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Original Investigation
Physician Work Environment and Well-Being
October 2018

Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction: A Systematic Review and Meta-analysis

Author Affiliations
  • 1National Institute for Health Research (NIHR) School for Primary Care Research, NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
  • 2NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
  • 3Bradford Institute for Health Research, University of Leeds, Leeds, United Kingdom
  • 4Laboratory of Hygiene, Aristotle Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
  • 5Research Institute, Primary Care and Health Sciences, Keele University, Keele, Newcastle, United Kingdom
  • 6Westminster Centre for Resilience, Faculty of Science and Technology, University of Westminster, London, United Kingdom
  • 7Institute of Applied Health Research College of Medical and Dental Sciences, Murray Learning Centre, University of Birmingham, Edgbaston, Birmingham, United Kingdom
JAMA Intern Med. 2018;178(10):1317-1330. doi:10.1001/jamainternmed.2018.3713
Key Points

Question  Is physician burnout associated with low-quality, unsafe patient care?

Findings  This meta-analysis of 47 studies on 42 473 physicians found that burnout is associated with 2-fold increased odds for unsafe care, unprofessional behaviors, and low patient satisfaction. The depersonalization dimension of burnout had the strongest links with these outcomes; the association between unprofessionalism and burnout was particularly high across studies of early-career physicians.

Meaning  Physician burnout is associated with suboptimal patient care and professional inefficiencies; health care organizations have a duty to jointly improve these core and complementary facets of their function.

Abstract

Importance  Physician burnout has taken the form of an epidemic that may affect core domains of health care delivery, including patient safety, quality of care, and patient satisfaction. However, this evidence has not been systematically quantified.

Objective  To examine whether physician burnout is associated with an increased risk of patient safety incidents, suboptimal care outcomes due to low professionalism, and lower patient satisfaction.

Data Sources  MEDLINE, EMBASE, PsycInfo, and CINAHL databases were searched until October 22, 2017, using combinations of the key terms physicians, burnout, and patient care. Detailed standardized searches with no language restriction were undertaken. The reference lists of eligible studies and other relevant systematic reviews were hand-searched.

Study Selection  Quantitative observational studies.

Data Extraction and Synthesis  Two independent reviewers were involved. The main meta-analysis was followed by subgroup and sensitivity analyses. All analyses were performed using random-effects models. Formal tests for heterogeneity (I2) and publication bias were performed.

Main Outcomes and Measures  The core outcomes were the quantitative associations between burnout and patient safety, professionalism, and patient satisfaction reported as odds ratios (ORs) with their 95% CIs.

Results  Of the 5234 records identified, 47 studies on 42 473 physicians (25 059 [59.0%] men; median age, 38 years [range, 27-53 years]) were included in the meta-analysis. Physician burnout was associated with an increased risk of patient safety incidents (OR, 1.96; 95% CI, 1.59-2.40), poorer quality of care due to low professionalism (OR, 2.31; 95% CI, 1.87-2.85), and reduced patient satisfaction (OR, 2.28; 95% CI, 1.42-3.68). The heterogeneity was high and the study quality was low to moderate. The links between burnout and low professionalism were larger in residents and early-career (≤5 years post residency) physicians compared with middle- and late-career physicians (Cohen Q = 7.27; P = .003). The reporting method of patient safety incidents and professionalism (physician-reported vs system-recorded) significantly influenced the main results (Cohen Q = 8.14; P = .007).

Conclusions and Relevance  This meta-analysis provides evidence that physician burnout may jeopardize patient care; reversal of this risk has to be viewed as a fundamental health care policy goal across the globe. Health care organizations are encouraged to invest in efforts to improve physician wellness, particularly for early-career physicians. The methods of recording patient care quality and safety outcomes require improvements to concisely capture the outcome of burnout on the performance of health care organizations.

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    4 Comments for this article
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    Suicidal Ideation does not equate to suicidality
    Louise Andrew, MD JD | www.physiciansuicide.com
    While I applaud the effort by Panagioti et al to take a rigorous scientific look at the association between self assessed burnout and patient safety, I am disturbed that the authors reiterate in their opening paragraph a misperception that is becoming more and more widespread, without justification, by both scientific and lay writers. The authors state "Burnout is associated with increased risk for cardiovascular disease and shorter life expectancy, problematic alcohol use, broken relationships, depression, and suicide", citing two studies by Shanafelt and associates.
    Neither study in fact concludes that burnout increases the risk for suicide.
    What both studies actually found is that physicians with significant burnout are at increased risk for suicidal ideation.


    There is a huge gap between those who ever have thoughts of suicide (experience suicidal Ideation and those who actually complete suicide. The surgeons and oncologists in the Shanafelt studies were asked whether they had contemplated suicide, not how serious the thoughts were, nor whether they had actually made plans. 2016 SAMSHA data suggests that a little more than one in 10 adults who experienced serious suicidal ideation actually made suicide attempts, let alone completed suicide. And although both the  cited studies and others have found significant overlaps between physicians who scored high on burnout measures and those who had diagnosable clinical depression (which diagnosis, or combination of one diagnosis with a significant job related stress syndrome would almost certainly increase the risk for suicide), and also an increased risk of suicide attempts in physicians who have made significant patient errors, no study has ever shown that there is an association between isolated physician burnout and suicide.


    Why does this matter? Because those who begin to conflate the occupational stress syndrome of burnout with the clinical diagnosis of depression because of a tangential association with suicidal ideation and completed suicide, may be led to believe that the treatment approaches to burnout (currently changes in working conditions) and depression (currently psychotherapy, medication, hospitalization, and in physicians, almost invariably screening and monitoring for potential impairment, particularly substance use disorders) should be the same. In many cases, the solution to burnout is workplace change or job change. To subject burned out physicians laboring in toxic jobs or workplaces to the "potential impairment paradigm" often assigned to depressed physicians (http://bit.ly/whyMLBsDiscriminate) is likely to increase, not decrease the potential for suicide in these physicians.
    CONFLICT OF INTEREST: None Reported
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    Lack of Association Between Burnout/Poor Well-being and Quality of Care
    Nicholas Lawson, M.D., J.D., in progress | Georgetown University Law Center
    The authors point to associations between physician burnout/poor well-being and quality of care when measured with physicians’ perceptions of their own performance as evidence suggesting that these physicians “may jeopardize patient care.” [1]

    The authors acknowledge, however, that “[a]n alternative explanation … is that physicians’ perceptions of safety are unreliable; however, this conclusion is not supported by previous research suggesting that staff reported patient safety outcomes overlap with objective safety indicators.” [1] The authors cite two studies in support of this later claim. But many other studies —including the authors’ own data—suggest just the opposite. [2]

    Most of
    the studies reviewed by the authors that measured quality of care objectively (i.e., through chart audits, patient reports) did not find statistically significant associations between burnout/poor well-being and quality of care (see Table).

    For patient safety, 2 studies found no associations; 1 actually found there were fewer errors committed by those with burnout; and 1 found that depressed residents made more errors.

    For professionalism, all 4-5 studies found no associations.

    For patient satisfaction, 2 found no associations; 1 found better empathy among those with burnout; and 3-4 found associations.

    Claims that burnout, poor-well-being, mental disorders, and disabilities are meaningful causes of worse patient care do not have evidentiary support, may exacerbate stigma, and distract from more pressing structural problems within the medical field. [3,4]

    References

    1. Panagioti M, Geraghty K, Johnson J, et al. Association between physician burnout and patient
    safety, professionalism, and patient satisfaction: a systematic review and meta-analysis. JAMA Intern Med 2018;178(10):1317-1330. doi: 10.1001/jamainternmed.2018.3713

    2. Davis DA, Mazmanian PE, Fordis M, Van Harrison RT, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA 2006;296(9):1094-102. doi: 10.1001/jama.296.9.1094

    3. Lawson ND. Burnout is not associated with increased medical errors. Mayo Clin Proc. 2018;93(11):1682. doi: 10.1016/j.mayocp.2018.08.015

    4. Lawson ND, Boyd JW. How broad are state physician health program descriptions of physician impairment? Subst Abuse Treat Prev Policy. 2018;13:30. doi: 10.1186/s13011-018-0168-z
    CONFLICT OF INTEREST: None Reported
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    Subgroup analyses on reporting methods of patient care outcomes
    Maria Panagioti, PhD | University of Manchester
    In response to comment, by Lawton, I would like to clarify that subgroup analyses are reported in the paper which specifically examined the association between physician burnout and patient safety and professionalism taking into account the reporting method of patient care outcomes.

    We reported the results of these subgroup analyses which showed statistically significant associations between physician burnout and self-reported patient safety and professionalism and non-significant associations between burnout and objectively-reported measures of patient safety and professionalism (page 1320).

    However, only a small number of studies (7 out of 43 in total; fewer studies per outcome)
    used objectively reported measures of patient safety and professionalism, and our critical appraisal assessments did not suggest that that these 7 studies were methodologically superior to the studies which employed self-reported outcomes. Thus, emphasising the results of this small number of studies over the main evidence would not be a viable approach. In the discussion, we provided plausible explanations for this finding and we have encouraged further research to explore the impact of different reporting methods on the association between physician burnout and patient care outcomes.

    In conclusion, the current evidence which mainly consists of studies which used self-reported measures to assess patient care outcomes (including prospective studies) suggests that there is a significant association between physician burnout and patient safety incidents, low professionalism and reduced patient satisfaction. Exploring the impact of reporting methods of burnout and patient care outcomes is a fruitful avenue for future research.
    CONFLICT OF INTEREST: None Reported
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    Invitation to debate current wellness (well-being) and burnout research
    Nicholas Lawson, M.D., J.D., in progress | Georgetown University Law Center
    I appreciate the authors’ candor and humility in assessing the limitations of the studies they summarized. I also understand that it is not easy to design studies examining these relationships with objective measures of clinical quality.

    That said, I do not think it is possible to draw reliable inferences from studies of these relationships measuring clinical quality with subjective self-reports of physicians. There is good reason to suspect that physicians with burnout or depressive symptoms are more likely than those without to have negative views about their own clinical performance, even if is, in fact, no worse than that
    of other physicians. [1]

    For leaders of initiatives on physician wellness (“physician wellness [is a term] used interchangeably with physician well-being” [2]) to selectively cite a couple of studies suggesting that “patient safety outcomes overlap with objective safety indicators” [3] or that “reported medical errors have been found to approximate observed medical errors with 84% congruence” [4] is misleading: most studies using objective measures of clinical quality have found that there is no association between burnout/poor well-being and clinical quality.

    Physician wellness (well-being) researchers should take care to accurately report this research. Almost every major media outlet reporting on their articles have summarized their findings with titles such as, “Doctor burnout likely to impair care,” or “Burnout in doctors has shocking impact on care.” This does not accurately reflect the state of current research, and the authors are responsible for these media reports.

    For these and other reasons, I would like to invite either the authors of Panagioti et al. [3] or the authors of the recent similar review from Tawfik and colleagues [5] to debate the state and implications of existing wellness (well-being) research in the medical journal of their choice.

    References

    [1] Lawson ND. Burnout is not associated with increased medical errors. Mayo Clin Proc. 2018;93(11):1683. doi: 10.1016/j.mayocp.2018.08.015

    [2] Brady KJ, Trockel MT, Khan CT, et al. What do we mean by physician wellness? a systematic review of its definition and measurement. Acad Psychiatry. 2018;42(1):94-108. doi: 10.1007/s40596-017-0781-6

    [3] Panagioti M, Geraghty K, Johnson J, et al. Association between physician burnout and patient safety, professionalism, and patient satisfaction: a systematic review and meta-analysis. JAMA Intern Med 2018;178(10):1317-1330. doi: 10.1001/jamainternmed.2018.3713

    [4] Tawfik DS, Profit J, Morgenthaler TI, et al. In reply—burnout is not associated with increased medical errors. Mayo Clin Proc. 2018;93(11):1683-84. doi: 10.1016/j.mayocp.2018.08.014

    [5] Tawfik DS, Profit J, Morgenthaler TI, et al. Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Mayo Clin Proc. 2018;93(11):1571-80. doi: 10.1016/j.mayocp.2018.05.014
    CONFLICT OF INTEREST: None Reported
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