Tait D. Shanafelt

Burnout and medical errors among American surgeons.

Objective:To evaluate the relationship between burnout and perceived major medical errors among American surgeons. Background:Despite efforts to improve patient safety, medical errors by physicians remain a common cause of morbidity and mortality. Methods:Members of the American College of Surgeons were sent an anonymous, cross-sectional survey in June 2008. The survey included self-assessment of major medical errors, a validated depression screening tool, and standardized assessments of burnout and quality of life (QOL). Results:Of 7905 participating surgeons, 700 (8.9%) reported concern they had made a major medical error in the last 3 months. Over 70% of surgeons attributed the error to individual rather than system level factors. Reporting an error during the last 3 months had a large, statistically significant adverse relationship with mental QOL, all 3 domains of burnout (emotional exhaustion, depersonalization, and personal accomplishment) and symptoms of depression. Each one point increase in depersonalization (scale range, 0–33) was associated with an 11% increase in the likelihood of reporting an error while each one point increase in emotional exhaustion (scale range, 0–54) was associated with a 5% increase. Burnout and depression remained independent predictors of reporting a recent major medical error on multivariate analysis that controlled for other personal and professional factors. The frequency of overnight call, practice setting, method of compensation, and number of hours worked were not associated with errors on multivariate analysis. Conclusions:Major medical errors reported by surgeons are strongly related to a surgeons degree of burnout and their mental QOL. Studies are needed to determine how to reduce surgeon distress and how to support surgeons when medical errors occur.

Burnout and Suicidal Ideation among U.S. Medical Students

Death by suicide is a major occupational hazard for physicians (1). The suicide rate among male physicians is more than 40% higher than among men in the general population, whereas that of female physicians is a staggering 130% higher than among women in the general population (1, 2). The increased risk for suicide among physicians may begin during medical school (3). Available studies suggest that the suicide rate among medical students is higher than in the age-matched population (35). Other small, single-institution studies (610) have reported that 3% to 15% of medical students have suicidal ideation during medical school training. Suicidal ideation is a well-established predictor of suicidal planning and attempts. The National Comorbidity Survey found that 34% of individuals in the general population with suicidal ideation develop a suicide plan and, of those who plan, more than 70% will attempt suicide (11). Notably, 26% of individuals with suicidal ideation progressed directly to an unplanned suicide attempt (11). Suicide is at the extreme end of the personal distress continuum, and it is critical for medical schools to identify students at greatest risk for suicide in the hope of intervening before a tragic outcome. Several multi-institutional studies (1214) reveal that medical students have a substantially lower mental quality of life than similarly aged individuals in the general population and that burnout affects up to 50% of U.S. medical students. We hypothesized that burnout would relate to suicidal ideation among medical students. We used a mixed longitudinal and cross-sectional study design to evaluate the prevalence of suicidal ideation among U.S. medical students and to evaluate the relationship between suicidal ideation and burnout, symptoms of depression, and quality of life. Our objective was to assess the frequency of suicidal ideation among medical students and explore its relationship with burnout. Methods Participants In the spring of 2006 (baseline) and 2007 (1-year follow-up), we invited all medical students at the Mayo Medical School, University of Washington School of Medicine, University of Chicago Pritzker School of Medicine, University of Minnesota Medical School, and University of Alabama School of Medicine to complete Web-based surveys. Students at the University of California San Diego School of Medicine and Uniformed Services University of the Health Sciences also participated in the 2007 survey. Participation was elective, and responses were anonymized. We included all students who responded to the 2007 survey in the cross-sectional analysis and those who responded in both 2006 and 2007 in the longitudinal analysis. Each institutions institutional review board approved the study before participation of their students. Data Collection Participants returned the surveys electronically. Preserving student confidentiality was an essential feature. We linked individual responses on the 2006 and 2007 surveys for longitudinal analysis by using unique identifiers and stripped all data of identifiers before forwarding them to study statisticians for analysis. Study Measures We used established instruments to measure burnout, symptoms of depression, and quality of life on both the 2006 and 2007 surveys. These surveys also included questions about demographic characteristics, and the 2007 survey included questions about suicidal ideation. Suicidal Ideation We assessed suicidal ideation by asking students: Have you ever had thoughts of taking your own life, even if you would not really do it?, During the past 12 months have you had thoughts of taking your own life?, and Have you ever made an attempt to take your own life? These questions, which originated from an inventory developed by Meehan and colleagues (15) that has been used to assess suicidal ideation among medical students (9), are similar to questions used in large U.S. epidemiologic studies intended to assess suicidality (11, 1618). Burnout, Symptoms of Depression, and Quality of Life The Maslach Burnout Inventory is a 22-item instrument that is considered the gold standard for measuring burnout (1921). This instrument has separate subscales to evaluate each domain of burnout: emotional exhaustion, depersonalization, and low personal accomplishment. Tests of discriminant and convergent validity have been acceptable, construct validity of the 3 dimensions has been demonstrated (22, 23), and predictive validity has been suggested by burnout score predicting risk for future sick leave absences (24). The Maslach Burnout Inventory has also been used extensively in studies of both physicians (20,21, 25) and medical students (13, 14, 2628). According to convention, a score of 27 or higher on the emotional exhaustion subscale or 10 or higher on the depersonalization subscale was considered an indicator of professional burnout for medical professionals (19). Health professionals are considered to have a low score on the personal accomplishment scale if their score is 33 or less. Normal scores for health care professionals, including physicians, are 22.19, 7.12, and 36.53 on the emotional exhaustion, depersonalization, and personal accomplishment subscales, respectively (19). We identified symptoms of depression by using the 2-item Primary Care Evaluation of Mental Disorders (29), a screening tool which performs as well as longer instruments (30). This instrument has a sensitivity of 86% to 96% and a specificity of 57% to 75% for major depressive disorder (29, 30). With a reported positive likelihood ratio of up to 3.42 for the diagnosis of major depression (30) and an estimated 25% prevalence of depression among medical students (12), a positive result implies a 50% probability of current major depression. We measured mental and physical quality of life by using the Medical Outcomes Study Short Form-8 (SF-8) (31, 32), an alternate version of the SF-36. Norm-based scoring methods of responses on this instrument are used to calculate mental and physical quality of life summary scores (31). The mean mental and physical quality of life summary scores for the U.S. population are 49.2 (SD, 9.46) and 49.2 (SD, 9.07), respectively (31). Previous research has demonstrated acceptable reliability and testretest reliability (31). Several studies (31) have demonstrated content, construct, and criterion-related validity for the SF-8, and other studies (33) have demonstrated high convergent validity and good discriminate validity. The SF-8 has also been used in samples of residents (32) and medical students (14, 27, 28). Statistical Analysis Our primary analysis involved descriptive summary statistics for estimating the prevalence of suicidal ideation, burnout, a positive depression screen, and mental and physical quality of life for medical students. We evaluated differences by reported suicidal ideation in the previous year by using the WilcoxonMannWhitney test (for continuous variables) and the Fisher exact test (for categorical variables). We used the Wilcoxon rank-sum test rather than parametric tests to account for the interval level nature of the psychological tests. All tests were 2-sided, with a type I error rate of 0.05. We performed collinearity testing to determine whether multiple-way collinearity existed among the independent variables (34). No variables had achieved a level of collinearity that would bias the modeling process. We performed forward stepwise logistic regression to evaluate independent associations of the independent variables with suicidal ideation. We used a saturated model and backward stepping to confirm results of the initial stepwise regression. In all cases, backward stepping produced the same model as the stepwise approach. All analyses were done by using SAS, version 9 (SAS Institute, Cary, North Carolina). Role of the Funding Source This work was supported by an Education Innovation award from the Mayo Clinic. The Mayo Clinic played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation of the manuscript or decision to publish the manuscript. Results Cross-Sectional Survey A total of 2248 (52.4%) of 4287 medical students responded to the 2007 survey. Responders were less likely than the overall population to be male (51.6% vs. 54.9%), between 25 and 30 years of age (55.4% vs. 62.4%), or nonwhite (25.8% vs. 31.0%) (all P< 0.02). Table 1 shows the demographic characteristics of cross-sectional survey respondents. Table 1. Participant Characteristics, 2007 Table 2 shows the percentage of responders reporting suicidal ideation, burnout, and symptoms of depression and the mean quality-of-life scores. Of the 2230 responders on the 2007 survey who responded to questions on suicidal ideation, 249 (11.2% [CI, 9.9% to 12.6%]) reported considering suicide in the previous year and 43 (1.9% [CI, 1.4% to 2.6%]) had made a suicide attempt at some point in the past. On sensitivity analysis, assuming that all nonresponders did not have suicidal ideation, the prevalence of suicidal ideation in the past 12 months would be 249 (5.8%) of 4287 students. Table 2. Burnout, Quality of Life, and Depression Symptoms, 2007 Overall, 1069 (49.6%, [CI, 47.5%51.8%]) of 2154 students met the criteria for burnout (94 students did not answer enough Maslach Burnout Inventory questions to be included in this analysis). Among these students, 860 (40.1%) of 2142 had high emotional exhaustion, 648 (31.8%) of 2037 had high depersonalization, and 595 of 1945 (30.6%) had a low sense of personal accomplishment. Compared with age-comparable individuals and the general U.S. population, medical students had lower mental quality-of-life scores (mean, 43.5 [SD, 11.0] vs. 47.2 [SD, 9.9] for age-comparable individuals [P< 0.001] and 49.2 [SD, 9.5] for the general U.S. population [P< 0.001]) but higher physical quality-of-life scores (mean, 52.2 [6.9] vs. 51.4 [SD, 7.9] for age-comparable

Association of Resident Fatigue and Distress With Perceived Medical Errors

CONTEXT Fatigue and distress have been separately shown to be associated with medical errors. The contribution of each factor when assessed simultaneously is unknown. OBJECTIVE To determine the association of fatigue and distress with self-perceived major medical errors among resident physicians using validated metrics. DESIGN, SETTING, AND PARTICIPANTS Prospective longitudinal cohort study of categorical and preliminary internal medicine residents at Mayo Clinic, Rochester, Minnesota. Data were provided by 380 of 430 eligible residents (88.3%). Participants began training from 2003 to 2008 and completed surveys quarterly through February 2009. Surveys included self-assessment of medical errors, linear analog self-assessment of overall quality of life (QOL) and fatigue, the Maslach Burnout Inventory, the PRIME-MD depression screening instrument, and the Epworth Sleepiness Scale. MAIN OUTCOME MEASURES Frequency of self-perceived, self-defined major medical errors was recorded. Associations of fatigue, QOL, burnout, and symptoms of depression with a subsequently reported major medical error were determined using generalized estimating equations for repeated measures. RESULTS The mean response rate to individual surveys was 67.5%. Of the 356 participants providing error data (93.7%), 139 (39%) reported making at least 1 major medical error during the study period. In univariate analyses, there was an association of subsequent self-reported error with the Epworth Sleepiness Scale score (odds ratio [OR], 1.10 per unit increase; 95% confidence interval [CI], 1.03-1.16; P = .002) and fatigue score (OR, 1.14 per unit increase; 95% CI, 1.08-1.21; P < .001). Subsequent error was also associated with burnout (ORs per 1-unit change: depersonalization OR, 1.09; 95% CI, 1.05-1.12; P < .001; emotional exhaustion OR, 1.06; 95% CI, 1.04-1.08; P < .001; lower personal accomplishment OR, 0.94; 95% CI, 0.92-0.97; P < .001), a positive depression screen (OR, 2.56; 95% CI, 1.76-3.72; P < .001), and overall QOL (OR, 0.84 per unit increase; 95% CI, 0.79-0.91; P < .001). Fatigue and distress variables remained statistically significant when modeled together with little change in the point estimates of effect. Sleepiness and distress, when modeled together, showed little change in point estimates of effect, but sleepiness no longer had a statistically significant association with errors when adjusted for burnout or depression. CONCLUSION Among internal medicine residents, higher levels of fatigue and distress are independently associated with self-perceived medical errors.

Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014.

OBJECTIVE To evaluate the prevalence of burnout and satisfaction with work-life balance in physicians and US workers in 2014 relative to 2011. PATIENTS AND METHODS From August 28, 2014, to October 6, 2014, we surveyed both US physicians and a probability-based sample of the general US population using the methods and measures used in our 2011 study. Burnout was measured using validated metrics, and satisfaction with work-life balance was assessed using standard tools. RESULTS Of the 35,922 physicians who received an invitation to participate, 6880 (19.2%) completed surveys. When assessed using the Maslach Burnout Inventory, 54.4% (n=3680) of the physicians reported at least 1 symptom of burnout in 2014 compared with 45.5% (n=3310) in 2011 (P<.001). Satisfaction with work-life balance also declined in physicians between 2011 and 2014 (48.5% vs 40.9%; P<.001). Substantial differences in rates of burnout and satisfaction with work-life balance were observed by specialty. In contrast to the trends in physicians, minimal changes in burnout or satisfaction with work-life balance were observed between 2011 and 2014 in probability-based samples of working US adults, resulting in an increasing disparity in burnout and satisfaction with work-life balance in physicians relative to the general US working population. After pooled multivariate analysis adjusting for age, sex, relationship status, and hours worked per week, physicians remained at an increased risk of burnout (odds ratio, 1.97; 95% CI, 1.80-2.16; P<.001) and were less likely to be satisfied with work-life balance (odds ratio, 0.68; 95% CI, 0.62-0.75; P<.001). CONCLUSION Burnout and satisfaction with work-life balance in US physicians worsened from 2011 to 2014. More than half of US physicians are now experiencing professional burnout.

Burnout and career satisfaction among American surgeons.

Objective:To determine the incidence of burnout among American surgeons and evaluate personal and professional characteristics associated with surgeon burnout. Background:Burnout is a syndrome of emotional exhaustion and depersonalization that leads to decreased effectiveness at work. A limited amount of information exists about the relationship between specific demographic and practice characteristics with burnout among American surgeons. Methods:Members of the American College of Surgeons (ACS) were sent an anonymous, cross-sectional survey in June 2008. The survey evaluated demographic variables, practice characteristics, career satisfaction, burnout, and quality of life (QOL). Burnout and QOL were measured using validated instruments. Results:Of the approximately 24,922 surgeons sampled, 7905 (32%) returned surveys. Responders had been in practice 18 years, worked 60 hours per week, and were on call 2 nights/wk (median values). Overall, 40% of responding surgeons were burned out, 30% screened positive for symptoms of depression, and 28% had a mental QOL score >1/2 standard deviation below the population norm. Factors independently associated with burnout included younger age, having children, area of specialization, number of nights on call per week, hours worked per week, and having compensation determined entirely based on billing. Only 36% of surgeons felt their work schedule left enough time for personal/family life and only 51% would recommend their children pursue a career as a physician/surgeon. Conclusion:Burnout is common among American surgeons and is the single greatest predictor of surgeons’ satisfaction with career and specialty choice. Additional research is needed to identify individual, organizational, and societal interventions that preserve and promote the mental health of American surgeons.

Burnout Among U.S. Medical Students, Residents, and Early Career Physicians Relative to the General U.S. Population

Purpose To compare the prevalence of burnout and other forms of distress across career stages and the experiences of trainees and early career (EC) physicians versus those of similarly aged college graduates pursuing other careers. Method In 2011 and 2012, the authors conducted a national survey of medical students, residents/fellows, and EC physicians (⩽ 5 years in practice) and of a probability-based sample of the general U.S. population. All surveys assessed burnout, symptoms of depression and suicidal ideation, quality of life, and fatigue. Results Response rates were 35.2% (4,402/12,500) for medical students, 22.5% (1,701/7,560) for residents/fellows, and 26.7% (7,288/27,276) for EC physicians. In multivariate models that controlled for relationship status, sex, age, and career stage, being a resident/fellow was associated with increased odds of burnout and being a medical student with increased odds of depressive symptoms, whereas EC physicians had the lowest odds of high fatigue. Compared with the population control samples, medical students, residents/fellows, and EC physicians were more likely to be burned out (all P < .0001). Medical students and residents/fellows were more likely to exhibit symptoms of depression than the population control samples (both P < .0001) but not more likely to have experienced recent suicidal ideation. Conclusions Training appears to be the peak time for distress among physicians, but differences in the prevalence of burnout, depressive symptoms, and recent suicidal ideation are relatively small. At each stage, burnout is more prevalent among physicians than among their peers in the U.S. population.

How do distress and well-being relate to medical student empathy? A multicenter study.

ObjectiveTo determine whether lower levels of empathy among a sample of medical students in the United States are associated with personal and professional distress and to explore whether a high degree of personal well-being is associated with higher levels of empathy.DesignMulti-institutional, cross-sectional survey.SettingAll medical schools in Minnesota (a private medical school, a traditional public university, and a public university with a focus in primary care).ParticipantsA total of 1,098 medical students.MeasurementsValidated instruments were used to measure empathy, distress (i.e., burnout and symptoms of depression), and well-being (high quality of life).ResultsMedical student empathy scores were higher than normative samples of similarly aged individuals and were similar to other medical student samples. Domains of burnout inversely correlated with empathy (depersonalization with empathy independent of gender, all P < .02, and emotional exhaustion with emotive empathy for men, P = .009). Symptoms of depression inversely correlated with empathy for women (all P ≤ .01). In contrast, students’ sense of personal accomplishment demonstrated a positive correlation with empathy independent of gender (all P < .001). Similarly, achieving a high quality of life in specific domains correlated with higher empathy scores (P < .05). On multivariate analysis evaluating measures of distress and well-being simultaneously, both burnout (negative correlation) and well-being (positive correlation) independently correlated with student empathy scores.ConclusionsBoth distress and well-being are related to medical student empathy. Efforts to reduce student distress should be part of broader efforts to promote student well-being, which may enhance aspects of professionalism. Additional studies of student well-being and its potential influence on professionalism are needed.

Prospective Evaluation of Clonal Evolution During Long-Term Follow-Up of Patients With Untreated Early-Stage Chronic Lymphocytic Leukemia

PURPOSE Retrospective studies suggest cytogenetic abnormalities detected by interphase fluorescent in situ hybridization (FISH) can identify patients with chronic lymphocytic leukemia (CLL) who will experience a more aggressive disease course. Other studies suggest that patients may acquire chromosome abnormalities during the course of their disease. There are minimal prospective data on the clinical utility of the widely used hierarchical FISH prognostic categories in patients with newly diagnosed early-stage CLL or the frequency of clonal evolution as determined by interphase FISH. PATIENTS AND METHODS Between 1994 and 2002, we enrolled 159 patients with previously untreated CLL (83% Rai stage 0/I) on a prospective trial evaluating clonal evolution by FISH. Patients provided baseline and follow-up specimens for FISH testing during 2 to 12 years. RESULTS Chromosomal abnormalities detected by FISH at study entry predicted overall survival. Eighteen patients experienced clonal evolution during follow-up. The rate of clonal evolution increased with duration of follow-up with only one occurrence in the first 2 years (n = 71; 1.4%) but 17 occurrences (n = 63; 27%) among patients tested after 5+ years. Clonal evolution occurred among 10% of ZAP-70-negative and 42% of ZAP-70-positive patients at 5+ years (P = .008). CONCLUSION This clinical trial confirms prospectively that cytogenetic abnormalities detected by FISH can predict overall survival for CLL patients at the time of diagnosis, but also suggests that many patients acquire new abnormalities during the course of their disease. Patients with higher ZAP-70 expression may be more likely to experience such clonal evolution. These findings have important implications for both clinical management and trials of early treatment for patients with high-risk, early-stage CLL.

Pathophysiology and Treatment of Hot Flashes

Hot flashes affect about three fourths of postmenopausal women and are one of the most common health problems in this demographic group. Dysfunction of central thermoregulatory centers caused by changes in estrogen levels at the time of menopause has long been postulated to be the cause of hot flashes. Treatment should begin with a careful patient history, with specific attention to the frequency and severity of hot flashes and their effect on the individuals function. For mild symptoms that do not interfere with sleep or daily function, behavioral changes in conjunction with vitamin E (800 IU/d) use is a reasonable initial approach. For more severe symptoms, the next step is to determine whether there is a contraindication or a personal reservation to estrogen replacement therapy. For women who are able and willing to use estrogen, it will successfully relieve symptoms by about 80% to 90%. In patients with a history of breast or uterine cancer, treatment with the progestational agent megesterol acetate appears to be a safe alternative that also decreases hot flashes by approximately 80%. For women unwilling or unable to use hormone therapy, one of the newer antidepressant agents can be prescribed. Venlafaxine decreases hot flashes by about 60%. Gabapentin is another drug that appears promising as therapy for women unable or unwilling to use estrogen, and the results of ongoing trials to determine its efficacy are eagerly awaited. The use of clonidine, methyldopa, and belladonna should be discouraged because of their modest efficacy and adverse effects.

Special Report: Suicidal Ideation Among American Surgeons

BACKGROUND Suicide is a disproportionate cause of death for US physicians. The prevalence of suicidal ideation (SI) among surgeons and their use of mental health resources are unknown. STUDY DESIGN Members of the American College of Surgeons were sent an anonymous cross-sectional survey in June 2008. The survey included questions regarding SI and use of mental health resources, a validated depression screening tool, and standardized assessments of burnout and quality of life. RESULTS Of 7905 participating surgeons (response rate, 31.7%), 501 (6.3%) reported SI during the previous 12 months. Among individuals 45 years and older, SI was 1.5 to 3.0 times more common among surgeons than the general population (P < .02). Only 130 surgeons (26.0%) with recent SI had sought psychiatric or psychologic help, while 301 (60.1%) were reluctant to seek help due to concern that it could affect their medical license. Recent SI had a large, statistically significant adverse relationship with all 3 domains of burnout (emotional exhaustion, depersonalization, and low personal accomplishment) and symptoms of depression. Burnout (odds ratio, 1.910; P < .001) and depression (odds ratio, 7.012; P < .001) were independently associated with SI after controlling for personal and professional characteristics. Other personal and professional characteristics also related to the prevalence of SI. CONCLUSIONS Although 1 of 16 surgeons reported SI in the previous year, few sought psychiatric or psychologic help. Recent SI among surgeons was strongly related to symptoms of depression and a surgeons degree of burnout. Studies are needed to determine how to reduce SI among surgeons and how to eliminate barriers to their use of mental health resources.