit from access to nutraceuticals and some dietary guidance so they can lift their mood naturally, without resorting to the drugs they can so easily acquire and so often turn to.