To the Editor
Danger to patients from medical care errors caused or aggravated by stress, burnout, and depression has been discussed often as a theoretical patient safety risk, but, until recently, surprisingly little studied. Stress and its effects on physicians is now being evaluated in the medical literature. The association of stress with alcohol and drug addiction is widely reported, and the degree to which these issues can compromise care has been documented. Certainly, stress and burnout are common in all medical specialties, including anesthesiology. Recent studies have looked at not only stress and burnout, but depression and other affective disorders in physicians and the possible role these may play in the commission of medical errors.
A recent study in the Annals of Surgery1 demonstrated that those surgeons with symptoms of depression were twice as likely to have committed an error within the last three months before the survey as their colleagues who were not depressed. While it is true that in this study it was not clear if depression contributed to or was, in fact, a result of the errors, other investigations have shown that depression is linked to an increase in errors, particularly a 2008 study showing that pediatric residents who were depressed made 6-times the medication errors than non-depressed peers.2 Interestingly, a repeat study after the implementation of the 80-hour work week for residents showed no decrease in the rate of depression in these residents.3
A 2008 survey of Michigan physicians investigated the incidence of depression in physicians and its effect on the clinician.4 The incidence of depression in these physicians was 11%, which is close to the incidence in the general population. The results showed that 43% of respondents knew a physician whose work had suffered because of depression. In addition, 24% reported they were aware of a physician whose professional standing had been hurt from the effects of depression. The majority of respondents who were judged to have moderate to severe depression admitted that their condition negatively affected their professional responsibilities, increased their personal and professional stress level, and decreased their work productivity and satisfaction.
It has been shown that physicians with depression are fearful of the stigma of depression and its potential negative effect on their ability to obtain licensure, privileges, and insurance.5 Because of this, many fail to seek treatment, which likely has potential consequences in the care that they provide to patients, including increased risk for errors.
Anesthesia professionals may be at even higher risk for not seeking treatment for depression. We are often isolated from colleagues in our daily practice; hence, symptoms of depression may not be recognized. The normal stress of our work may mask depression. Affected individuals may seek inappropriate treatment by self-medicating (such as with alcohol) or asking colleagues for prescriptions for antidepressants. It is not known how many cases of substance abuse among anesthesiologists stem from self-medication for depression. It is probably safe to conclude that some substance abuse is a result of depression, while in other cases it is the cause of depression.
Anesthesia professionals, as a group, need to bring attention to the fact that depression can be detrimental to not only ourselves, but to our patients as well. With the ASA Wellness Campaign and the AANA Wellness Program, our professional organizations have recognized the importance of health to the personal and professional lives of their members. Despite this, the part that depression and burn out play in the potential threat to the safe care of patients has not been highlighted. It remains for the APSF, in its capacity as the conscience of the specialty, to bring this issue to the fore by shining a light on this professional and patient safety issue that is likely much more common than abuse of drugs and alcohol.
Gregory L. Rose, MD
Raeford E. Brown, MD
John H. Eichhorn, MD
- Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg 2009;250:463-71.
- Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ 2008;336:488-91.
- Landrigan CP, Fahrenkopf AM, Lewin D, et al. Effects of the accreditation council for graduate medical education duty hour limits on sleep, work hours, and safety. Pediatrics 2008;122:250-8.
- Schwenk TL, Gorenflo DW, Leja LM. A survey on the impact of being depressed on the professional status and mental health care of physicians. J Clin Psychiatry 2008;69:617-20.
- Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA 2003;289:3161-6.