Who Guards the Guardians?

Author: Dr. David Vaughan
Respiratory Paediatrician, Our Lady of Lourdes Hospital, Drogheda and the National Children's Hospital, Dublin, Ireland
Director of Leadership, Patient Safety and Quality Improvement, Royal College of Physicians of Ireland

Quis custodiet custodies? “Who guards the guardians?”, the poet Juvenal asked almost 2000 years ago.

The question he raised remains pertinent for those of us who believe that the safety and quality of care we offer can and must constantly be improved. To paraphrase Juvenal, “who cares for the caregivers?” And more importantly, why should we care about this?

While the six domains of quality as defined by the Institute of Medicine are well known, I believe that there is a seventh domain, that is no less important and should we fail to address this seventh domain, we are less likely to succeed in delivering on and continually improving the traditional six domains. One authority, Bryan Sexton has suggested we need to redefine quality by asking three questions:

1. How do we care for our patients?
2. How do we care for each other?
3. How do we care for ourselves?

This putative seventh domain, ensuring the health of the caregiver is optimal, is likely to emerge as an increasingly important subject. A confluence of factors, financial pressures, increasing patient expectations, rising regulatory demands, and the growing complexity of care, are meeting the reality that many of our healers are in need of healing themselves.

Mental Health in healthcare professionals.

As long ago as 1858, physicians were noted to be at greater risk of taking their own lives. Numerous studies have confirmed this association and there is no little irony in the fact that physician mortality from cancer and cardiovascular disease is lower than the general population, but mortality from suicide remains greater compared to the general population. One can contrast the changes physicians have made to behaviours such as smoking that have reduced this mortality risk, but there is little evidence that they have tackled risk factors such as depression, despite in many respects having greater awareness of such risk factors and superior access to supports. It is likely that this elevated risk of suicide may simply be the tip of the iceberg in terms of physician ill health.

The literature is stark. A recent study reports that the prevalence of burnout amongst US physicians is substantially higher than the general population, (37.9% vs. 27.8%); over 60% of emergency medicine physicians self reported symptoms of burnout. (1)Although difficult to measure, there appears to be a clear correlation between burnout, decreased professionalism, reduced quality of care and increased risk of medical errors. Burnout has been associated with a greater likelihood of early retirement, reduced empathy, and doctors reporting burnout are more likely to report making a medical error recently.(2)

The culmination of these multiple stressors is manifested in a suicide rate that is strikingly higher than the general population; male physicians take their own lives 40% more frequently than male non-physicians. The risk of dying by suicide for female physicians is 130% than non physician females.(3)

Worryingly, there is evidence that substantial numbers of medical students were recently found to have substantial levels of distress, and the degree of distress was associated with thoughts of both dropping out of medical school and suicidal ideation.(4)

The impact of healthcare reform on clinician health & the linkage to quality healthcare.

Physician burnout in the US has been recognized as a major threat to healthcare reform.(5) It is likely that healthcare systems around the world, faced with the twin drivers of increasing demand, higher expectations of quality and reduced healthcare expenditure will seek more from their healthcare professionals, thereby increasing the risk of burnout and stress. It would be somewhat ironic if moves to improve health quality in the general population inadvertently harmed the very staff we rely on to deliver higher quality care.

A study of NHS consultants (surgical and medical oncologists, gastroenterologists and radiologists) found that 32% reported psychiatric morbidity. Those with psychiatric morbidity were more likely to drink alcohol excessively, be irritable with colleagues and patients, reported that they were reducing their standards of care and more were intending to retire earlier. Male and middle aged consultants were at substantially higher risk. (6) A similar study by the same authors in the early 1990s found a rate of 27% of psychiatric symptoms amongst consultants, substantially higher than the rate of 18% reported at the time in the general population. A similar paper by the same authors in 2005 suggested that decreased job satisfaction arising in part from changes in services designed to deliver better patient care may have given rise to psychiatric morbidity.(7)

The evidence for linking employee health and better healthcare outcomes.

Although one would think it self evident, there is a relative paucity on data that supports the link between better self health, especially mental health of front line staff and better patient outcomes.

A study from Ascension Healthcare found that when <60% of staff reported good team working in a clinical area, staff were more likely to report more burnout, fatigue, depression and poorer self care. A positive team working climate in turn was highly associated with lower blood stream infections in Michigan ICUs.(8) Another study has found that in operating rooms where team working was measured, ORs with a higher level of reported teamworking had lower rates of post-operative sepsis. Obviously it is challenging to distinguish causation and correlation in such a study, but one can reasonably speculate that poor team working can result in greater sick leave, increasing the workload on others, may result in a stressful work environment in which staff find it challenging to raise concerns or hold others to account.

Another study found that as teamwork increased in labour and delivery units, not only were there fewer delays and more predictability but critically there was less staff burnout.(9)

Even when looked at coldly from a financial perspective, there are compelling reasons for healthcare providers to consider whether they are currently providing a safe environment for their staff.

Moving from the Triple Aim to the Quadruple Aim

Lastly, perhaps we should reconsider whether the IHI Triple Aim (better patient experience, better population health, lower per capita expenditure) might be more effective and meaningful as a quadruple aim, the fourth leg being better staff experience and better health.

If the broader healthcare community agrees that such matters need to be addressed, how best can they be tackled? Like all complex endeavors, there needs to be awareness, alignment and agreement amongst all interested parties. These include payers, employers, undergraduate and postgraduate training bodies. There is also a critical need for research that continues to measure the burden of ill-health amongst healthcare professionals, the link if any between provider illness and poorer healthcare quality, but most importantly, what are the most effective interventions.

There are a number of resources I would recommend to the interested reader.

A recent publication by the Royal College of Psychiatry in London, entitled “Intelligent Kindness; Reforming the culture of healthcare”(10) and anything by Bryan Sexton. Another timely and outstanding resource is the recent paper by the Lucian Leape Institute, available here: http://www.npsf.org/about-us/lucian-leape-institute-at-npsf/lli-reports-and-statements/eyes-of-the-workforce/.

As always, mother knows best, and motherly advice to improve our health includes such pearls as get more sleep, don’t take work home, and focus more on a sustainable work-life balance.

1. Shanafelt TD. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. 2012 Aug 21;:1–9.
2. Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, et al. Burnout and Medical Errors Among American Surgeons. Annals of Surgery. 2010 Jun;251(6):995–1000.
3. Schernhammer E. Taking their own lives—the high rate of physician suicide. N. Engl. J. Med. 2005;352(24):2473–6.
4. Dyrbye LN, Harper W, Durning SJ, Moutier C, Thomas MR, Massie FSJ, et al. Patterns of distress in US medical students. Med Teach. 2011;33(10):834–9.
5. Dyrbye LN, Shanafelt TD. Physician burnout: a potential threat to successful health care reform. JAMA: The Journal of the American Medical Association. 2011 May 18;305(19):2009–10.
6. Taylor C, Graham J, Potts H, Candy J, Richards M, Ramirez A. Impact of hospital consultants' poor mental health on patient care. The British Journal of Psychiatry. 2007 Mar 1;190(3):268–9.
7. Taylor C, Graham J, Potts HWW, Richards MA, Ramirez AJ. Changes in mental health of UK hospital consultants since the mid 1990s. Lancet. 2005 Sep;366(9487):742–4.
8. Sexton JB. A Safety Culture Primer for the Critical Care Clinician. 2009 Aug 19;:1–12.
9. Sexton JB, Holzmueller CG, Pronovost PJ, Thomas EJ, McFerran S, Nunes J, et al. Variation in caregiver perceptions of teamwork climate in labor and delivery units. J Perinatol. 2006 Aug;26(8):463–70.
10. Holland M. Intelligent Kindness: Reforming the Culture of Healthcare. The Psychiatrist. 2012.

Related Links:
-Cincinnati Children's Hospital: Reduce Employee Injury Rates
-ICT: Organizational Culture Should Support Patient, Healthcare Worker Safety
-Joint Commission: Improving Patient and Worker Safety - Opportunities for Synergy, Collaboration and Innovation
-NPSF: Lucian Leape Institute at NPSF Releases Report Urging Emphasis on Joy, Meaning, and Workforce Safety in Health Care
-OSHA: Organizational Safety Culture-Linking patient and worker safety
-Premier Safety Institute: Workforce joy and well-being is linked to patient safety