Physicians who believe they have committed a major medical error in the previous three months are more likely to report symptoms of burnout and depression, which may also increase the risk of a future error, according to findings of a Mayo Clinic study published in the current issue of Journal of the American Medical Association (JAMA).
Since the Institute of Medicine's 1999 report that as many as 100,000 patients die each year because of preventable medical errors, several studies of physicians in medical and surgical residency programs have found that a significant proportion of medical trainees make medical errors. "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," says Tait Shanafelt, M.D., the Mayo Clinic physician who led the current study. "Better understanding these effects on physicians, and how they may affect the care future patients receive, is the goal of our research."
Previous studies asking residents about errors either had taken a single snapshot in time or asked residents to look back on their entire residency and recollect whether they had made a serious error. The Mayo study is the first to follow a group of residents prospectively, enabling researchers to examine the relationship between physician distress and the future likelihood of an error.
"We knew from previous studies some of the effects on physicians of making an error," explains Dr. Shanafelt. "This new study takes it a step further, enabling us to see the time relationship between errors and burnout, and vice versa."
The researchers followed 184 medical residents from 108 U.S. and international medical schools who were continuing their training in the Mayo Clinic Rochester Internal Medicine Residency program. Residents completed quarterly surveys asking, "Are you concerned you have made any major medical errors in the last three months?" They also completed validated survey instruments to measure quality of life and burnout, and to screen for depression.
On average, 14.7 percent of the participants reported making an error in the previous three months on each quarterly survey. Those who reported an error experienced substantially higher levels of burnout and were more than three times more likely to have a screening test indicate possible depression.
The connection between errors and various measures of distress also operated in reverse; those who scored high on burnout measures were twice as likely to report an error in the next three months as those with low burnout. The study also found a trend toward increased future errors for physicians with symptoms of depression.
"Not only are physicians who perceive they have made errors more likely to experience burnout and symptoms of depression, but those who are distressed appear more likely to make an error in the next three months," says Dr. Shanafelt.
"Much of the quality improvement movement has rightly focused on adjusting systems to prevent errors," says study author Colin West, M.D., Ph.D. "It's important to do whatever we can in the practice environment and care system to build in safeguards, but our study highlights the human dimension. If a physician is experiencing personal distress, it makes a future error more likely. Making an error also has a strong effect on burnout, empathy and depression, and this forms a vicious cycle that can negatively impact patient care."
The researchers say additional study is needed to identify effective approaches to assist physicians who have made medical errors, and that residency programs, HMOs, and hospital administrators should also establish efforts to prevent, identify and treat burnout in physicians, for the benefit of their patients. Mayo Clinic is committed to continue to study this problem and identify solutions, and has made several strategic changes to its residency program to address physician burnout.
The study was funded by a Medicine Innovation Development and Advancement System (MIDAS) grant from the Mayo Clinic Department of Medicine. In addition to Dr. Shanafelt and Dr. West, other authors of the paper include Mashele Huschka; Paul Novotny; Jeff Sloan, Ph.D.; Joseph Kolars, M.D. and Thomas Habermann, M.D.
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