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    2 Comments for this article
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    Misuse of Terms Diminishes Value of Report
    Louise B. Andrew, MD, JD | no affiliation
    This well-intentioned effort to shed more light on the potential relationship between physician depression and medical errors actually further confuses the issue, by inaccurately interchanging key terms such as “medical errors” vs “perceived errors” and “depressive symptoms” vs “depression” throughout the analysis, including the title.

    Because of this imprecision, both lay and popular medical news writers have already begun to propagate the attention-grabbing (but misleading) headline “Physician depression leads to medical errors”.

    91% of the studies measured “perceived” or self reported, as opposed to objective measures of error. This is of particular concern
    when those reporting are also experiencing depressive symptoms. Such self-reporters of medical errors are more likely to recall negative events and to view themselves in a negative light, and are therefore more likely to assess a clinical event with a suboptimal outcome as an error, and to blame themselves for that error. Self-reported errors thus may reflect differences in reporting and self-judgment—not actual differences in objective error rates. Only 101 of the 21,517 participants had any kind of external identification of error. In all of the others, the existence of error was assumed from retrospective self report.

    The unfortunate conflation of perceived and actual errors throughout the present article is mysteriously justified 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 (Weingart SN, Callanan LD, Ship AN, Aronson MD. A physician-based voluntary reporting system for adverse events and medical errors. J Gen Intern Med. 2001;16(12):809-814 doi:10), a resident peer survey of purported errors, actually illustrates no such thing as it involved residents reporting all errors observed on a service, and NOT personal errors.

    The studies included in the meta-analysis use several population screeners for depressive symptoms, highly sensitive but not specific for a diagnosis of depression. Most screens were not followed by any definitive testing or clinical interviews. Yet throughout the paper, the terms “depression” and “depressive symptoms” are regularly conflated. This confuses the issue of whether the physicians being surveyed met clinical criteria for depression, or whether they were experiencing symptoms related instead to burnout, exhaustion, poor sleep, or high stress. Further, while depression screeners assess recent symptoms (typically several weeks), elicitation of self error reports typically covered much longer periods (3-12 months), so the two phenomena being collated, may not even have overlapped in time.

    While true 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”, the paper does not seem to have provided such, instead offering a review on how often physicians with depressive symptoms self-report perceived errors. Such reports may or may not relate to the actual incidence of errors.

    Finally, it is disappointing to see the IOM and Makary papers regarding generic adverse events in hospitalized patients cited in support of studies purporting to relate to physician medical errors. Continued amplification of these papers (Mazer and Nabhan, J Gen Intern Med 34(10):2264–7 DOI: 10.1007/s11606-019-05156-7) in the popular press could sustain misperceptions of the roots of the problem.
    CONFLICT OF INTEREST: None Reported
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    The Devil is in the Details
    Stephen Strum, MD, FACP | Community Practice of Hematology-Oncology
    First, the comment by Louise Andrew MD, JD is an excellent comment and informs the reader more accurately than this meta-analysis by Pereira-Lima et al. I am old school and love technology, but what I find in reviewing meta-analyses is that they are far from being a substitute for an actual investigation that is based on a review of the medical records. Using "keywords" or Medicare billing codes or some other surrogate marker is too glib and often too misleading a way to conduct research. At the very least, take a subset of the patients (in this case physicians) involved and look into the details to see if they correlate with the conclusions of the meta-analysis.

    What I have seen in the peer-reviewed literature in the last few decades is what I have evidenced in medicine in general i.e., a move towards fast-food medicine, or what I call McMedicine, and dispensing of the leg-work, the cognitive effort that goes into a sincere assessment. This is echoed not only in publications but in the care of patients, where the history and physical examination has been abridged by copy-paste of the EHR, where there is less analytic (cognitive) thought and instead reliance on laboratory testing and imaging. These short-cuts in medicine, be they in publications or in care, degrade the magnificent essence of science & the medical care of our patients.
    CONFLICT OF INTEREST: None Reported
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    Original Investigation
    Health Policy
    November 27, 2019

    Association Between Physician Depressive Symptoms and Medical Errors: A Systematic Review and Meta-analysis

    Author Affiliations
    • 1Department of Psychiatry, University of Michigan Medical School, Ann Arbor
    • 2Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
    • 3Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
    • 4Department of Neuroscience and Behavior, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
    JAMA Netw Open. 2019;2(11):e1916097. doi:10.1001/jamanetworkopen.2019.16097
    Key Points español 中文 (chinese)

    Question  What are the magnitude and direction of associations between physician depressive symptoms and medical errors?

    Findings  In this systematic review and meta-analysis of 11 studies involving 21 517 physicians, physicians with a positive screening for depression were highly likely to report medical errors. Examination of longitudinal studies demonstrated that the association between physician depressive symptoms and medical errors is bidirectional.

    Meaning  This study found that physician depressive symptoms were associated with medical errors, highlighting the relevance of physician well-being to health care quality and underscoring the need for systematic efforts to prevent or reduce depressive symptoms among physicians.

    Abstract

    Importance  Depression is highly prevalent among physicians and has been associated with increased risk of medical errors. However, questions regarding the magnitude and temporal direction of these associations remain open in recent literature.

    Objective  To provide summary relative risk (RR) estimates for the associations between physician depressive symptoms and medical errors.

    Data Sources  A systematic search of Embase, ERIC, PubMed, PsycINFO, Scopus, and Web of Science was performed from database inception to December 31, 2018.

    Study Selection  Peer-reviewed empirical studies that reported on a valid measure of physician depressive symptoms associated with perceived or observed medical errors were included. No language restrictions were applied.

    Data Extraction and Synthesis  Study characteristics and RR estimates were extracted from each article. Estimates were pooled using random-effects meta-analysis. Differences by study-level characteristics were estimated using subgroup meta-analysis and metaregression. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline was followed.

    Main Outcomes and Measures  Relative risk estimates for the associations between physician depressive symptoms and medical errors.

    Results  In total, 11 studies involving 21 517 physicians were included. Data were extracted from 7 longitudinal studies (64%; with 5595 individuals) and 4 cross-sectional studies (36%; with 15 922 individuals). The overall RR for medical errors among physicians with a positive screening for depression was 1.95 (95% CI, 1.63-2.33), with high heterogeneity across the studies (χ2 = 49.91; P < .001; I2 = 82%; τ2 = 0.06). Among the variables assessed, study design explained the most heterogeneity across studies, with lower RR estimates associated with medical errors in longitudinal studies (RR, 1.62; 95% CI, 1.43-1.84; χ2 = 5.77; P = .33; I2 = 13%; τ2 < 0.01) and higher RR estimates in cross-sectional studies (RR, 2.51; 95% CI, 2.20-2.83; χ2 = 5.44; P = .14; I2 = 45%; τ2 < 0.01). Similar to the results for the meta-analysis of physician depressive symptoms associated with subsequent medical errors, the meta-analysis of 4 longitudinal studies (involving 4462 individuals) found that medical errors associated with subsequent depressive symptoms had a pooled RR of 1.67 (95% CI, 1.48-1.87; χ2 = 1.85; P = .60; I2 = 0%; τ2 = 0), suggesting that the association between physician depressive symptoms and medical errors is bidirectional.

    Conclusions and Relevance  Results of this study suggest that physicians with a positive screening for depressive symptoms are at higher risk for medical errors. Further research is needed to evaluate whether interventions to reduce physician depressive symptoms could play a role in mitigating medical errors and thus improving physician well-being and patient care.

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