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“A critical weekly review of important new research findings for health-conscious readers”

THE SILENT EPIDEMIC OF SURGEON

BURNOUT AND DEPRESSION

Here in the United States, we face momentous, and as yet unclear, changes in the delivery of health care.  Approximately 46 million Americans lack any health insurance at this time, and tens of millions of others have grossly inadequate health insurance.  Therefore, many millions of Americans are just one major illness away from a financial catastrophe.

In addition to the huge dilemma of how we go about making health care more efficient and more affordable for everyone, the United States, like most countries around the world, is in the midst of a dramatic shift in the average age of its population.  As the graying of America continues (not to mention the ongoing epidemic of obesity across all age ranges, as well), the growing need for high quality, comprehensive health care will continue to present major challenges to our health care system here, and in many other countries around the world.

When I graduated from medical school in 1988, health care experts were predicting a huge surplus of physicians in this country, and in response to this concern, medical schools around the United States began cutting back their class sizes, and a de facto moratorium on opening new medical schools was initiated.  Fast forward to 2010, and it has since become apparent that these dire predictions of an impending physician glut were absolutely incorrect.  As our population grows older, and more diverse, the demand for physicians is increasingly in danger of outstripping the projected supply of doctors, including surgeons.

Aging patients have a higher incidence of illnesses and injuries that require the expertise of surgeons, and general surgeons in particular.  Broadly trained and experienced general surgeons are the primary care doctors, and the workhorses, of the surgical world, and they manage an astonishing array of diseases and injuries.  Unfortunately, and for a variety of reasons, comprehensive general surgeons are slowly withering in numbers, while the demand for their skills only continues to increase.  Generational attitude shifts among recently graduating physicians have seen young new doctors gravitate towards less demanding “boutique” specialties, and away from the more challenging surgical specialties (like general surgery).  Even among those young doctors who still elect to pursue residency training in general surgery, more than two-thirds will go on to train and practice in more restricted subspecialty surgery areas.  (Disclaimer:  As a surgical oncologist, I am one of those subspecialty surgeons.  However, I still include a great deal of general surgery care in my practice, and I continue to take general surgery call in our medical center.)  Another factor that discourages potential general surgeons is the enormous debt load that most newly minted doctors graduate from medical school with, and the resultant pressure that they feel to train in specialties that do not require the additional 5 to 10 years of training that general surgeons must complete.  (Increasingly, new medical school graduates are, instead, seeking out specialties that are more financially lucrative, and require shorter durations of residency training, than general surgery.) 

Yet another adverse factor that has harmed the recruitment of new general surgeons is the ongoing and progressive fragmentation of traditional general surgery practice into other subspecialty domains.   For young doctors who are attracted to the diverse and clinically challenging sort of surgical practice that has historically made general surgery a highly desirable profession, the increasing practice restrictions imposed upon general surgeons have removed a major incentive to undergo the many years of training necessary to become a comprehensive general surgeon

Against the backdrop of these and other pressures that continue to dwindle the ranks of broadly trained and practicing general surgeons (as well as other critical core surgical specialists), the issue of surgeon burnout has only recently started to receive its due attention.  The comprehensive practice of general surgery, and other demanding surgical specialties, can be grueling and exhausting, particularly in the private practice setting where declining reimbursements compel surgeons to work ever longer hours to maintain their income and lifestyle.  (Future threatened cuts in reimbursements to surgeons will likely only further exacerbate surgeon workload problems, and eventual surgeon shortages, as new health care reform initiatives begin to roll out in the coming years.)

A newly published research study, which appears in the current issue of the Journal of the American College of Surgeons, reveals a very disturbing picture of burnout, exhaustion, and depression among surgeons, and the potentially adverse consequences of distressed surgeons on patient outcomes.

In this study, nearly 8,000 surgeon members of the American College of Surgeons responded to a detailed survey, which included self-assessments of their practice details, a validated depression screening tool, and validated assessments of both burnout and overall quality of life.  The results of these surgeon surveys were, in a word, depressing.

Among the surgeons who reported working less than 60 hours per week, 30 percent described themselves as burned-out with their profession.  Among surgeons who worked 60 to 80 hours per week, 44 percent felt burned-out, and among those surgeons who put more than 80 hours per week, 50 percent experienced significant feelings of burnout.  In addition to the number of hours spent in clinical practice per week, the number of nights spent performing overnight surgery call was a highly significant predictor of surgeon burnout.  These two surgeon workload factors were also highly statistically significantly linked to clinical depression, difficulties in finding a reasonable home-work balance, and increased conflicts at both home and at work.  Additionally, the rates of both personal emotional exhaustion and feelings of depersonalization towards patients were directly associated with working more than 80 hours per week, and with performing 2 or more night calls per week.

Excessive hours spent in clinical practice, as well as performing 2 or more overnight calls per week, also correlated with a significant increase in the number of self-reported medical and surgical errors committed by exhausted and burned-out surgeons.  Nearly 11 percent of surgeons who worked more than 80 hours per week admitted to committing medical or surgical errors, compared to about 7 percent of surgeons who worked less than 60 hours per week.

Surgeons who either worked more than 80 hours per week, or who took more than 2 night calls per week, were also significantly more likely to express regret regarding their choice of specialty, and more likely to indicate that they would not choose to become surgeons if they had an opportunity to choose their specialty all over again.

The results of this survey of surgeons across the United States have been generally confirmed by other similar studies, recently.  These disturbing findings, as reported by surgeons themselves, paints a picture of a large population of highly essential physician specialists who are, increasingly, feeling burned-out, depressed, emotionally exhausted, regretful of their career choices, and progressively more prone to both depersonalizing their relationships with their patients and to committing more medical and surgical errors.  In short, my chosen profession appears to be a profession that is, frankly, approaching a state of crisis.

Because of these enormous (and growing) pressures and stresses that are being experienced by many surgeons, including general surgeons, many public health experts are viewing the current and future surgical workforce with considerable consternation.  As more and more surgeons hang up their white coats and put away their scalpels early in their careers, and as more and more newly graduated doctors shy away from the more demanding surgical specialties, our country appears to be headed for a potentially catastrophic mismatch between the demands of an aging population for surgical care and the diminishing pool of physicians who are willing to shoulder the heavy responsibilities, and significant stresses, of surgical practice.

It is my hope that the governmental agencies responsible for implementing current and future health reforms will pay close attention to this study, and others like it.  If hard-working surgeons cannot sustain reasonable income levels (against the decades of grueling training required, and the hundreds of thousands of dollars in educational loans that most young doctors acquire) without working themselves into a state of exhaustion, burnout, and divorce, the ranks of general surgeons, and other core surgical specialists, will continue to become thinner and thinner.  Ultimately, if things do not change, and soon, you and I might find it difficult to obtain access to high quality surgical care, particularly for emergency illnesses and injuries…. 

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Disclaimer: As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity

Dr. Wascher is an oncologic surgeon, a professor of surgery, a cancer researcher, an oncology consultant, and a widely published author

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I and the staff of Weekly Health Update would again like to take this opportunity to thank the more than 100,000 health-conscious people, from around the world, who visit this premier global health information website every month.  (As of 9/16/2010, more than 1,000,000 health-conscious people have logged onto Weekly Health Update so far this year!)  As always, I enjoy receiving your stimulating feedback and questions, and I will continue to try and personally answer as many of your inquiries as I possibly can.

Welcome to Weekly Health Update

“A critical weekly review of important new research findings for health-conscious readers”

PHYSICIAN ERROR

Ah ne’er so dire a Thirst of Glory boast,
Nor in the Critick let the Man be lost!
Good-Nature and Good-Sense must ever join;
To err is human, to forgive divine.

Alexander Pope (1688-1744)

According to the prestigious Institute of Medicine, between 50,000 and 100,000 patient deaths are caused each year in the United States by negligence on the part of doctors, nurses, and other health care providers.  Nearly 1,000,000 patient injuries per year are also attributed to human error in the delivery of health care.

The presumptive causes underlying negligence in patient care are multiple and varied, and continue to be the subject of much debate among patient safety experts.  However, virtually all such experts agree that largely preventable human errors account for the vast majority of patient injuries and deaths associated with negligent patient care.

In the operating room, where I spend much of my time, as a cancer surgeon, we have adopted patient safety “check lists” inspired by the airline industry, and which are designed to reduce the possibility of errors during surgery.  At our institution, the patient’s identity (and the surgical procedure to be performed) is confirmed, twice, by everyone in the operating room before an incision is made.  Towards the end of the surgical procedure, an additional “debriefing” is performed, and the surgeon reviews the procedures that he or she has just performed.  The operating room nurse also confirms that all sponges, needles, and instruments have been accounted for, in an effort to reduce the possibility that any of these foreign bodies will be left within the patient.

One important aspect of physician error is that of errors in diagnosis.  In a newly published clinical study, which appears in the current issue of the journal Pediatrics, 1,362 pediatricians at three major academic medical centers, and 109 affiliated clinics, were invited to anonymously complete an Internet-based survey regarding their self-perceived frequency of diagnostic errors.  These doctors included experienced academic pediatricians, experienced community-based pediatricians, and resident doctors who were training to become pediatricians.  Altogether, 53 percent of the queried pediatricians agreed to complete the anonymous survey. 

More than half (54 percent) of these responding doctors indicated that they made significant diagnostic errors at least one or two times per month.  Not surprisingly, the resident doctors in training acknowledged the highest number of diagnostic errors, with 77 percent of these trainees admitting to at least one or two significant diagnostic errors per month.

Based upon their anonymous responses, nearly half (45 percent) of these 726 pediatricians believed that one or more of their diagnostic errors had harmed patients at least once or twice per year. 

When asked to analyze the underlying causes for their errors, these doctors cited the following explanations:  failure to gather adequate patient history information, inadequate physical examination, inadequate review of the patient’s chart, and inadequate coordination of care and communication among the providers involved (“inadequate teamwork”). 

Specific examples of diagnostic errors cited by these pediatricians included viral illnesses being misdiagnosed as bacterial infections, misdiagnosis of medication side effects, misdiagnosis of psychiatric disorders, and misdiagnosis of appendicitis. 

When asked to offer solutions to common diagnostic errors, these pediatricians most commonly recommended the implementation of electronic health records, as well as closer patient follow-up.

(It is important to note that, in view of the human tendency to “under-report” personal failures, it is very likely that the true incidence of significant diagnostic errors is actually considerably higher than what these pediatricians have self-reported in this study.)

In a perfect world, we physicians would never make the wrong diagnosis, or miss a diagnosis altogether, or miss an adverse reaction to medications or other treatments.  We would never prescribe the wrong medication or perform the wrong operation; and we would never, through acts of either commission or omission, perform anything less than a perfect surgical operation.  Unfortunately, the practice of Medicine, as with all human endeavors, will never become a “zero error” profession.  However, all of us, both patients and physicians (and physicians are patients, as well), certainly would agree that every effort must be made to drive preventable patient care errors down as close to “zero” as is humanly possible. 

While it is unlikely that human error can ever be completely eliminated, in Medicine or in any other profession, the findings of this important study are significant, and point to areas where substantial improvements in the delivery of health care can be achieved by physicians and other health care providers (and, I might add, by patients as well). 

Look for the imminent publication of my new landmark evidence-based book, “A Cancer Prevention Guide for the Human Race,” in August of this year. 

Disclaimer: As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity

Dr. Wascher is an oncologic surgeon, a professor of surgery, a cancer researcher, an oncology consultant, and a widely published author

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I and the staff of Weekly Health Update would like to take this opportunity to thank the more than 100,000 new and returning readers who visit our premier global health information website every month.  As always, we enjoy receiving your stimulating feedback and questions, and I will continue to try and personally answer as many of your inquiries as I possibly can.