Residents Who Make Bad Errors Suffer Severe Personal Pangs

ROCHESTER, Minn., Sept. 5 -- When medical residents make major errors, as about a third of them believe they do, their guilt and emotional suffering may require counseling to avoid burnout, according to Mayo investigators.

Personal distress, depression, and decreased empathy engendered by the mistakes were also associated with an increased likelihood of future errors, suggesting that perceived errors and distress may lead to self-perpetuating behavior, reported Colin West, M.D., Ph.D., and colleagues, in the Sept. 6 issue of the Journal of the American Medical Association.

Medical errors have received increased attention since 1999 when the Institute of Medicine reported that up to 100,000 U.S. patients die each year because of preventable adverse events. But little is known about the quality of life for residents who may make such errors, said Dr. West and colleagues.

A majority of the residents discussed their errors with colleagues, supervising faculty, or friends and family, but formal programs to provide additional support for physicians who make errors appear warranted, Dr. West said.

Their prospective longitudinal study included data from 184 (84%) of 219 eligible internal medicine residents at the Mayo Clinic who began training in the 2003-2004, 2004-2005, and 2005-2006 academic years and completed surveys quarterly through May 2006. The surveys included assessment of medical errors and quality of life every three months and measures of burnout (depersonalization, emotional exhaustion, and sense of personal accomplishment) and symptoms of depression every six months.

One caveat, the researchers noted, was that because major medical errors were not specifically defined for the residents, the study represents errors as perceived by the physicians and might have varied with the individual's personality.

Examples of errors from other studies might be an act of omission by a caregiver, which should have been judged wrong by a knowledgeable peer, or a complication resulting from medical mismanagement and not from the patient's underlying condition.

During the year-long study period, overall 34% of the participants reported making at least one major medical error, while 43% of the residents who had completed at least a year of training reported errors. Making a medical error in the previous three months was reported by a mean of 14.7% of participants at each quarter.

Of the participants, 20% reported one error, 6% reported two errors, and 8% reported three or more errors, the researchers said.

Self-perceived medical errors were associated with a subsequent decrease in quality of life (P=.02) and worsened measures in all three domains of burnout (P=.002 for each).

Participants who reported self-perceived errors were also three times more likely to screen positive for depression at the subsequent time point (odds ratio 3.29, 95% confidence interval, 1.90-5.64).

In addition, increased burnout in all domains and loss of empathy or compassion were associated with increased odds of making an error in the following three months, including depersonalization (P=.001), emotional exhaustion (P<.001), and lower personal accomplishment (P=.02); as well as loss of emotive (P=.02) and cognitive empathy (P=.01).

In a review of the study's limitations, the researchers referred to the inability to determine whether the errors actually affected patients, the inability to generalize the findings, which came from a single medical institutions, the limitation of distress measurements to specific survey points in time, and the inability to diagnose depression by itself and the possible link between depression and making a medical error.

In addition, they said, some confounding effects could come from the physicians' personality traits-highly self-critical versus confident-and, finally, the role of sleep deprivation.

"Further investigation to identify the most effective post-error support mechanisms is needed in parallel with ongoing system efforts to reduce error rates and resident distress," he concluded.