Internal medicine residents who reported higher levels of fatigue and distress were more likely to report a medical error, according to a study in the September 23/30 issue of JAMA, a theme issue on medical education.

"Medical errors and patient safety continue to be an important concern for patients and physicians, especially since the Institute of Medicine reported in 1999 that between 48,000 and 98,000 Americans die each year due to preventable adverse events," according to background information in the article. "Fatigue and distress have been separately shown to be associated with medical errors. The contribution of each factor when assessed simultaneously is unknown."

Colin P. West, M.D., Ph.D., of Mayo Clinic, Rochester, Minn., and colleagues assessed the independent contributions of fatigue and distress to self-reported medical errors when considered simultaneously. The study included data provided by 380 internal medicine residents who began training from 2003 to 2008 and completed surveys quarterly through February 2009. The surveys included self-assessment of medical errors, overall quality of life (QOL) and fatigue; and measures of burnout, depression, and sleepiness.

The average response rate to individual surveys was 67.5 percent. Of the 356 participants (93.7 percent) providing error data, 39 percent reported making at least 1 major medical error during the study period. In analyses, there was an association of subsequent self-reported error with measures of sleepiness and fatigue score. Each 1-point increase in fatigue or sleepiness score was associated with a 14 percent and 10 percent increase, respectively, in the odds of reporting a medical error. Subsequent error was also associated with burnout, a positive depression screen and overall QOL.

"Fatigue and distress variables remained statistically significant when modeled together with little change in the point estimates of effect. Sleepiness and distress, when modeled together, showed little change in point estimates of effect, but sleepiness no longer had statistical significance associated with errors when adjusted for burnout or depression," the researchers write.

"In summary, this study suggests that fatigue, sleepiness, burnout, depression, and reduced QOL are independently associated with an increased risk of future self-perceived major medical errors. In addition to the national efforts to reduce fatigue and sleepiness, well-designed interventions to prevent, identify, and treat distress among physicians are needed. Additional research is necessary to determine the most effective strategies for accomplishing these goals. Changes to the process of physician training should address both resident fatigue and distress in an effort to improve resident and patient safety," the authors conclude.

Another study in the same issue of JAMA reported that primary care physicians who participated in an educational program that included an emphasis on mindful communication reported improvement in personal well-being, emotional exhaustion, empathy and attitudes associated with patient-centered care.

"Primary care physicians report alarming levels of professional and personal distress. Up to 60 percent of practicing physicians report symptoms of burnout, defined as emotional exhaustion, depersonalization (treating patients as objects), and low sense of accomplishment. Physician burnout has been linked to poorer quality of care, including patient dissatisfaction, increased medical errors, and lawsuits and decreased ability to express empathy," according to background information in the article.

The authors add that another consequence of physician burnout is a decline in the percentage of graduates entering careers in primary care in the last 20 years, with reasons related to burnout and poor quality of life. "Even though the problem of burnout in physicians has been recognized for years, there have been few programs targeting burnout before it leads to personal or professional impairment and very little data exist about their effectiveness."

Michael S. Krasner, M.D., of the University of Rochester Medical Center, Rochester, N.Y., and colleagues designed a continuing medical education (CME) course to improve physician well-being. "One proposed approach to addressing loss of meaning and lack of control in practice life is developing greater mindfulness-the quality of being fully present and attentive in the moment during everyday activities," the researchers write.

The course is based on 3 techniques: mindfulness meditation, narrative medicine, and appreciative inquiry. "Mindfulness meditation is a secular contemplative practice focusing on cultivating an individual's attention and awareness skills. Both narrative medicine and appreciative inquiry involve focusing attention and awareness through telling of, listening to, and reflecting on personal stories."

Seventy primary care physicians participated in the course, which included an 8-week intensive phase (2.5 hours/week, 7-hour retreat), followed by a 10-month maintenance phase (2.5 hours/month). The course included mindfulness meditation, self-awareness exercises, narratives about meaningful clinical experiences, appreciative interviews, didactic material and discussion. Physicians were surveyed before, during and after the course regarding levels and measurements of mindfulness, burnout, empathy, psychosocial orientation, personality and mood.

"Our study demonstrated that primary care physicians participating in a CME program that focused on self-awareness experienced improved personal well-being, including burnout (emotional exhaustion, depersonalization, and personal accomplishment) and improved mood (total and depression, vigor, tension, anger, and fatigue). They also experienced positive changes in empathy and psychosocial beliefs, both indicators of a patient-centered orientation to medical care that has been associated with patient-centered behaviors such as attending to the patient's experience of illness and its psychosocial context and promoting patient participation in care," the authors write.

"The skills cultivated in the mindful communication program appeared to lower participants' reactivity to stressful events and help them adopt greater resilience in the face of adversity," they add. "Further study will be necessary to investigate the effects on practice efficiency, patients' experience of care, and clinical outcomes."