Depression in Docs Leads to Medical Errors and Vice Versa

Pauline Anderson

November 27, 2019

Depressive symptoms in physicians are linked to self-perceived medical errors and vice versa, new research shows.

Results of the systematic review and meta-analysis show that physicians with depressive symptoms are 95% more likely to report making medical errors. The analysis also showed that doctors who made medical errors are 67% more likely to report subsequent depressive symptoms.

Karina Pereira-Lima, PhD

"When you consider that depressive symptoms are preventable and treatable and that medical errors cost millions of dollars to the healthcare system every year, our findings suggest that supporting the well-being of physicians is not only important for them, but also for their patients. It also makes financial sense," study investigator Karina Pereira-Lima, PhD, University of Sao Paulo, Brazil, told Medscape and Medical News.

The findings were published online November 27 in JAMA Network Open.

Impact on Quality of Care

Depression is highly prevalent among physicians and has previously been associated with an increased risk of medical errors, the investigators note. However, they add that the magnitude and the relationship between the two phenomena remains unclear.

In other words, does depression in physicians lead to the perception that they are making medical errors, or do medical errors lead to depression?

To investigate the researchers analyzed data from 11 studies — seven longitudinal and four cross-sectional — which included a total of 21,517 physicians. Nine studies were carried out in the United States, one in Japan, and one in South Korea.

Eight studies included only physicians in training. The remainder included physicians from any career level. Seven studies recruited physicians from multiple specialties, whereas four recruited physicians from a single specialty — one in pediatric residents, one in anesthesiology residents, and two in internal medicine residents.

Eight studies inquired about "major medical errors" in the past 3 months, two inquired about errors in the past year, and one actively surveyed errors in a 1-month interval.

"Major medical error" could refer to those that had patient or healthcare system consequences, said Pereira-Lima.

Research suggests that there's a "very strong correlation" between self-reported and objective measure of medical errors, although this needs to be further investigated, she added.

The pooled relative risk (RR) of medical errors among physicians with depressive symptoms was 1.95 (95% confidence interval [CI], 1.63 - 2.33).

The magnitude of the association was generally consistent across studies that assessed practicing physicians and those in training.

"This tells us that depressive symptoms can affect quality of care [provided by physicians] independent of the level they're at," said Pereira-Lima.

Differences Between Specialties?

However, she added that since most of the studies examined doctors in training, more research in practicing physicians is necessary.

The association was significantly higher in cross-sectional vs longitudinal studies (2.51 [95% CI, 2.20 - 2.83] vs 1.62 [95% CI, 1.43 - 1.84]) and appeared to be bidirectional.

In addition, medical errors were associated with future depressive symptoms (RR, 1.67; 95% CI, 1.48 - 1.87).

Pereira-Lima noted that this is the first systematic review of the direction of the association between depressive symptoms in physicians and medical error.

Studies that only included surgical specialties yielded a summary RR estimate that was significantly higher than studies that also included nonsurgical specialties (2.59 [95% CI, 2.10 - 3.16] vs 1.79 [95% CI, 1.46 - 3.16]).

This may suggest, said Pereira-Lima, that some specialties are more prone to medical errors or that some errors are "more memorable." That said, only one study looked at surgical specialties alone. This finding also needs more exploration, she added.

The US studies yielded higher estimates of the association between depression and medical errors compared with non-US studies (2.10 [95% CI, 1.77 - 2.46] vs 1.39 [95% CI, 1.00 - 1.93]).

However, since most studies only assessed US physicians, "this is definitely something that needs to be more investigated in other cultures before we can make a conclusion," said Pereira-Lima.

Summary RR estimates for studies assessing depressive symptoms through the HANDS or the PRIME-MD-2 were significantly higher compared with those identified via the PHQ-9.

The study reinforces the need for interventions aimed at improving the physician work environment, said Pereira-Lima. "Institutions should make systemic changes to prevent errors and protect the well-being of physicians."

"First-Rate" Research

Commenting for Medscape Medical News, Michael F. Myers, MD, professor of clinical psychiatry, Department of Psychiatry & Behavioral Sciences, SUNY Downstate Medical Center, Brooklyn, New York, and a specialist in physician health, described the study as "a first-rate research paper."

Both the substance of the article and the "novel bidirectional piece" validate what experts like himself have seen "for a long time" in clinical practice, said Myers.

The new findings will be helpful for experts who conduct independent medical evaluations to determine a physician's fitness to practice. Myers said he often tells doctors with depression that they have enough on their plate with their illness and "don't need a medical error on top of that."

"This makes it easier for me to defend my wish for them to either take a week or two of medical leave" or to at least briefly curtail their clinical work to do just their research or writing, said Myers.

He noted that depressive symptoms could affect work by interfering with memory and the ability to concentrate.

Myers noted that the medical errors in the current analysis are "subjective" and that a doctor's perception of his or her errors may not be "nearly as bad as they think."

However, he emphasized that a doctor who feels as though he or she has made an error, or could make an error, still needs to be assessed.

Physicians who have made errors need support. "Even though that old adage says 'to err is human,' it's an awfully devastating thing," said Myers.

The study was funded in part by the Arnold P. Gold Foundation Research Institute. Pereira-Lima and Meyers have disclosed no relevant financial relationships.

JAMA Netw Open. 2019;2(11):e1916097. Full text

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