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Clinical Laboratories and Pathology Groups

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Clinical Laboratories and Pathology Groups

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Stanford University Researchers Finds Physician Burnout as Big a Threat to Patient Safety as Unsafe Hospital Conditions; Exhausted Providers Twice as Likely to Make Medical Errors

Pathologists might be able to help overburdened doctors by adding medical laboratory support services that assist providers in selecting the right tests and identifying the best therapeutic options for patients

In a new Stanford University School of Medicine study published in the July 9, 2018, issue of Mayo Clinic Proceedings, researchers indicate that physician burnout may be as big a cause of medical errors as unsafe healthcare environments. This highlights an opportunity for clinical laboratory professionals and pathologists to help physicians improve both diagnostic accuracy and the selection of the most appropriate therapies.

The study found that exhausted providers were twice as likely to report making a medical error. However, it’s a complex problem with no easy solutions.

“Just trying to fix the setting of healthcare environments in order to prevent errors is not sufficient,” Stanford University’s Daniel Tawfik, MD, MS, the study’s lead author, told Reuters Health. “We also need to address the actual underlying human factors that contribute to errors—specifically looking at physician burnout.”

Nevertheless, while there is no one-size-fits-all solution to physician burnout, clinical laboratory managers and pathologists potentially could help overburdened providers reduce burnout and fatigue by adopting new lab testing support services designed to assist physicians in selecting the right tests and identifying the best therapeutic options for their patients.

Medical Errors Third-Leading Cause of Death in America

Stanford researchers wanted to learn how physician burnout contributes to medical errors which, according to Johns Hopkins, is the third-leading cause of death in the US. They surveyed 6,695 physicians from across America. Of the respondents:

  • More than 54% reported symptoms of burnout­;
  • 33% experienced excessive fatigue;
  • Nearly 7% had thoughts of suicide; and,
  • Roughly 4% reported a failing safety grade in their primary work area.

Even in medical units judged to have excellent safety records, the study found rates of medical errors nearly tripled when physicians working in those units had high levels of burnout. The prevalence of errors became similar to a non-burned-out physician working in a unit with a safety grade of “acceptable” or “poor.”

“We found that physicians with burnout had more than twice the odds of self-reported medical error, after adjusting for specialty, work hours, fatigue, and work unit safety rating,” Tawfik noted in a Stanford news release. “We also found that low safety grades in work units were associated with three to four times the odds of medical errors.”

According to the study, overall, 10.5% of physicians surveyed acknowledged in the prior three months making:

  • An error in judgment;
  • A wrong diagnosis;
  • A technical mistake during a procedure;
  • Prescribing a wrong drug/dosage; and/or,
  • Ordering medication/intervention for the wrong patient.

While more than half of mistakes (55.4%) did not affect patient outcomes, or only caused a temporary problem (22.6%), more than 5% of errors did lead to major permanent health problems and 4.5% resulted in a patient death, the study found.

Radiologists, neurosurgeons, and emergency medicine specialists had the highest prevalence of error rates, with more than 21% of providers in each of those fields acknowledging recent mistakes.

Physicians reporting errors were more likely to have symptoms of overall burnout (77.6% versus 51.5%), as well as fatigue (46.6% versus 31.2%), than error-free providers. Physicians reporting recent errors also had a higher prevalence of suicidal thoughts (12.7% versus 5.8%), the study found.

Ted Hole, MD, a family practice physician in Ventura, Calif., is not surprised by the correlation between medical mistakes and overall well-being. “If your brain isn’t working right, you’re going to make errors,” Hole told the Ventura County Star. “That’s what burnout does. It makes your brain not work right.”

Stanford Connects Physician Burnout and Poor Workspace Safety Ratings

In their paper, the Stanford researchers argue a “combination of physician-targeted burnout interventions and unit-targeted patient improvement measures” are needed to tackle the problem of medical errors. Physicians who gave their work units an excellent, very good, or acceptable safety grade were less likely to make a medical error than those who described workplace safety as poor or failing.

Of the physicians who reported a poor or failing work unit safety grade, nearly 25% reported a recent error. Errors were incrementally lower for work units with higher safety grades regardless of physician burnout levels.

“This indicates both the burnout level as well as work unit safety characteristics are independently related to the risk of errors,” Tait Shanafelt, MD, Director of the Stanford WellMD Center and Associate Dean of the School of Medicine, noted in a Stanford statement.

“Today, most organizations invest substantial resources and have a system-level approach to improve safety on every work unit,” he said in the Stanford news release. “We need a holistic and systems-based approach to address the epidemic of burnout among healthcare providers if we are truly going to create the high-quality healthcare system we aspire to.”


Tait Shanafelt, MD (above), is Director of the Stanford WellMD Center, Associate Dean of the School of Medicine, and an author of the Stanford study. He maintains the “epidemic of burnout” among healthcare providers should receive as much attention as safety issues. Shanafelt became Stanford Medicine’s first Chief Wellness Officer in 2017. (Photo copyright: Stanford School of Medicine.)

Burnout Among Physicians Increasing

Other studies, including Medscape’sLifestyle Report 2017: Race and Ethnicity, Bias and Burnout,” confirm an upward trend in burnout rates among US physicians. In the Medscape study, 51% of physicians surveyed reporting being “burned out,” defined as a loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment. Since the Medscape Lifestyle Report first queried physicians about burnout in 2013, the number of providers reporting burnout has increased 25%.

Physician burnout has been attributed to a variety of factors, including:

  • Excessive workloads;
  • Financial stress;
  • Extra hours spent on clerical work or EHR-related tasks; and,
  • Loss of human-to-human interaction between physician and patient.

Robert Lum, MD, an Oxnard, Calif.-based radiation oncologist, blames the shift to corporate-owned medical practices for some of the reported increases in burnout among physicians. Lum told the Ventura County Star he stays upbeat by never losing sight of why he became a physician.

“If you focus on the reason you went into medicine in the first place, which is to help people and marvel at the miracles modern medicine is able to do, then you’ll have less burnout,” he said.

Nevertheless, other solutions also can help. Clinical laboratories play a key role in maximizing physician/patient encounters. By extension, physicians and laboratories are linked in unique ways that enable labs to reduce physician burden and ensure positive healthcare outcomes.

—Andrea Downing Peck

Related Information:

Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors

Study Suggests Medical Errors Now the Third Leading Cause of Death in the U.S.

Medical Errors May Stem more from Physician Burnout than Unsafe Health Care Settings

Study Says Rising Doctor Burnout Means Rising Medical Errors

In a First for U.S. Academic Medical Center, Stanford Medicine Hires Chief Physician Wellness Officer

Medscape Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout

Physician Burnout a Key Driver of Medical Errors


Researchers in Two Separate Studies Discover Gut Microbiome Can Affect Efficacy of Certain Cancer Drugs; Will Findings Lead to a New Clinical Laboratory Test?

If the link between certain types of gut bacteria and improved effectiveness of certain cancer treatments can be leveraged, then medical laboratories could soon have another diagnostic tool to use in supporting physicians with cancer care

From improving treatments for chronic diseases to extending lives, gut microbiome (bacteria that is part of human microbiota) has been at the forefront of developing clinical laboratory testing and anatomic pathology diagnostic technologies in recent years. Now, two studies recently published in the online journal Science confirm research that the “composition” of gut bacteria may have a significant influence on the effectiveness of certain cancer drugs.

The goal of both studies was to determine whether there was a link between gut bacteria and the efficacy of cancer drugs known as PD-1 inhibitors. These drugs are used for several types of cancer, including:

  • Melanoma;
  • Lung;
  • Bladder; and,
  • Stomach cancers.

They function by freeing up the immune system to attack cancer cells.

Greater Bacterial Diversity in Gut Brings Improved Response to PD-1 Inhibitors

One of the studies, “Gut Microbiome Modulates Response to Anti–PD-1 Immunotherapy in Melanoma Patients,” found that a microbiome populated with “good” bacteria can elevate the potency of certain drug treatments. The researchers discovered that the gut bacteria in patients who responded well to PD-1 inhibitors differed from that found in patients who did not respond to the treatment.

For this study, researchers at the MD Anderson Cancer Center at the University of Texas collected oral, gut, and fecal microbiome samples and tumor biopsies from 112 patients with advanced melanoma. Clinical laboratorians took the samples before and after PD-1 treatments. They divided the patients into two groups—responders and non-responders—and profiled each microbiome using genetic sequencing.

“What we found was impressive: There were major differences both in the diversity and composition of the gut microbiome in responders versus non-responders,” Jennifer Wargo, MD, MMSc, leader of the study, told STAT. “Those who did well had greater bacterial diversity in their gut, whereas those whose tumors didn’t much shrink had fewer varieties of microbes present.”

Melanoma patients who experienced success with PD-1 therapy had a more diverse microbiome and higher concentrations of bacteria known as Ruminococcus and Faecalibacterium. Patients involved in the study who did not respond well to PD-1 therapy had the presence of another bacterium called Bacteroidales.

Jennifer Wargo, MD (above center) with her team at the MD Anderson laboratories. The researchers cautioned that clinical trials are needed before a definitive conclusion can be reached on whether altering gut bacteria can improve the effectiveness of PD-1 therapy. “If you’re changing the microbiome, depending on how you do it, it may not help you—and it might harm you,” Wargo emphasized in STAT. “Don’t try this at home.” (Photo copyright: MD Anderson.)

Antibiotics Can Reduce Effectiveness of PD-1Therapy

The other study, “Gut Microbiome Influences Efficacy of PD-1-based Immunotherapy Against Epithelial Tumors,” discovered that some drug therapies were less effective in patients who were also taking antibiotics to treat infections shortly before beginning treatment with PD-1 drugs.

Researchers for this study, led by Laurence Zitvogel, MD, PhD, of the Gustave Roussy Cancer Campus in Villejuif, France, examined 249 patients who were given a PD-1 inhibitor for lung, kidney, or urinary tract cancers. A little over one fourth of these patients had recently taken antibiotics, which can strip the gut of essential bacteria necessary to treat infections.

The team found that patients who had ingested an antibiotic relapsed faster and did not live as long as patients who had not taken an antibiotic before receiving PD-1 therapy. When they analyzed variances between patients who responded well to treatment versus patients who did not, they detected the presence of Akkermansia muciniphila, a mucin-degrading bacterium, in the responders.

Personalized Treatment Based on Each Patient’s Gut Microbiome

The culmination of this type of research raises questions about how cancer medications may interact with microbiomes.

“Should we be profiling the gut microbiome in cancer patients going into immunotherapy?” asked Wargo in the STAT article. “And, should we also be limiting, or closely monitoring, the antibiotic use in these patients?

“This is all very context-specific, and multiple different factors need to be considered on how best to change the microbiome,” she continued. “When it comes to optimizing cancer therapy, treatments will have to be heavily personalized, based on what a patient’s gut microbiome looks like already.”

Diagnostic tests that could determine whether a certain drug will be beneficial for a patient would perform a critical role in healthcare decision-making. Since cancer drug treatments can cost tens of thousands of dollars or more, it would be advantageous to know which therapies would be optimal for individual patients. The hope is that in the future, clinicians, working with anatomic pathologists and clinical laboratories, will have the tools needed to ascertain if patient’s microbiomes will best work with a particular drug and if they would likely encounter any side effects.

—JP Schlingman

Related Information:

Patients’ Gut Bugs May Play Role in Cancer Care

Gut Microbiome Modulates Response to Anti–PD-1 Immunotherapy in Melanoma Patients

Gut Microbiome Influences Efficacy Of PD-1–Based Immunotherapy Against Epithelial Tumors

Your Gut Bacteria Could Determine How You Respond to Cutting-edge Cancer Drugs

The Bacteria in Your Gut Could Help Determine if a Cancer Therapy Will Work

Attention Microbiologists and Medical Laboratory Scientists: New Research Suggests an Organism’s Microbiome Might Be a Factor in Longer, More Active Lives

Get the Poop on Organisms Living in Your Gut with a New Consumer Laboratory Test Offered by American Gut and uBiome

Mayo Clinic and Whole Biome Announce Collaboration to Research the Role of the Human Microbiome in Women’s Diseases Using Unique Medical Laboratory Tests

Continuing Popularity of Employer Medical Clinics Brings New Opportunities for Medical Laboratory Outreach

As the number of on-site and near-site clinics grow, medical laboratories and pathologists could find unique opportunities to bridge the information gap between traditional health systems and new employer-based offerings

Employers have a big stake in lowering the cost of healthcare. That is one reason why more employers are incorporating employee wellness programs into their health benefit offerings. This is a favorable trend for medical laboratories, because such wellness programs often incorporate clinical laboratory tests as benchmarks from which employees can monitor their progress.

In 2013, Dark Daily reported on the increase in employee wellness programs across corporations. Medical laboratories and pathology groups found new opportunities to help with wellness monitoring, screening, and helping individuals through medical consultations.

Three years later, this trend continues to evolve and grow. Today, employers are going beyond simple wellness programs, creating on-site or near-site clinics to save their employees a trip to their local doctor, urgent care, or hospital. (more…)

Physician Practice Management Companies Stage a Comeback; Anatomic Pathology Groups Remain Skeptical

As reimbursement models shift, physician practice management companies (PPMCs) offer increased value and appeal for hospital-based physicians (HBPs)

Are physician practice management companies (PPMCs)—a hot trend during the 1990s—poised to make a comeback in this decade? Whether this healthcare business model can gain traction during the 2010s remains to be seen, but, of all physician specialties, pathologists are likely to be among the most skeptical, just as they were during the 1994-2000 heyday of PPMCs.

In the mid-1990s, such physician practice management companies as MedPartners, Phycor, and others raised billions of dollar to invest in both independent physician practices and hospital-based physician (HBP) groups. But not even 10 years later, competition for viable practices drove prices above sustainable levels and many PPMCs closed shop. (more…)

Clinical Laboratories and Pathology Groups May See Fewer Fee-For-Service Payments as More Hospitals and Health Systems Become Self-Insured

As national health insurers push more risk to hospital systems and medical groups, many hospital administrators become more interested in establishing their own health insurance companies

New modes of provider reimbursement—such as bundled payments and budgeted payments—are motivating hospitals and health systems to reconsider their existing relationships with health insurers. Hospital administrators want to control the dollars they save by improving patient care, instead of allowing insurance companies to capture that money.

To accomplish these goals, more and more hospitals and health systems across the country are making one of three moves:

• Funding their own health plans;
• Partnering with health insurance companies; or,
• Buying health insurance companies.

As this trend gathers momentum, it will put the medical laboratories of hospitals in a much better position to regain access to patients. It can be expected that hospital administrators will include their own clinical laboratories and anatomic pathology providers in their own health insurance provider networks. (more…)