Physician Wellness and Patient Safety

Abstract

Imagine you are flat on your back on a stretcher, being wheeled into an operating room, and about to undergo a substantial abdominal procedure. You have a choice of 2 equally competent and experienced surgeons. One surgeon suffers from emotional exhaustion, the feeling that “I have nothing left to give,” while the other is fully engaged, and loves the practice of surgery. Which would you choose? The answer is obvious. All surgeons assume that mental distress could influence performance, but no actual data existed to support this assumption until the excellent work, appearing in this month’s Annals of Surgery, by Shanafelt et al, entitled “Burnout and Medical Errors Among American Surgeons.” The authors demonstrate convincingly that mental distress is associated with medical error. It would be difficult for a patient to know whether a surgeon was burned out or depressed, but one would hope that redundant safety net systems, now present in most hospitals, would mitigate against whatever error the burned out surgeon might make. A common example might be insulin dose checking by at least 2 nurses at the bedside, or, from a more surgical perspective, the routine use of a preoperative checklist. Such systems do work to increase patient safety, but here is where Shanafelt et al make their most important point: the practice of surgery might be less amenable to such system based approaches to safety. Indeed, twice as many surgeons having committed a recent medical error felt that the error was due to a “lapse in judgment” by the individual surgeon rather than a system failure (32% vs. 15%). In all, 70% of errors were thought due to individual factors, which, including the judgment problem, also meant burnout or stress, or a lapse in concentration. What an “error in judgment” meant specifically is not clear, but we are surgeons, and one could infer that some, or perhaps most, involved an intraoperative decision or maneuver. Other studies have supported the theory that most errors made by surgeons are technical in nature, or judgments that lead to an inappropriate operation or delayed diagnosis. This category of error seems inherently less correctable by relying on systems of care: surgeons are individuals; the individual makes the decisions and performs the surgery. While not denying that system-based approaches to safety in surgery are important—they certainly are—the work by Shanafelt et al suggest that another very important, and largely overlooked strategy to improve safety in surgery should be directed toward the mental health of the surgeon. It could be argued that making a medical error leads to burnout and depression, rather than the other way around. If this were true a stress reduction strategy aimed at reducing medical error would seem less logical. The study in question is cross sectional in design, and thus sheds no light on this stress–error, chicken, or egg problem. However, it may not matter, because other recent work suggests that the relationship is in fact bi-directional. Sen et al followed 740 interns longitudinally throughout their internship, and saw that higher levels of mental distress (depression) seemed to predispose to error, and that committing an error predisposed to subsequent depression (Sen et al, unpublished data). What seems clear is that a broad strategy to reduce errors could logically be based on attention to both the individual and to the system in which the individual functions. On an individual level one might assume that physical fatigue would be associated with mental fatigue and error, but the Shanafelt data do not support this association. After controlling for different levels of distress using multivariable analysis, no association was found between medical errors and hours worked per week, or number of nights on call per week. So the clue here might be that a work restriction approach might not be the most productive error reduction strategy, because it is actually mental, not physical fatigue that underlies the problem. To be fair, there is another body of work that would disagree. Nevertheless, I think most surgeons are willing to be tired, within reason, if they love what they do. This means that an important direction for the safety-in-surgery effort must involve some level of individual introspection, often done at a midcareer time point, about how we surgeons feel about being surgeons; do we love it or not? My experience, based on a previous survey of several hundred Midwestern surgeons, was that the underpinnings of burnout were an imbalance between work, family, and personal growth and loss of the sense of “meaning” one once had in the practice of surgery. If we have lost either, we need to understand why. Perhaps