In the JournalsPerspective

Physicians with depression more likely to self-report medical errors

Karina Pereira-Lima

Physicians who screen positive for depressive symptoms have an increased risk for medical errors, according to results of a systematic review and meta-analysis published in JAMA Network Open.

“This study identified that physician depressive symptoms associated with higher risk of reporting medical errors, which strongly suggests that physician well-being is critical to patient care,” Karina Pereira-Lima, PhD, of the department of psychiatry at the University of Michigan Medical School, told Healio Psychiatry. “Given the large body of work demonstrating the high prevalence of depressive symptoms among physicians, these data underscore the need for systemic efforts to prevent and reduce depressive symptoms among these professionals.”

According to the researchers, previous studies on physician depressive symptoms and medical errors reported a significant association, but the results were not unanimous as questions about the direction of these associations remain. Pereira-Lima and colleagues conducted their study to provide summary relative risk estimates for potential associations. In their analysis, they included 11 peer-reviewed empirical studies that reported on a valid measure of physician depressive symptoms associated with observed or perceived medical errors. The included studies involved 21,517 physicians.

The overall relative risk for medical errors among physicians who screened positive for depression was 1.95 (95% CI, 1.63-2.33). The researchers noted high heterogeneity across the studies, most of which was explained by study design among the variables assessed. Lower relative risk estimates were associated with medical errors in longitudinal studies, and higher relative risk estimates in cross-sectional studies. Meta-analysis of four longitudinal studies found a pooled relative risk of 1.67 (95% CI, 1.48-1.87) for medical errors associated with subsequent depressive symptoms, which suggests that the association between medical errors and physician depressive symptoms is bidirectional, according to the researchers.

Considering data from previous research showing that few physicians with depression seek treatment, these findings point to the need for systemic polices to reduce barriers to the delivery of mental health care to physicians with depressive symptoms,” Pereira-Lima said. “Future studies should investigate the degree to which interventions for reducing physician depressive symptoms could also mitigate medical errors.” – by Joe Gramigna

Disclosures: Pereira-Lima reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Karina Pereira-Lima

Physicians who screen positive for depressive symptoms have an increased risk for medical errors, according to results of a systematic review and meta-analysis published in JAMA Network Open.

“This study identified that physician depressive symptoms associated with higher risk of reporting medical errors, which strongly suggests that physician well-being is critical to patient care,” Karina Pereira-Lima, PhD, of the department of psychiatry at the University of Michigan Medical School, told Healio Psychiatry. “Given the large body of work demonstrating the high prevalence of depressive symptoms among physicians, these data underscore the need for systemic efforts to prevent and reduce depressive symptoms among these professionals.”

According to the researchers, previous studies on physician depressive symptoms and medical errors reported a significant association, but the results were not unanimous as questions about the direction of these associations remain. Pereira-Lima and colleagues conducted their study to provide summary relative risk estimates for potential associations. In their analysis, they included 11 peer-reviewed empirical studies that reported on a valid measure of physician depressive symptoms associated with observed or perceived medical errors. The included studies involved 21,517 physicians.

The overall relative risk for medical errors among physicians who screened positive for depression was 1.95 (95% CI, 1.63-2.33). The researchers noted high heterogeneity across the studies, most of which was explained by study design among the variables assessed. Lower relative risk estimates were associated with medical errors in longitudinal studies, and higher relative risk estimates in cross-sectional studies. Meta-analysis of four longitudinal studies found a pooled relative risk of 1.67 (95% CI, 1.48-1.87) for medical errors associated with subsequent depressive symptoms, which suggests that the association between medical errors and physician depressive symptoms is bidirectional, according to the researchers.

Considering data from previous research showing that few physicians with depression seek treatment, these findings point to the need for systemic polices to reduce barriers to the delivery of mental health care to physicians with depressive symptoms,” Pereira-Lima said. “Future studies should investigate the degree to which interventions for reducing physician depressive symptoms could also mitigate medical errors.” – by Joe Gramigna

Disclosures: Pereira-Lima reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

    Perspective
    Michael R. Privitera

    Michael R. Privitera

    Pereira-Lima et al have clarified a bidirectional relationship between depressive symptoms and perceived medical error. Depressive symptoms occur in physicians following a medical error and separately, depressive symptoms in physicians are associated with increased subsequent risk of medical error. This article helps add to the mounting evidence that physician well-being and patient well-being are inextricably linked. Depression-related cognitive dysfunction in patients with depression occurs in areas of attention, verbal and nonverbal learning, short-term and working memory, visual and auditory processing, problem solving, processing speed and motor function. Although much of the literature used in the meta-analysis refers to depressive symptoms without certainty that they represent the diagnosis of major depression, the degree of depressive symptoms predicted the risk of perceived medical error and vice versa. Studying major depression in physicians is difficult for a number of reasons, but beyond being personal health information (PHI), a number of issues get in the way. Physicians seem to be somewhat more willing to discuss burnout than the PHI of clinical depression as a disorder. One study used the Major Depression Inventory that is self-rating and has good correlation with diagnosis of major depression. The risk of major depression is highly correlated with increasing severity of burnout. On an individual level, depression must be addressed, but organizationally, leaders can use aggregate institutional burnout data as a proxy to the extent of the problem uncovered in this study — especially if the instrument can help show the proportion of those with high burnout or “at risk” scores in other instruments.

    Some of the difficulties in studying depression in physicians is promulgated by culture of medicine that is machismo, superman or superwoman, denying overwhelm. The current tsunami of increasing requirements on physicians has made work-life regularly difficult for reasons that have nothing to do with clinical work itself. The perfect storm is that this overwhelm is occurring in a population who has difficulty speaking up. A work environment has developed around the physician that invalidates human needs, creating the dangerous “normalized deviance” that we know from The Challenger incident, which led to disaster. Electronic medical record usability is poor, and note bloat exists from excessive documentation requirements that both lead to regularly completing the day’s documentation at home in the evening, instead of having time to spend with family.

    Since the institution does not immediately see the financial and other human impact, there currently is no managerial pressure to stop this overwork. Educational mandatories and high cost/high stakes exams have created worry and pressure to study at home for months in preparation, knowing the severe consequences of not being able to practice or get paid by the insurance company if failed. In well-meaning but overly aggressive efforts to protect the public, some regulatory agencies have asked overly intrusive questions into past history of mental health issues in physicians beyond the basic need to know of whether they are currently impaired to practice medicine. As was pointed out by Pereira-Lima et al, depression is treatable, yet our society has made it more difficult for physicians to get help without risking their careers, which, as their paper illustrates, is backfiring on patient safety.

    This article gives hard evidence as to why all leaders in health care at all levels must prioritize the mental health of physicians and other clinicians like any other patient safety initiative. A root cause analysis of why physicians are getting depressed must be activated and action taken. Physician suicides do not require police or other authority to investigate, yet patients have the health department to oversee quality and investigate suicides. Why this disparity?

    Who are the authoritative organizations that are listened to, to make the needed organization/systemic changes in health care delivery, education, regulation and competency evaluation? There are many such organizations at a national, state and industry level. This work by Pereira-Lima et al should be a call for collaboration between these organizations to make the needed changes in the experience of providing care (fourth aim of Quadruple Aim). Our patients’ well-being and that of the clinicians that serve them depends upon it.

    References

    Federation of State Medical Boards. Physician wellness and burnout: Report and Recommendations of the Workgroup on Physician Wellness and Burnout. http://www.fsmb.org/siteassets/advocacy/policies/policy-on-wellness-and-burnout.pdf. Accessed Dec. 3, 2019.

    Privitera MR. Is burnout a form of depression? It’s not that simple. https://www.medscape.com/viewarticle/896537 accessed 12-3-19. Accessed Dec. 3, 2019.

    Ramsey D. Depression-related cognitive dysfunction. https://reference.medscape.com/recap/915839. Accessed Dec. 3, 2019.

    Shanafelt TD, et al. Healing the Professional Culture of Medicine. Mayo Clin Proc. 2019;doi:10.1016/j.mayocp.2019.03.026.

    Vaughan D. (1996). The Challenger launch decision: risky technology, culture, and deviance at NASA. Chicago: University of Chicago Press.

    Wurm W, et al. PLoS One. 2016;doi:10.1371/journal.pone.0149913.

    • Michael R. Privitera, MD
    • Professor of psychiatry
      University of Rochester Medical Center
      Member
      Federation of State Medical Boards Task Force on Physician Burnout

    Disclosures: Privitera reports no relevant financial disclosures.

    Perspective
    Louise B. Andrew

    Louise B. Andrew

    The study by Pereira-Lima et al was a well-intentioned effort to shed more light on the potential relationship between physician depression and medical errors. Unfortunately, the authors (and perhaps copy editors), by inaccurately conflating key terms such as “medical errors” and “perceived errors” and “depressive symptoms” and “depression” throughout the article, may have inadvertently muddied the field and compounded the confusion regarding this critical issue.

    As a result of imprecise use of terms (especially in the title) by these researchers, both lay and popular medical news writers attempting to publicize scientific findings have already widely disseminated the attention-grabbing (but misleading) headline, “Physician depression leads to medical errors.”  

    The overwhelming majority of the studies analyzed in the study (91%) measured “perceived” or self-reported, as opposed to objective measures of error. Those physicians reporting errors also reported experiencing depressive symptoms. Physicians experiencing features of depression are more likely to recall negative events and to view themselves in a negative light and are therefore more likely to retrospectively assess a clinical event with a suboptimal outcome as an error, and to blame themselves for that error. Such self-reported errors thus may reflect self-judgment and willingness to report, rather than actual differences in objective error rates. This important distinction was noted in the limitations section of the study but was unfortunately completely lost in the titling and throughout much of the article. Only 101 of the 21,517 participants had any kind of external identification of error. In the other 21,416 participants, the existence of error was assumed from retrospective self-report. 

    This unfortunate conflation of perceived and actual errors was then “justified” in the limitations section by reference to a single study purporting to show that “self-reported errors have been found to be highly correlated with recorded events.” That study, a resident peer survey of purported errors, involved residents reporting on all errors observed on a service, and not personal errors; it was no justification at all for the contention.

    The studies included in the meta-analysis used several population-based screens for depressive symptoms, more than half of which are highly sensitive but not specific for a diagnosis of depression. Most of these screens were not subsequently followed by any definitive testing or clinical interviews to establish a diagnosis of depression.

    Yet despite this deficiency, throughout the paper, the terms “depression” and “depressive symptoms” are regularly conflated. This confuses the issue of whether the physicians being surveyed (most of them trainees) met clinical criteria for depression, or whether they were instead experiencing depressive symptoms related to burnout, exhaustion, poor sleep or high stress common in residents. Indeed, in the one study where burnout and depression were formally measured, the number of residents with diagnosed depression was rather small relative to those with defined burnout.

    Further, while depression screens used in the majority of the studies assess recent symptoms (typically several weeks), elicitation of self-error reports typically covered much longer periods (3 to 12 months). Therefore, the two phenomena being collated (depressive symptoms and self-reported perceived errors) may not even have occurred coincidentally.

    Although it is undeniable, as opined by the authors, that “a reliable estimate of the degree to which physicians with a positive screening for depression are at higher risk for medical errors would be useful,” this analysis did not achieve that goal. Instead, it made an estimate as to how often physicians with self-reported depressive symptoms self-report perceived errors or even risk of errors. Such estimates may or may not relate to the actual incidence of errors occurring in depressed physicians.

    Last but certainly not least, it was disappointing to see yet again the solidly discredited Institute of Medicine and Makary papers regarding the purported rampancy of generic adverse events in hospitalized patients recycled in support of studies whose focus was to be physician medical errors. Such indiscriminate propagation of erroneous memes as happened with these misapplied statistics in the popular press will now be applied to a new misperception of the roots of the problems of adverse events and medical error.

    Indeed, in just 1 week following the release of this study, there have already been at least a dozen iterations of the false meme, “Depressed doctors make more mistakes.”

    Although I agree with Dr. Privitera and no doubt the study authors that depressive symptoms in doctors must be addressed in every conceivable supportive and nonpunitive way, in my opinion, in the current regulatory environment, providing fuel for the propagation of salacious memes inciting public fears about the dangers of depressed doctors seems unlikely to help to achieve this end.

    References

    Emmons RS, et al. J Am Physicians and Surgeons. 2018; https://www.jpands.org/vol24no2/emmons.pdf.

    Fahrenkopf AM, et al. BMJ. 2008;doi:10.1136/bmj.39469.763218.BE.

    Institute of Medicine Committee on Quality of Health Care in America; Kohn LT, et al. ”To Err Is Human: Building a Safer Health System” Vol 6. Washington, DC: National Academies Press; 2000.

    Mazer BL, et al. J Gen Intern Med. 2019;doi:10.1007/s11606-019-05156-7.

    Makary MA, et al. BMJ. 2016;doi:10.1136/bmj.i2139.

    Shojania KG, et al. BMJ Qual Saf. 2016;doi:10.1136/bmjqs-2016-006144.

    Disclosure: Andrew reports no relevant financial disclosures.

    • Louise B. Andrew, MD, JD
    • Founder and principal consultant
      MDMentor