In this tricentre study 20% of residents were depressed and 75% were burnt out. On active surveillance those who were depressed made more than six times as many errors in medication as their non-depressed peers. Furthermore, those who were depressed or burnt out reported poorer health and higher error rates than those who were not burnt out or depressed. This prospective study of burnout and depression among residents at three centres correlated the mental health of house staff with objective data on rates of medication error. Our finding that depressed residents had a medication error rate six times higher than that of non-depressed residents indicates that mental health may be a more important contributor to patient safety than previously suspected.
The prevalence of depression in our cohort of residents was nearly twice that expected in the general population28
and was near the mid-point of previously reported rates of depression among residents (range 7%-56%).1 2 10 11
Comparisons with rates of depression in the general population should be made with caution; however, given the infrequency with which residents reported a history of depression, it seems that residency itself may be associated with the onset of depression in a sizeable number of residents. Other authors have suggested that the commission of errors may itself lead to depression, making the doctor a “second victim” in an apparent vicious cycle.18 29
Nearly half of the depressed residents seemed unaware of their depression, despite being doctors, and only a small number were receiving treatment. These findings are sobering and warrant not only further investigation but also regular screening and treatment efforts in training programmes.
Burnout, although more pervasive than depression, had no objectively measurable association with medication errors. This is an important finding, as burnt out residents reported making significantly more medical errors than their non-burnt out colleagues in several studies, including our own. It is difficult to determine whether non-burnt out residents underestimate their error rates or whether burnt out residents overestimate their error rates or make an increased number of error types that were not captured in this study (for example, diagnostic errors). As in other studies, nearly all the depressed residents were burnt out, begging the question which came first?1 9 11
The high burnout rate in this study, which is consistent with that in other studies, also raises questions about whether current methods of doctors’ training generate avoidable stress that is detrimental to the health of residents.
Our study has several limitations. To do our statistical analysis assuming a Poisson distribution we had to make two key assumptions: that the resident workload was evenly distributed across the resident subpopulations and that the depressed or burnt out residents were evenly distributed across the wards for which orders were reviewed. We have data that support the first assumption from the resident work logs, showing no statistically significant difference in sleep or work hours between the different populations of residents. For the second assumption it is statistically highly unlikely that such a chance distribution could explain the differences observed, given the magnitude of difference observed between depressed and non-depressed groups; the likelihood of this cannot be entirely excluded, however. We did consider the possibility that one or two outliers could be responsible for the higher error rate among depressed residents. On review of the error data, errors were fairly evenly distributed across resident groups, with the exception of one resident responsible for 11 errors, who was both burnt out and depressed. We undertook a cluster adjusted analysis to tackle this problem. In addition, we reanalysed our data in a sensitivity analysis to see if our primary results changed if this resident was excluded and found that although the number of errors per resident month was reduced for both depressed and burnt out residents, the statistically significant differences between depressed and non-depressed residents persisted. The difference between burnt out and non-burnt out residents also remained unchanged, with no statistically significant difference.
Secondly, this study focused solely on residents in paediatrics, so the manner in which depression and burnout may affect house staff in other specialties is unclear. Although we have no reason to postulate that the relation between residents’ depression and error rates would be unique to paediatrics, further studies are needed to quantify the relation across specialties. Thirdly, we were unable to use data on errors from one of our three sites (Children’s National Medical Center), as the data were collected without the coded identifiers that allowed us to link errors to specific residents. Although we had sufficient power to show a significant link between depressed residents and medication errors on the basis of data from two centres, the additional data would have contributed to the robustness of the study. Fourthly, we collected our data before the implementation of any work hour limits for residents in the United States. Despite the fact that the link between depression and medical errors is unlikely to be affected by the change, the prevalence of mental health disorders could possibly have been affected by this intervention. Effects of reduced work hours on residents’ quality of life is unclear30
; however, recent studies suggest that changes to work hours in the United States significantly decreased burnout scores but did not alter rates for depression.10 11
Lastly, whereas the number of residents who volunteered to participate in this study was high, particularly considering the time commitment required, and although available personal data suggest that our population of residents was typical of American paediatric residents,31
our population may have differed from the national cohort of residents in certain non-measurable respects. Participants signed informed consent and were aware that we were collecting data on work hours, mental health, and medication errors, but they were not aware of the specific hypothesis of this study. Thus we have no reason to believe that they would have chosen to participate or not on the basis of whether they were depressed or burnt out, and data on errors were collected by investigators blinded to the residents’ depression and burnout status.
This study raises important ethical concerns. Twenty four participants were found to be at high risk of major depression yet they could not be approached and encouraged to seek treatment owing to the confidentiality agreement, as none of them expressed active suicidal or homicidal ideation. Scoring positive for depression in the absence of expressing suicidal or homicidal ideation was not deemed adequate to break the confidentiality agreement. The general results of the study were shared with the three directors of the residency programmes in an effort to improve screening and treatment options, but it is unknown whether any of those residents received appropriate medical care. After the study had finished depressed residents were found to make significantly more medical errors yet this was unknown at the time of data collection and hence they could not be approached about their errors, nor could their attending doctors be notified of the need for more careful supervision. Without assured confidentiality it is unlikely that participants would be as candid in their responses in a research setting; however the presence of significant numbers of depressed residents on the paediatric wards, committing medical errors at a high rate, is cause for concern.
Our results highlight the need for better research on the mental health of doctors. Efforts should be made to screen residents for signs and symptoms of depression and to ensure proper treatment. Additional research is necessary to define better how depression and burnout affect residents and patient care in other specialties and to define better the causal relation between depression and errors. More information is also needed on the mental health of senior doctors. Lastly, rigorous trials are needed on interventions to improve the mental health of trainees.
Mental health problems are associated with decreased quality of life and loss of productivity in the workplace. Depressed healthcare providers may also put patients at risk of unintentional harm. Our study adds to an increasing body of literature showing the substantial relation between healthcare providers’ working conditions and health and the safety of patients and residents.15 16 17 18 19 20 22 23 32 33
Further efforts to study and improve the working conditions and mental health of doctors should be a priority.
What is already known on this topic
- Depression and burnout are highly prevalent in doctors in training
- Burnout is associated with a higher rate of self reported errors among residents
What this study adds
- Depressed residents in paediatrics were more than six times as likely to make errors in medication as their non-depressed colleagues
- Burnout did not seem to be associated with higher rates of medication errors