Physician burnout triples the incidence of medical errors

Physician burnout is more likely to cause medical errors than unsafe medical workplace conditions, according to a recent study published in Mayo Clinic Proceedings. Furthermore, the study researchers concluded that both physician well-being and work unit safety must be addressed to reduce medical errors.

Medical errors are responsible for 100,000 to 200,000 deaths per year. Physician burnout has become a national epidemic, with about 50% of all physicians experiencing symptoms of exhaustion and cynicism, as well as feelings of reduced effectiveness. 

"If we are trying to maximize the safety and quality of medical care, we must address the factors in the work environment that lead to burnout among our health-care providers," said senior author Tait Shanafelt, MD, professor of hematology, and director, Stanford WellMD Center, Stanford University School of Medicine, Stanford, CA, and associate dean of the School of Medicine. "Many system-level changes have been implemented to improve safety for patients in our medical workplaces. What we find in this study is that physician burnout levels appear to be equally, if not more, important than the work unit safety score to the risk of medical errors occurring."

Dr. Shanafelt and colleagues conducted this large, national, population-based survey of US physicians in active practice from August 28, 2014, to October 6, 2014. The 60-question survey covered burnout, fatigue, suicidal ideation, work unit safety grade, and recent medical errors.

Upon tallying responses from 6,586 physicians (67% male), they found that 54.3% reported symptoms of burnout, 32.8% cited excessive fatigue, and 6.5% reported recent suicidal ideation. In addition, 3.9% acknowledged a poor or failing patient safety grade in their primary work areas, and 10.5% admitted making a major medical error in the previous 3 months.

The most common were errors in judgment (39.2%), wrong diagnosis (20.0%), or technical mistakes (13.0%). Although 55.4% had no perceived effects on patient outcomes, 5.3% of medical errors resulted in “significant permanent morbidity” and 4.5% in patient death.

Upon further analysis, Dr. Shanafelt and colleagues found that physicians who reported medical errors were more likely to have symptoms of burnout (77.6% vs 51.5%; P < 0.001), fatigue (46.6% vs 31.2%; P < 0.001), and recent suicidal ideation (12.7% vs 5.8%; P < 0.001).

Upon multivariate logistic regression, they determined that perceived errors were independently more likely to be reported by physicians with burnout (OR: 2.22; 95% CI: 1.79-2.76) or fatigue (OR: 1.38; 95% CI: 1.15-1.65), and those with incrementally worse work unit safety grades (OR: 1.70, 95% CI: 1.36-2.12 for a grade of B; OR: 1.92, 95% CI: 1.48-2.49 for a grade of C; OR: 3.12, 95% CI: 2.13-4.58 for a grade of D; and OR: 4.37, 95% CI: 2.06-9.28 for a grade of F).

The odds of perceived medical errors decreased by 1% for each year of increased age and increased by 4% for each additional night on call per week. Upon multivariate analysis, radiology and emergency medicine were associated with higher self-reported medical errors, and pediatric subspecialties, psychiatry, and anesthesiology with a lower rate of perceived medical errors.

Dr. Shanafelt and fellow researchers also found that the incidence of medical errors tripled even in medical units that were rated as extremely safe when physicians had high levels of burnout. Thus, they concluded, burnout may be a greater cause of medical errors than poor safety in the environment.

"Up until just recently, the prevailing thought was that if medical errors are occurring, you need to fix the workplace safety with things like checklists and better teamwork. This study shows that that is probably insufficient. We need a two-pronged approach to reduce medical errors that also addresses physician burnout," said lead author Daniel Tawfik, MD, MS, instructor, pediatric critical care medicine, Stanford University.

"Today, most organizations invest substantial resources and have a system-level approach to improve safety on every work unit. Very few devote equal attention to address the system-level factors that drive burnout in the physicians and nurses working in that unit," said Dr. Shanafelt. "We need a holistic and systems-based approach to address the epidemic of burnout among health-care providers if we are truly going to create the high-quality health-care system we aspire to."

Is smaller better?

In a related study regarding physician burnout, researchers found that doctors who work in small, independent, primary-care practices have a much lower rate of burnout than the national average (13.5% vs 54.4%). Researchers from the New York University School of Medicine, New York, NY, published their results in the Journal of the American Board of Family Medicine.

Although they focused on a small representative sample of physicians working in small practices in New York City, researchers noted that their findings may show that the independence and sense of autonomy that physicians have in a small practice may confer some protection against burnout.

This study was supported by the National Institutes of Health, the Jackson Vaughan Critical Care Research Fund, the Mayo Clinic Program on Physician Well-Being, the American Medical Association, the Mayo Clinic Program on Physician Well-Being, and Stanford's Department of Medicine.