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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


EHR Systems Continue to Cause Burnout, Physician Dissatisfaction, and Decreased Face-to-Face Patient Care

New study published in the Annals of Family Medicine (AFM) indicates that despite efforts to improve EHR usability and efficiency, primary care physicians continue to spend more than 50% of their workdays on computerized physician order entry (CPOE) and other clerical tasks instead of engaging in direct patient care

Do electronic health record (EHR) systems improve or degrade the productivity of physicians? That question has been the subject of robust debate. Now comes a new study in a peer-reviewed journal with a surprising finding: physicians spend up to 50% or more of their workday on EHR-related tasks.

In theory, EHRs offer a wealth of benefits over traditional paper-based systems. In practice, however, between interoperability concerns and implementation costs, they have proven a daunting undertaking for even the largest healthcare systems.

While EHRs might offer easy access to patient data—including medical laboratory records and anatomic pathology reports—this information doesn’t enter itself into databases or make itself instantly accessible. That requires human interaction, which is time consuming and prone to errors.

Thus, research from the American Medical Association (AMA) and the University of Wisconsin revealing that the time it takes to enter data, address communications, and perform other clerical tasks adds up to more than 50% of a physician’s workday is of paramount importance. That’s because physician dissatisfaction and departures from medical practice have increased each year since the EHR revolution began, and reports are the situation is getting worse.

In their retrospective cohort study involving 142 family medicine physicians, published in the Annals of Family Medicine (AFM), Brian G. Arndt, MD, from the School of Medicine and Public Health, Department of Family Medicine and Community Health, University of Wisconsin, et al, reported that clinicians spend 52% of their 11.4-hour workday interacting with an EHR system. On average, nearly 1.5 hours of this EHR interaction occurred outside clinic hours during physicians’ personal time. The researchers assessed interactions using event logs from the Epic EHR system spanning from July 1, 2013, to June 30, 2016.

Researchers validated their data through direct observation of 14 nonresident family medicine physicians from May through June of 2016. This observation showed similar findings. During clinical hours, 60% of physician time related to non-EHR tasks, with 40% of time devoted to EHR tasks.

Documentation Burden Leads to Physician Burnout, Dissatisfaction

“Our family medicine physicians spent 44% of their workday (157 minutes) in the EHR doing clerical and other administrative tasks,” study authors reported. “Computerized physician order entry accounted for 12.1% of their clinic hours (43 minutes) in the EHR. The burden related to order entry has been associated with clinician burnout, dissatisfaction, and intent to leave practice.”

Researchers tracked various tasks and assigned them to categories. Of the tasks tracked, only 32.1% fell under the heading of “medical care.” Reviewing chart notes, chart medications, and problem lists topped medical care tasks.

Review of clinical laboratory results in charts ranked near the bottom, with only 2.5% of the total time spent performing medical care tasks. These tasks, however, could offer opportunities for medical laboratories to help physicians identify opportunities to optimize reporting and test-ordering processes and improve productivity for clinicians who are responsible for most of the data entry burden associated with EHRs.

One potential solution to EHR burnout involves the use of medical scribes who work with physicians during and after a patient’s visit inputting encounter data. Alan Bank, MD, cardiologist at Allina Health, and medical scribe Jaeda Roth, are shown above during a patient visit. Bank told the StarTribune  that he’s convinced scribes help doctors get more done and reduce billing errors. (Photo and caption copyright: Elizabeth Flores/StarTribune.)

Researchers also questioned the EHR’s role as a communication or telemedicine hub. “There is insufficient evidence that such asynchronous care improves health outcomes, cost, and overall healthcare use,” they noted.

However, even for intra-practice communications between healthcare professionals, EHRs may not be the most efficient approach. “Face-to-face communication is associated with increased efficiency,” the researchers noted. “Whereas more electronic communication among team members leads to greater clinician and staff dissatisfaction, as well as poorer clinical outcomes and increased healthcare use among patients with coronary artery disease.”

EHR Cost/Benefits Generate Debate

This latest study is not the first to suggest that EHRs are creating problems for clinicians. While there appear to be no trends between studies, multiple researchers have highlighted the workload created by EHR systems in recent years.

In a study published in the Annals of Internal Medicine (AIM), Christine A. Sinsky, MD, of the American Medical Association, et al, analyzed data from the observation of 57 US-based physicians in family medicine, internal medicine, cardiology, and orthopedics.

Comparing data across 430 hours of observation, researchers concluded, “For every hour physicians provide direct clinical face time to patients, nearly two additional hours are spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another one to two hours of personal time each night doing additional computer and other clerical work.”

However, in a 2015 study published in the Annals of Family Medicine (AFM), Valerie Gilchrist, MD, Chair of the Department of Family Medicine and Family Health at the School of Medicine and Public Health, University of Wisconsin, et al, found lower numbers. Observing 27 community-based family physicians across a single practice day, the researchers found that 39% of the practice day on average was devoted to office-based time. Of that time, 61% was spent on medical care related tasks.

Building a Better EHR

While medical laboratories and diagnostic specialists—such as anatomic pathologists—can work with physicians to streamline ordering and reporting processes relating to EHRs, much of the burden comes from how EHR systems are designed and used.

In a 2016 New England Journal of Medicine Catalyst Panel on EHRsTait Shanafelt, MD, Director of the Mayo Clinic Department Program on Physician Wellness, noted that one of the most contested features of EHR systems in the US, according to the AMA and Mayo Clinic, is computerized physician order entry (CPOE).

Later in the discussion, Sinsky discussed a recent trip to the UK, where she observed general practitioners (GPs) at the National Health Service (NHS). She noted that most GPs loved their EHRs. However, those EHRs were designed with GP input to best work with an NHS GP’s typical workflows and procedures. She also noted that overall usage is different in the UK, as EHRs there are not tied into billing systems.

As Dark Daily has reported, up to 70% of data stored in a patient’s electronic health record is clinical pathology laboratory related. As newer EHRs replace outdated models, it will remain critical for healthcare professionals—including clinical laboratory professionals who generate most of the data stored in EHRs—to assess, track, and report on what is working with various platforms and what is not.

Communicating this end-user data to EHR developers is essential to designing EHRs that reduce unneeded burden and clerical load on physicians, rather than increasing it.

Clinical laboratories tat wish to take proactive steps might contact physicians and other professionals in their workgroups to tailor data generation, reporting, and ordering processes to the EHRs in use at those practices.

—Jon Stone

Related Information:

Primary Care Doctors Spend More Than 50% of Workday on EHR Tasks, American Medical Association Study Finds

Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-motion Observations

Study: EHRs Bloat Clerical Workload for Docs

Harried Doctors Hail the Rise of the Medical Scribe

Type and Click Tasks Drain Half the Primary Care Workday

Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties

Doctors Wasting Over Two-Thirds of Their Time Doing Paperwork

Physician Activities During Time Out of the Examination Room

Heavy Burden of EHRs Could Contribute to Physician Burnout