If the human and economic impacts of the epidemic of physician burnout are not enough to motivate systemic change, then perhaps the impact on patients will focus minds. Emerging evidence supports an increasingly robust link between physician burnout and medical error. Burned out doctors seem to make more mistakes, patients get harmed, and everyone loses. This article explores the evidence between physician burnout and medical error, and the impact on patients.
Medical error is the 3rd leading cause of death in the US after heart disease and cancer, according to a report in BMJ. These shocking statistics are more so, given that medical care is intended to reduce risk of death. There is also growing evidence that physician burnout may impact patient safety, possibly by contributing to medical errors, which are responsible for an estimated 100,000 – 200,000 deaths in US hospitals every year.
A 2016 meta-analysis confirmed that poor physician wellbeing and moderate to high levels of burnout were associated with poor patient safety outcomes such as medical errors, however, a lack of prospective studies reduced the ability to determine causality.
A recent study by Daniel Tawfik MD and colleagues surveyed 6,695 U.S. doctors on whether they experienced symptoms of burnout or fatigue or suicidal thoughts, and whether they had made any major medical errors in the previous three months. The demographics and specialties of physicians in the survey were considered representative of the general U.S. physician population.
Overall, 10.5 percent of study participants reported having made a major medical error recently, including errors in judgment, a mistaken diagnosis, or a technical error. Fifty-five percent of the errors did not affect patient outcomes, however, some 5.3 percent led to permanent health problems and 4.5 percent to a patient’s death.
Seventy-eight percent of the doctors who reported errors had symptoms of burnout, compared to 52% of those who did not report errors. The physicians who made mistakes were also more likely to have high levels of fatigue (78 percent vs. 52 percent), and to have had recent suicidal thoughts (13 percent vs. 6 percent). The relationship between physician burnout and medical errors was very strong even after the researchers adjusted for work unit safety grades.
Physicians with burnout had more than twice the odds of self-reported medical error, after adjusting for specialty, work hours, fatigue, and “work unit safety rating”. Low safety grades in work units were associated with three to four times the odds of medical error, so safety grades are an essential area to address – as we said this is a systemic issue.
According to Tawfik and his colleagues, the observed association between burnout and errors is not limited to individuals at the extremes of the burnout spectrum; rather, it shows a continuum: Institutions tend to focus on what proportion of physicians are ‘burned out’, however, this study suggests that improving physician well-being can help prevent errors even if they are not burned out.
While the Tawfik study above does not confirm directionality, the relationship is likely to be bidirectional according to the authors.
An earlier study found that healthcare staff involved in a patient safety incident could become a “second victim”. This survey of nurses and physicians found that staff experience significant negative outcomes in the aftermath of a patient safety incident.
These outcomes included more than twice the odds of burnout, nearly twice the risk of problematic medication use, as well as more turnover intentions. Where the incident resulted in harm to the patient, these odds increased further.
The Tawfik et al study (above) does however give us hope: just a 1 point decrease on the 30 to 55-point burnout severity scale was linked to fewer reported medical errors.
This implies that lower levels of burnout severity are associated with fewer medical errors, hence better patient safety. While the study does not prove causality like a prospective trial might (imagine the ethics application on that study…) it makes intuitive sense: happier, healthier doctors make fewer mistakes, and everyone benefits.
Physician burnout and medical error are indeed systemic, complex, and entrenched problems, as we have previously published in Sick physicians – sick system. Yet just reducing hours worked will not necessarily solve burnout or indeed medical error.
Moreover, there are barriers to sick doctors getting help, as we wrote about in Why don’t struggling physicians seek help?
Furthermore, health care workers who feel they need time away worry deeply about how that will be perceived. Will it affect their ability to remain employed and be perceived as productive and competent? Will it affect their careers or license to practice?
While fear is a key barrier to reaching out, denial is a high and sometimes impenetrable wall. The burned-out physicians who are a real liability are the ones in denial. These colleagues (myself included) are physicians who harm more than just themselves.
There is an undeniable link between physician burnout and medical error sometimes resulting in harm to patients, or even death.
Addressing and reducing physician burnout is not just an economic imperative, it is an ethical and moral obligation, because of the impact on both patients and physicians. Reducing burnout is a win-win.
One way to overcome barriers to getting help is anonymity: hence Physicians Anonymous has set up safe, confidential, physician-only peer-support groups.
We trust that these groups will allow suffering and struggling doctors to support each other in safe spaces, as brothers and sisters in the medical family. By creating happier, healthier doctors, everyone’s a winner.