Exhausted junior doctors putting patients’ safety at risk — NHS survey

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Patients in the UK are being put at risk by “stark” levels of exhaustion among junior doctors, laid bare in the first major survey since a new contract to make the National Health Service (NHS) safer at weekends came into force last year. The Independent reports that the General Medical Council (GMC) warned nearly a third of junior doctors say they are exhausted before the work day even begins, according to the results of its annual nationwide survey of medical training.

Safety groups said the findings would be “concerning for patients across the country” as tired doctors are more likely to make mistakes. They called on those in charge of medical education to act quickly to ensure doctors had time to care for themselves and their patients.

The report says protection for junior doctors’ training and welfare was meant to be central to the contract pushed through by health secretary Jeremy Hunt in the face of unprecedented strike action in 2016. It has affected all junior doctors since October last year, and saw “guardians of safe working hours” introduced to offset concerns about the extra weekend and evening working it required.

But the GMC findings on burnout revealed a widespread culture of long and intense hours and heavy workloads, which are “affecting doctors’ training experience and their personal wellbeing”.

The report says the regulator polled almost 52,000 doctors in training and 19,000 of their trainers across the UK. It found that almost a quarter of trainees (24%) and one in five trainers said they feel burned out because of their work. Many said they were missing training opportunities to cover staffing gaps elsewhere. Roughly one-third of trainees (32%) said they were often or always exhausted in the morning at the thought of another day at work. Half said they were always worn out by the end of the day. It also found one in five said that they feel short of sleep at work.

“Patients across the country will be concerned by these findings,” said Rachel Power, CEO of the Patients Association. “Tired doctors make more mistakes – and patient safety suffers as a result. A vulnerable person in hospital wants to be cared for by well-rested doctors who are alert and capable of making the best clinical decisions for their patients.”

Charlie Massey, CEO of the GMC, said: “Training must be protected and it must be safe, and employers need to address this urgently. But it is also important that the wider issues reported in our surveys, around work-life balance, burn-out and exhaustion, are acted on.

“We can put off no longer the need to give doctors in training – who make up a fifth of all doctors – the resources they need and deserve.”

The GMC said it is working to ensure doctors were confident that if they raised staffing concerns these would be addressed but said “it will take investment” to solve these issues.

The report says UK Prime Minister Theresa May recently announced a £20bn increase in NHS funding over the next five years, but a report by the group NHS Providers warned that nearly all of this would be used up repairing the damage of eight years of austerity.

A Department of Health and Social Care spokesperson said of the GMC figures: “We know how hard our junior doctors work and we are making sure they get the support they need to provide high-quality care for their patients – that’s why we recently announced brand new measures to help staff improve their work/life balance, as well as the biggest ever increase in training places for doctors, including five new medical schools.”

 

Physician burnout is at least equally responsible for medical errors as unsafe medical workplace conditions, if not more so, according to a study led by researchers at the Stanford University School of Medicine. “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 Dr Tait Shanafelt, director of the Stanford WellMD Centre 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.”

Shanafelt, who is also a professor of haematology and the Jeanie and Stew Ritchie professor, is the senior author. Dr Daniel Tawfik, an instructor in paediatric critical care medicine at Stanford, is the lead author.

Medical errors are common in the US. Previous studies estimate these errors are responsible for 100,000 to 200,000 deaths each year. Limited research, though, has focused on how physician burnout contributes to these errors, according to the new study.

The researchers sent surveys to physicians in active practice across the US. Of the 6,695 who responded, 3,574 – 55% – reported symptoms of burnout; 10% also reported that they had made at least one major medical error during the prior three months, a figure consistent with previous published research, the study said. The physicians were also asked to rank safety levels in the hospitals or clinics where they worked using a standardised question to assess work unit safety.

“We found that 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,” Tawfik said. “We also found that low safety grades in work units were associated with three to four times the odds of medical error.”

Shanafelt said, “This indicates both the burnout level as well as work unit safety characteristics are independently related to the risk of errors.”

Physician burnout has become a national epidemic, with multiple studies indicating that about half of all doctors experience symptoms of exhaustion, cynicism and feelings of reduced effectiveness. The new study notes that physician burnout also influences quality of care, patient safety, turnover rates and patient satisfaction.

“Today, most organisations 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,” Shanafelt said. “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.”

The study also showed that rates of medical errors actually tripled in medical work units, even those ranked as extremely safe, if physicians working on that unit had high levels of burnout. This indicates that burnout may be an even a bigger cause of medical error than a poor safety environment, Tawfik said.

“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,” Tawfik said. “This study shows that that is probably insufficient. We need a two-pronged approach to reduce medical errors that also addresses physician burnout.”

In addition to their effect on patients, both errors and burnout can also have serious personal consequences for physicians. “We also know from our previous work that both burnout and medical errors independently double the risk of suicidal thoughts among physicians,” Shanafelt said. “This contributes to the higher risk of death by suicide among physicians relative to other professionals.”

Dr Jochen Profit, associate professor of paediatrics at Stanford, and researchers at the Mayo Clinic also contributed to the study.

Abstract
Objective: To evaluate physician burnout, well-being, and work unit safety grades in relationship to perceived major medical errors.
Participants and Methods: From August 28, 2014, to October 6, 2014, we conducted a population-based survey of US physicians in active practice regarding burnout, fatigue, suicidal ideation, work unit safety grade, and recent medical errors. Multivariate logistic regression and mixed-effects hierarchical models evaluated the associations among burnout, well-being measures, work unit safety grades, and medical errors.
Results: Of 6695 responding physicians in active practice, 6586 provided information on the areas of interest: 3574 (54.3%) reported symptoms of burnout, 2163 (32.8%) reported excessive fatigue, and 427 (6.5%) reported recent suicidal ideation, with 255 of 6563 (3.9%) reporting a poor or failing patient safety grade in their primary work area and 691 of 6586 (10.5%) reporting a major medical error in the prior 3 months. Physicians reporting errors were more likely to have symptoms of burnout (77.6% vs 51.5%; P<.001), fatigue (46.6% vs 31.2%; P<.001), and recent suicidal ideation (12.7% vs 5.8%; P<.001). In multivariate modeling, perceived errors were independently more likely to be reported by physicians with burnout (odds ratio [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; OR, 1.92; 95% CI, 1.48-2.49; OR, 3.12; 95% CI, 2.13-4.58; and OR, 4.37; 95% CI, 2.06-9.28 for grades of B, C, D, and F, respectively), adjusted for demographic and clinical characteristics.
Conclusion: In this large national study, physician burnout, fatigue, and work unit safety grades were independently associated with major medical errors. Interventions to reduce rates of medical errors must address both physician well-being and work unit safety.

Authors
Daniel S Tawfik, Jochen Profit, Timothy I Morgenthaler, Daniel V Satele, Christine A Sinsky, Liselotte N Dyrbye, Michael A Tutty, Colin P West, Tait D Shanafelt

 

In South Africa a young medical intern wrote in a Facebook post that has gone viral: “You will be drunk tired at 3am wishing a terminally ill patient could keel over or you could die, so that you can rest.”

The Times reports that in a recent interview, Dr Nthabi Motaung said the emotional burnout from working long hours in public hospitals was often worse than the physical fatigue.

“I feel detached from myself most of the time‚ because I spend most of my time at work‚ so I don’t get time to reconnect with myself. When I feel detached‚ I feel like‚ ‘Who am I?’ Sometimes I ask myself‚ ‘Am I still the person that I am? Do I still like the things that I like? Do I still like my job?’

“You feel like a shell of yourself‚ because you pour so much of yourself into the system and there are so many sick people and it’s overwhelming. It’s a constant stressor‚ because you’re surrounded by sick people every day. A lot of them die‚” Motaung said.

She is quoted in the report as saying it often starts as burnout before one resorts to other coping mechanisms. “Some people engage in consuming alcohol or if you realise your symptoms‚ you go out and seek professional help from a psychologist that you can just speak to.”

According to Motaung‚ intern doctors are supposed to work 40 hours per week and be on standby for an extra 80 hours per month. “But it’s not actually 80 hours‚ because you end up having to stay beyond the 26 hours and go 30 hours of constantly working. We have hours‚ we have rules in place‚ but in reality they don’t work.”

She added: “There is not much time to teach us as well … We end up‚ especially in academic hospitals‚ being like the paper pushers‚ booking scans and all that.”

The report says the emotional and physical fatigue has led to Motaung questioning and sometimes regretting that she studied medicine in the first place‚ given that academically these students have a range of options. “In hindsight‚ I had no idea what being a doctor in South Africa entails‚” she wrote on Facebook.”

The Independent report
GMC survey
Stanford Medicine material
Mayo Clinic Proceedings abstract
The Times report


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