CMPA news

A missing quality indicator

Experts stress that there is now so much evidence linking physician wellness to patient outcomes, medical-legal risk, and the performance of healthcare teams that wellness should be assessed as an independent indicator of health system quality.

For instance, physician stress and burnout have been associated with “suboptimum” patient care practices. Burned out physicians report: taking short cuts, failing to follow established procedures, not answering patient questions, not discussing treatment options, and making treatment or medication errors that cannot be attributed to a lack of knowledge.1 Research has shown that patients of dissatisfied physicians tend to be less adherent to treatment plans4 and may take longer to recover after discharge from hospital.2

Higher burnout levels have been linked to an increased likelihood of residents reporting a major self-perceived medical error. In turn, self-perceived medical errors have been linked to higher burnout scores and worse depressive symptoms in residents. A survey of over 7,000 U.S. surgeons found that burnout was strongly associated with having been named in a recent medical malpractice suit. Medical malpractice suits led to less career satisfaction, suggesting a reciprocal relationship between medical errors and burnout among residents and practising physicians.3,4

In addition, a number of studies suggest that burnout can be infectious and spread from one team member to another,5 and that the departure of a burned out physician can increase burnout among remaining team members over the following 12 months.5 Burnout at the team or unit level can adversely affect patient care. A Swiss study of 54 intensive care units found that highlevels of burnout were associated with a poorer sense of teamwork and higher patient mortality rates.2

Like other quality indicators, physician wellness is measurable and actionable. Burnout can be assessed using existing instruments, and evidence-based interventions can reduce burnout among physicians.4

Costs to the healthcare system

Two recent reviews have stressed the need to view physician wellness from a financial perspective.1 The “business case” for wellness is relatively new, and encourages physician leaders and other stakeholders to recognize the impact that burnout can have on the healthcare system as a whole.

Physician burnout has been linked to decreased productivity. One study of physicians at the Mayo Clinic found that every single-point increase in burnout scores increased the odds of physicians reducing their hours over the subsequent 24 months.1 Burnout scores are also a strong predictor of physicians planning to leave practice entirely for reasons other than retirement.2 Reduced work hours among physicians mean fewer elective surgery cases, fewer admissions, and less imaging,3 while physician departures signal disruptions in care for existing patients and decreased access to care for individuals who need physicians.2,4

Physician turnover triggers costs associated with finding replacements and increases the cost of providing care to individual patients, who may have to see a different physician every few years.3 Burned out physicians who stay on the job may increase costs by ordering more tests and making more referrals; they may also increase costs associated with medical-legal complaints.4 Turnover due to burnout deprives younger physicians of mentors, represents a loss of expertise at the team level, and reduces the ability of organizations to pursue grants and implement clinical trials.3

A 2014 study by researchers at the University of Toronto estimated that burnout cost the Canadian health system $213.1 million as a result of early retirement and reduced work hours. The authors stressed that the costs and inefficiencies associated with burnout are a significant problem in a healthcare system already struggling with long wait times and physician shortages.