Are maladaptive brain changes the reason for burnout and medical error?

Central MessageBurnout and medical error are problems related to cognition with biological correlates. Future effort should consider brain biology in potential solutions.See Commentary on page 1141.Feature Editor's Introduction—The article by Manji colleagues relates burnout errors. The authors make the case that burnout, characterized “emotional exhaustion, detachment, cynicism, a sense of low personal accomplishment efficacy” is pervasive our profession, associated depression high rates suicide, which twice national average. If not bad enough, appears be with, if causative of, personally destructive cycle this disease physicians perpetuates itself because harming patients virtue decision making inflicts moral injury contributes even further depression. As pointed out authors, there neuroanatomic site responsible for depression, evidence-based pharmacologic therapy address its symptoms, many outlined American Psychiatric Association Practice Guidelines (http://psychiatryonline.org/guidelines.aspx). remind us suicidal ideation, so requiring treatment, sign some inherent weakness those who experience these symptoms. We no more than we would develop soft tissue infection, symptomatic coronary artery disease, or diabetes. effectiveness pharmacotherapy, such as monoamine oxidase inhibitor selective serotonin reuptake inhibitor, substantiates notion treatable illness physiologic/anatomic basis, viewed light. successfully makes association errors undeniable. increasingly learn about basis benefits treatment mental illness, must increase sensitivity manifestation colleagues, lower threshold treatment. point out, learning neurobiologically based will benefit only each but patients, well.Glenn J. R. Whitman, MD Burnout solutions. See 1141. recognized substantial health care system concerns show little evidence improvement despite decades attention problems. In review, description linking 2 provided. Specifically, it proposed (diagnostic error) cognitive overload (depleted working memory resources). It also may processes occurring similar parts lead both error. Keeping mind important devising new solutions problem. Dr X has been quite distressed over past number months. Policies being discussed thinks harmful costly system. brought up his numerous times feels ignored powerless. He getting cynical whether actually patient care. On top that, he already put 120 hours cardiac surgery intensive unit week behind charts. admits postemergent bypass graft non–ST-elevation myocardial infarction heart failure needing an urgent difficult intubation catheterization lab. Over next 24 48 hours, worsens regard hypoxia hypotension. asked reassess frequently, interrupted frequently other issues. There 13 sick unit, they all seem need help at same time. electronic record constantly freezes, hard complete work. treats diuretics increasing vasoactive drugs eventually renal ischemic bowel laparotomy. retrospect, realizes likely had aspiration pneumonia (from intubation) superimposed septic shock have treated volume antibiotics. does understand why did think usually things. frustrated system, emotionally exhausted, cynical, worthless. burned harmed due faulty thinking. described long-term, unresolvable job-related stress leads emotional depersonalization/feelings detachment from one's job responsibilities, accomplishment/efficacy (See Table 1).1Kane L. Medscape physician & suicide report 2020: generational divide.https://www.medscape.com/slideshow/2020-lifestyle-burnout-6012460Date accessed: July 31, 2020Google Scholar,2West C. Dyrbye Erwin P. Shanafelt T. Interventions prevent reduce burnout: systematic review meta-analysis.Lancet. 2016; 388: 2272-2281Abstract Full Text PDF PubMed Scopus (938) Google Scholar asphyxiates people's ambitions, idealism, worth.3Michel A. brain.https://www.psychologicalscience.org/observer/burnout-and-the-brainDate reported occur ∼40% (2 every 5) United States ∼15% 20%.1Kane Rates completed suicide—approximately 1% 2% physicians1Kane average reports.4Anderson Doctors' rate highest any profession.https://www.webmd.com/mental-health/news/20180508/doctors-suicide-rate-highest-of-any-profession#1Date World Health Organization recognizes workplace occupational phenomenon 11th edition International Classification Diseases.5World Burn-out “occupational phenomenon”: Diseases.https://www.who.int/mental_health/evidence/burn-out/en/Date When chronic imbalance between individual 6 areas (ie, workload, control, reward, community, fairness, values), passion erodes, one risk physical problems.6Leka S. Jain OrganizationHealth impact psychosocial hazards work: overview.https://apps.who.int/iris/handle/10665/44428Date caused factors, including distress (not able do what you know right organizational/cultural obstruction), perfectionist personality, psychiatric boredom, factors.2West Scholar,5World Scholar,6Leka recent survey 15,000 29 specialties, main reason (55%) overwhelming workload factors directly figuring patient's problem (eg, correct diagnosis).1Kane Other reasons include excessive work (33%) lack respect administrators, employers, staff (32%).1Kane Studies suggested related.7Iskander M. Burnout, overload, metacognition medicine.Med Sci Educ. 2019; 29: 325-328Crossref (8) ScholarTable 1Characteristics burnout1.Burnout: Emotional accomplishment/efficacy2.Forty percent burnout; 15% 20% depression; suicide3.Burnout terms values4.Burnout disruptive behavior harm Open table tab Not hurt physicians, hurts (Table 2). Physician affects care/patient safety behavior.8Panagioti Geraghty K. Johnson Zhou Panagopoulou E. Chew-Graham et al.Association safety, professionalism, satisfaction: meta-analysis.JAMA Intern Med. 2018; 178: 1317-1330Crossref (477) estimated 50% depressed sort issues normally make, expressing frustration front less motivated careful taking notes, easily exasperated patients.1Kane Despite negative effects 60% plan seek and/or comments was present methods delivery (system problem).1Kane 2Characteristics error1.Third leading cause death costing $100 billion2.Most common diagnostic made doctors3.Most diagnoses missed: infections, cardiovascular diagnoses, cancer4.Most errors: order appropriate tests, perform adequate history/physical exam, incorrect interpretation test, consultation5.Most error: Cognitive biases 1 (but only) 40-fold publications addressing safety/medical 1999 (when To Err Human9Institute Medicine Committee Quality Care AmericaKohn Corrigan J.M. Donaldson Is Human: Building Safer System. National Academy Press, Washington DC2000Google published) 2016, deaths increased eighth $50 billion9Institute third death10Makary Daniel Medical error—the US.BMJ. 353: i2139Crossref (1561) billion.11Newman-Toker D.E. Schaffer A.C. Yu-Moe C.W. Nassery N. Saber Tehrani A.S. Clemens G.D. al.Serious misdiagnoses-related harms malpractice claims: “big-three”—vascular events, cancers.Diagnosis (Berl). 6: 227-240Crossref (46) Thus, 3 big people die cancer, professionals. professionals strokes respiratory disease.10Makary Because certificates rarely list death, very possible first second States. most wrong diagnosis, delayed missed diagnosis).10Makary Scholar,11Newman-Toker generally doctors (leaders multidisciplinary team), catastrophic errors.11Newman-Toker enormous, costly, underrecognized problem, organizations like Society Improve Diagnosis formed growing exponentially securing millions dollars funding. lobby US government HR 5014 (a bill improve quality, appropriateness, diagnosis care) introduced House Representatives November 2019. Diagnostic believed anywhere 5 (20%) encounters11Newman-Toker Scholar,12Tudela Carreras Ballester emergency departments.Med Clin. 2017; 149: 170-175Crossref (11) encounters13Meyer Payne V. Meeks D. Rao Singh H. Physicians' accuracy, confidence, resource requests: vignette study.JAMA 2013; 173: 1952-1958Crossref (150) depending complexity case. situations where seeing time their initial presentation under pressure departments, family medicine clinics, internal practice) versus information pathology).14Singh Mayer Thomas frequency outpatient care: estimations three large observational studies involving adult populations.BMJ Qual Saf. 2014; 23: 727-731Crossref (257) hospitalized infections sepsis, pneumonia, central line Clostridium difficile colitis) acute syndrome, aortic dissection, pulmonary embolism).11Newman-Toker cancer.11Newman-Toker test (58% cases), history exam (43% (37% consultation (33% cases).15Kachalia Gandhi Puopolo Yoon Griffey al.Missed department: study closed claims 4 liability insurers.Ann Emerg 2007; 49: 196-205Abstract (307) Scholar,16Singh Giardina T.D. Meyer Forjuoh Reis Types origins primary settings.JAMA 418-425Crossref (299) unintentional (errors omission) 75% cases.17Leape Brennan Laird Lawthers Local Barnes B. al.The nature adverse events patients. Results Harvard practice II.N Engl J 1991; 324: 377-384Crossref (2858) (heuristics shortcuts) failures thinking appropriately.18O'Sullivan E.D. Schofield S.J. bias clinical medicine.J R Coll Physicians Edinb. 48: 225-232Crossref (85) mentioned, (making Also doing ordering incorrectly interpreting tests.15Kachalia These having too much (overload). Hence, (cognitive overload), exceeding capacity (limitation brain). Perhaps, when busy, instituting shortcuts biases) take coping mechanism brain19Croskerry ED cognition: anyone time.CJEM. 16: 13-19Crossref (43) Making performing way she injury, refers emotional, physical, spiritual feel after “perpetrating, failing prevent, bearing witness acts transgress deeply held beliefs expectations.”20Bailey Too time: say face ‘moral injury’ business model interferes care.https://www.washingtonpost.com/health/too-many-tests-too-little-time-doctors-say-they-face-moral-injury-because-of-a-business-model-that-interferes-with-patient-care/2020/01/31/c00e9d58-3d3a-11ea-8872-5df698785a4e_story.htmlDate Chronic exposure then contribute burnout. above link concept keep contemplating future Both overload. Examining literature suggests perhaps structures damaged thus overlap. better, involved different types (that can explored followed examining affected compares examine overlap.Table 3Brain automatic controlled burnoutAutomatic: System 1Control: 2BurnoutVentromedial prefrontal cortexDorsomedial cortexLateral cortexMedial cortexRight cortex (reduced thickness)Medial (decreased gray matter thinning) Medial parietal cortexPrefrontal: Parietal functional connectivity negatively influenced during executive performance taskLateral temporal lobeLeft superior gyrus thickness)Anterior insular 5-HT1A-serotonin receptor binding)Hippocampus binding)Dorsal anterior cingulate cortexRostral cortexAnterior thinning)Anterior binding)AmygdalaAmygdala reduced connectivityAmygdala (enlarged)Basal gangliaCaudate (reduced)5-HT1A, 5-hydroxytryptamine 1A. 5-HT1A, Kahneman, Nobel Prize Laureate, dual-process thinking) explain errors21Kahneman Thinking Fast Slow.1st ed. Farrar, Straus, Giroux, New York2011Google (see 4). humans ∼95% automatic, impulsive, associative, fast, unconscious. environmental conditions, task characteristics, age/experience, affective state, gender, personality.22Saposnik G. Redelmeier Ruff Tobler decisions: review.BMC Med Inform Decis Mak. 138Crossref (346) One multitask consuming minimal energy.21Kahneman (automatic) ideal use pressures overloaded prone major error.18O'Sullivan Functional magnetic resonance imaging (MRI) localize 1) ventromedial cortex, basal ganglia, amygdala, lateral dorsal cingulate23Lieberman M.D. Social neuroscience: core processes.Annu Rev Psyschol. 58: 259-289Crossref (1272) Scholar; is, limbic structures. hand deliberate, reflective, analytical, logical, conscious.21Kahneman education, training, critical skills, logical competence, rationality, feedback, intellectual ability.22Saposnik consumes lot energy, slow, cannot thinking, poor overloaded, MRI 2) medial lobe, rostral dorsomedial cortex23Lieberman cerebral hemisphere structures.Table 4Comparison systems thinkingVariableSystem 1System 2Frequency use95%5%CharacteristicsAutomaticImpulsiveAssociativeEmotionalFastGenerally unconsciousAbility multitaskDeliberateReflectiveLogicalAnalyticalSlowConsciousUnable multitaskInfluenced byEnvironmental conditionsTask characteristicsAge/experienceAffective stateGenderPersonalityEducation/intellectual abilityTrainingCritical skillsLogical competenceRationalityFeedbackEnergy expenditureMinimalHighRisk errorHighLow well. studies24Savic I. Perski Osika W. shows exhaustion syndrome partially reversible changes.Cereb Cortex. 28: 894-906Crossref (29) participants thickness left gyrus, caudate volume, enlarged amygdala volumes maladaptive changes). found 1A binding (ACC)/hippocampus/anterior thinning ACC ACC.24Savic shown high-stress influence function prefrontal-parietal task.24Savic inhibiting undergoing thinking25Goel Dolan R.J. Explaining modulation reasoning belief.Cognition. 2003; 87: B11-B22Crossref (316) well attention.26Savic Structural changes relation stress.Cereb 2015; 25: 1554-1564Crossref lists involved/affected interesting degree overlap following hypothesis: Perhaps brain, harder type expansion changed occurs within 200 years, explore space genetically modify organisms, fix A detailed discussion topic get solved. Solutions education/awareness, decreasing load using technology artificial intelligence, techniques mindfulness training behavioral therapy, drug change brain.2West Scholar,24Savic clearly research funding ways decrease entertains hypothesis brain. By analogy, once pathophysiology resulting damage myocardium understood, therapies were developed antihypertension diuretics) mitigate ongoing injury. currently done better.27Dias Ngo-Howard Boskovski Zenati Yule Systematic measurement tools assess surgeons' intraoperative workload.Br Surg. 105: 491-501Crossref (69) accepts premise limits do, measures place (by institutions) into failure. formally educate trainees practicing psychology teach them recognize signs cope asking help. processes, shame feelings Realizing automatic), institutions create environments (based infrastructure act significant least partly changes, considering offer innovative future. Resources obtained Thoracic Surgeons website (https://www.sts.org/publications/videos/strategies-surgeons-prevent-burnout). (https://www.improvediagnosis.org).