Doctors look after patients, but who is looking after doctors?

November 12, 2009

Doctors are looking after their patients' health, but who is looking after the health of the doctors themselves? A Review in this week's edition of the Lancet shows that doctors are not very good at monitoring the health of either themselves or their colleagues, and looks at the possible link between poor doctor health and poor patient care. Given mounting evidence to support this link, the authors propose that health care systems should routinely measure physician wellness as an indicator of health-system quality. The Review is written by Professors Jean E Wallace, Jane B Lemaire, and William A Ghali, University of Calgary, Canada.

Doctors are important citizens of health-care systems, and evidence indicates that many doctors are unwell. Doctors who are affected by the stresses of their work may go on to experience substance abuse, relationship troubles, depression, or even death. Results of emerging research show that doctors' stress, fatigue, burnout, depression, or general psychological distress negatively affects health-care systems and patient care. The authors propose that because wellness may not only benefit the individual doctor but also be vital to the delivery of quality health care, physician wellness should be included as an indicator of health-system quality. Traditionally, health-care organisations assess their performance using patient-based indicators such as patient survival rates after major surgery. Doctor wellness as an indicator of the quality of the health-system would acknowledge the growing recognition that doctors who are unwell negatively affect how the health system performs. Wallace and colleagues discuss several issues that will need to be addressed to achieve the desired outcomes of improved physician wellness and system quality.

Practising medicine is stressful to many doctors. For example, authors of a Canadian study reported that 64% of doctors feel that their workload is too heavy, and 48% have had an increase in their workload in the past year. Additionally, surveys consistently document that doctors work many hours, averaging 50󈞨 h per week when not on call. When doctors frequently work shifts longer than 24 h, the resulting fatigue is associated with negative consequences for doctors, both personally and professionally. Personally, they have increased risk of burnout, needle stick injuries, and motor vehicle crashes or near-miss incidents when driving home. Professionally, doctors working long shifts (i.e. more than 16-24 consecutive hours) have significantly more failures of attention and make more serious medical errors than those working shorter shifts. Wallace and colleagues say that these extremely long shifts are very common, especially during doctors' training periods after they graduate from medical school.

Research suggests that many doctors are not very good at tending to their own health or seeking help from others. A study by Arnetz refers to the "ignorance, indifference and carelessness of doctors towards their own health"; doctors neglect to have physical examinations and procrastinate when seeking medical treatment. This pattern of behaviour seems to be widespread. For example, in one study, of 18% of Canadian doctors who were identified as depressed, only 25% considered getting help and only 2% actually did. Many doctors do not have family doctors as reported in another study where only 42% of Australian doctors studied had a general practitioner, and most had self-prescribed drugs. Wallace and colleagues say: "Physicians often rely on denial and avoidance as coping strategies, which are not very effective; the problem is exacerbated by the medical profession's poor record for giving mutual support and feedback... doctors might feel uncomfortable in the role of patient, and fear that others will interpret their need for help as an indicator of their inability to cope. Findings show, however, that doctors who receive support from their colleagues or spouse are more successful in achieving wellness". They also discuss a study that says general practitioners feel pressure from both their patients and colleagues to appear physically well, even when they are sick, because they believe their health is interpreted as an indicator of their medical competence.

The authors say that many countries are now trying to address aspects of doctor wellness. Countries including Canada, Australia, and the UK, are developing programmes to identify and treat impaired or disruptive doctors, and some health-care organisations are targeting prevention and promoting wellness. But there are no standards to dictate how to promote doctor wellness, enforce these mandates, or measure success.

Growing evidence points to important negative consequences of doctors' ill health to health-care systems by affecting recruitment and retention of doctors, workplace productivity and efficiency, and patient care and safety. For example, medical school training is extremely stressful and often has negative effects on students' mental health, which could deter individuals from becoming doctors or entering certain medical specialties.

Perhaps of even greater concern is the direct effect of physician wellness on quality of care and patient safety. For example, in a study of doctors' perceptions of the link between work-related stress and patient care, 57% of participants believed that tiredness, exhaustion, or sleep deprivation negatively affected patient care, and another 28% believed that pressures from being overworked were negatively related. Work-related stress led to 50% reporting reduced standards of patient care (eg, taking short cuts, not following procedures), 40% reporting irritability or anger, 7% reporting serious mistakes not leading to patient death, and 2.4% reporting incidents in which the patient died. Tiredness and overwork were most often judged to be responsible for these outcomes, especially the most serious ones. Another study demonstrated that sleep deprivation can be more incapacitating than a high blood alcohol concentration, and on call-associated fatigue is related to increased error rates in the cognitive skill domain for surgeons. The authors say: "Factors such as overwork, inadequate sleep, and exhaustion, compounded with feelings of guilt, often result in poor care that could contribute to a cycle of stress and diminishing quality of patient care."

Although interventions could improve physician wellness, very little research has directly examined the effect of such interventions on patient care or health system performance. The few studies that have examined stress management interventions suggest that they appear beneficial to both physicians and the care they provide to their patients. Further research is needed to explore how interventions designed to improve physician wellness are also beneficial to patients.

The authors conclude: "Ultimately, individual doctors will personally benefit from taking better care of themselves. Such efforts would probably lead to increased job satisfaction and overall wellbeing, and reduced likelihood of doctors experiencing an overwhelming sense of stress and burnout. The organisations employing doctors will benefit by having more productive and efficient health-care providers in conjunction with reduced absenteeism, job turnover, and recruitment and retention issues. And perhaps the patients themselves will benefit by receiving better quality of care."

A linked Editorial, discusses how, at the Global Forum of Health Leaders in Taipei, Taiwan on Nov 9, Dana Hanson, President of the World Medical Association, spoke about "silent desperation" among some doctors. He urged the profession and governments to pay more attention to stress and burnout among doctors, especially to remove the stigma that burnout brings. Hanson concluded that healthy doctors meant healthier patients, safer care, and a more sustainable workforce. "Physicians", he said, "should not have to choose between saving themselves and serving their patients", adding "many physicians were inwardly burning".

The Editorial concludes: "Keeping doctors well and fit for work can only be a win-win situation."
-end-
Professor Jean E Wallace, University of Calgary, Canada. T) +1 403-220-6515 E) jwallace@ucalgary.ca

The Lancet Press Office. T) +44 (0) 20 7424 4949 E) pressoffice@lancet.com

For full Review and Editorial, see: http://press.thelancet.com/doctorwell.pdf

Lancet

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