Physicians' Well-being and Safety: It's Not All About Sleep

In this issue of Mayo Clinic Proceedings, West et al¹ evaluate the effect of resident physicians' distress on their personal safety. In addition to fatigue and sleepiness, positive screens for depression and measures of diminished quality of life and burnout were each associated with increased reports of motor vehicle incidents.

“A good doctor is a good person.”² So asserted philosopher Jacob Needleman.² In The Way of the Physician, he elaborated that “the qualities of a good physician are inseparable from the qualities … of a real and authentic human being”^{(p 83)} and “the meaning of being a physician can only be recovered through a rediscovery … of the meaning of human life itself, the meaning of being alive.”^{3(p xiii)} Needleman worried that physicians were becoming dispirited victims of a “medical arms race” in which financial pressures were trumping the welfare of patients.² Addressing physicians directly, the author lamented, “You are dying in your tracks, and you know it.”²

Needleman's book was published in 1985, when “physician productivity” was a catchphrase. I was in midcareer, balancing the demands of patient care, teaching, research, and administration with the responsibilities of family and fatherhood. To make matters worse, as president of our group practice, I needed to ensure that our physicians' productivity met the practice's financial goals. I didn't think I was dying in my tracks, but managing these conflicting roles wasn't easy. We have not made it any easier for the generation of physicians who have followed us. Depersonalization and burnout have increased, and many physicians question their career decisions.^4-6

Recent attempts to ease the physical and mental stressors for resident physicians—namely, duty hour limits—may have actually succeeded in intensifying them. Within their 80-hour workweek, patient care responsibilities have become more compressed and complex. Shift-work and night-float schedules have fragmented their service teams and increased their professional isolation. They spend more time at keyboards and computer screens and less time at patients' bedsides.⁷

The finding by West et al¹ that resident physicians' distress affects their safety is not surprising. My mentor, DeWitt C. “Bud” Baldwin, has been formulating similar hypotheses for some time. Dr Baldwin has surveyed residents for decades, following the trends of their learning environment.

Recent research by Baldwin et al⁸ showed that higher levels of resident physician distress (specifically depression) strongly correlate with self-reported errors in patient care and other problems in the learning environment. Specifically, adding a measure of depression to an assessment of sleepiness markedly improves the power to predict negative residency experiences. The findings of Baldwin et al parallel the work of West et al,¹ Dyrbye et al,^9,10 and others. The findings are clear: Physicians who are neither fatigued nor distressed provide safer patient care and are less likely to injure themselves.

The challenge for each of us is to maintain (or regain) the enthusiasm for being a physician by finding meaning and satisfaction throughout our professional careers. We must find ways to rehumanize our work environments and recover the joy of being a physician in both training and practice. We should look for guidance from other endeavors that depend on alert, creative, and positive teams that achieve common goals, like those of winning sports teams and prosperous information technology companies. Solutions must also include supportive interprofessional teams: physicians, nurses, and clinical staff who pull together to obtain the best effort from each team member and produce the best results for our patients. Teamwork is more critical as we face a shortage of physicians and a growing demand for our services.

As Needleman said, to be a good physician, we must rediscover “the meaning of human life itself, the meaning of being alive.”^{3(p xiii)} Shanafelt et al¹¹ categorized factors in several domains that can assist in our rediscovery: relationships: spending time with our family, friends, and significant others; religious beliefs/spiritual practices: attending to and nurturing our spirituality; self-care practices: actively cultivating our personal interests and self-awareness through, for example, reading, exercise, and self-expression; adequate sleep, nutrition, and regular medical care are essential, although we often think these needs only apply to our patients; and life philosophy: developing and maintaining a positive philosophic approach to life that engages our values, including finding a balance between our personal and professional lives.

West and colleagues' plea for further attention to these domains is supported by the work of Sonnentag,¹² which demonstrates that one's ability to mentally disengage from work enhances both health and productivity. Revitalizing oneself outside work requires time and autonomy in one's personal life. Therefore, it is sad that Baldwin et al¹³ found that nearly a third of resident physicians may not use their off-work time in restorative ways.

Are we making any progress since the observations of Needleman more than 25 years ago? We should take some comfort that, in addition to a philosopher prodding us to renew our humanism, we now have a cadre of colleagues who directly influence the work environment of our trainees and are conscientiously measuring physician well-being and relating it to patient care and physician safety. We need to take their findings to heart for practicing physicians as well. Were I today in the practice leadership post that I occupied in 1985, I would seek out enthusiastic physicians and surgeons whose joie de vivre infused their personal lives and professional work; I would promote physician well-being with as much vigilance as I monitored practice revenue. The best physicians would gravitate to such practices and collectively achieve the best patient outcomes.