Depressed doctors in training make more errors

Study suggests depression is a more important factor than burnout

February 8, 2008

Many doctors in residency programs are depressed, and the condition leads them to make errors that can harm patients, according to a study led by Children's Hospital Boston researchers. The study, published online February 8 in the British Medical Journal, raises the need for more attention to doctors' mental health and possible changes within residency programs.

Depression and burnout are known to be high among doctors in residency programs, known for their stressfulness and long hours. Studies estimate that between 41 and 76 percent of residents suffer burnout (emotional exhaustion and detachment in response to chronic occupational stress), and between 7 and 56 percent are depressed. However, no studies have conclusively shown whether either condition affects medical errors or patient safety.

The new study, led by Amy Fahrenkopf, MD, MPH, a pediatric hospitalist at Children's Hospital Boston, included 123 doctors who were training to be pediatricians in residency programs at three U.S. hospitals. The residents were screened for two mental health conditions - burnout and depression - using established diagnostic questionnaires.

Over one month, trained nurses and doctors tracked residents' medication errors - mistakes in requesting, writing instructions for, or giving medication. The study was restricted to errors made on hospital floors, not outpatient centers or intensive care units.

Screening showed that 74 percent of the residents were burned out. About 20 percent of the residents were depressed, twice the rate in the general U.S population.

The total error rate was low, at 0.7 percent, or 45 errors in 6,078 total orders. Burnout was not linked to higher rates of medication errors. However, depressed residents made 6.2 times more errors than colleagues who weren't depressed.

None of the errors caused injury to patients - most were minor or caught by hospital "safety nets" before they could cause harm - but Fahrenkopf cautions that more severe medication errors could slip by if this problem is not properly addressed. She adds that other kinds of errors that are harder to catch and correct, such as those in diagnosis, might also be increased.

Few of the doctors had a history of depression before entering residency, suggesting that residency itself may bring on the condition, says Fahrenkopf. All the depressed residents in the study were also burned out, suggesting that programs may burn residents out to the point they become depressed, she says.

Most concerning was residents' failure to recognize their condition. "The majority of these residents seemed unaware they were depressed, despite being doctors and completing screening that indicated their depression," Fahrenkopf says.

Medical culture may be somewhat responsible. "It's considered expected to be miserable as a resident, so it's hard to see when unhappiness has crossed the line into illness," Fahrenkopf says.

Supervisors may overlook or accept residents' depression because such symptoms are common among residents and were common when they underwent training, but they need to be more proactive, she says.

"Hospitals and residency programs need to be aware of the problem of resident depression, and begin to find solutions," says Christopher Landrigan, MD, MPH, director of the Sleep and Patient Safety Program at Brigham and Women's Hospital, and senior author of the study.

Specifically, residency directors should seek out residents who they think are not functioning well, look for signs of depression, and refer them to evaluation and treatment, says Fahrenkopf. "We need to pay attention to the mental health of our residents, not just for their sake, but for the sake of patients."

The three hospitals studied were Children's Hospital Boston, Lucile Packard Children's Hospital in Palo Alto, California, and Children's National Medical Center in Washington, DC. The study was funded by the Agency for Healthcare Research and Quality and the Departments of Pediatrics at Lucile Packard Children's Hospital, Children's National Medical Center, and Children's Hospital Boston.

Contact:
Keri Stedman
617-919-3110
keri.stedman@childrens.harvard.edu

Children's Hospital Boston is home to the world's largest research enterprise based at a pediatric medical center, where its discoveries have benefited both children and adults since 1869. More than 500 scientists, including eight members of the National Academy of Sciences, 11 members of the Institute of Medicine and 12 members of the Howard Hughes Medical Institute comprise Children's research community. Founded as a 20-bed hospital for children, Children's Hospital Boston today is a 377-bed comprehensive center for pediatric and adolescent health care grounded in the values of excellence in patient care and sensitivity to the complex needs and diversity of children and families. Children's also is the primary pediatric teaching affiliate of Harvard Medical School. For more information about the hospital and its research visit: www.childrenshospital.org/newsroom.