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it begs the question
- benjamin dean (13 February 2008)
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What are the consequences?
- Ronald HMA Bartels (15 February 2008)
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The Study has Basic Problems
- Arie Shirom (2 March 2008)
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Depression and medical errors
- Partha Pratim Das, Sandeep Grover (2 March 2008)
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Fired up or burnt out
- Christopher L. Manning (3 March 2008)
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Is there a case for screening doctors for depression?
- nicholas a ware (3 March 2008)
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Inherent difficulty of prescribing for neonates
- John M Davies (5 March 2008)
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Error’s cause stretch far beyond the actions
- KHALID ALKHOULY (6 April 2008)
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benjamin dean, sho oxford
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This study surely demonstrates the dangers of poorly thought out training reform in the form of MMC and MTAS. A large cohort of thousands of doctors have been put into an unenviable state of stressful limbo that cannot be good for their mental health (1), and consequently their patients. If only the government cared as much for the health of its hard working medical staff as it does for its election warchest, as then the long term interest of patients would be better served. The government should invest far more than in currently does in supporting its staff, providing them with adequate facilities at work, funding their study and helping them train to be the best than they can possibly be. Instead millions are wasted on gimmicky short termist reform that results in mass demoralisation, training is not funded adequately and a culture of blame only worsens the pressure on an already highly pressurised group of employees. It is not rocket science that happy doctors will do a much better job than depressed demoralised ones. 1. Lydall GJ, Malik A, Bhugra D. Mental health of MMC applicants. BMJ Rapid Response 20 June 2007. Competing interests: None declared |
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Ronald HMA Bartels, neurosurgeon Radboud University Nijmegen Medical Centre, Dpt Neurosurgery, 6500 HB Nijmegen, The Netherlands
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As an active neurosurgeon, I am involved in training residents. Therefore, I´ve read the article by Fahrenkopf et al.1 with interest. When I read the abstract, my first thought was either the questionnaires are not validated or very peculiar people apply for a residency in pediatrics. Not convinced about either, I very carefully read the article. In addition to the mentioned flaws, two other flaws should be addressed. First, the authors claim that the rate of residents volunteering to participate is high. However, only 50% volunteered as has been pointed out in the Editorial. Information about the reason for not volunteering is not given. It can contribute to significant bias. For example, patients without any signs of depression or burnout have probably a higher grade of self-esteem. They might be less attracted to questionnaires relating to negative feelings, and might not volunteer. If this assumption is correct a best scenario could be estimated. Then, the number of residents with depression or burnout would be divided by two (10% respectively 37%). I agree that these numbers are still high, although the number for depression might be a representative of its occurrence in the general population. At this point, I will address the second flaw. The authors state that no association was found between the postgraduate year and depression or burnout. In my opinion, it does mean that the prevalence of depression and burnout is the same for the three investigated phases of the residency. The conclusion would be that in the first year the prevalence of depression would also be 10% and for burnout 37%. Since depression can be regarded as psychic disease, it is normal that in the whole population of residents some will suffer from depression. The prevalence will be nearly the same during the residency. The authors give support to this explanation. On the other hand, burnout is a modern entity that occurs during life and is related to psychic stress. I would assume that in the higher years of the residency the prevalence increases. I can not imagine that someone in the first year of the residency will suffer from burnout. This should be explained in the discussion. A comparison between the workload in hours and observed depression and burnout would contribute to the discussion about the optimal residency program. A good suggestion would also be to assess the future residents with these questionnaires. If the score suggests a depression or burnout, the candidate should not be offered a residency. Finally, this study will certainly contribute to the discussion between residents and their teachers. References 1. Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ, Lewin D, Chiang VW et al. Rates of medication errors among depressed and burn out residents: prospective cohort study. BMJ 2008;doi:10.1136/bmj39469.763218.BE. Competing interests: None declared |
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Arie Shirom, Professor Emeritus Tel Aviv University, Tel Aviv, Israel, POB 39010, Israel 69978
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The recent study by Fahrekopf et al.1, relating depression and burnout to medication errors, appears prone to basic problems of conceptualization and analyses. 1. Depression and burnout were shown to overlap each other conceptually 2 and to be closely associated empirically 3. Therefore, in assessing the effects of burnout on medical errors, depression should have been controlled for. 2. The Authors constructed a total burnout score by combining two dimensions of the Maslach burnout inventory (MBI), disregarding the MBI Manual's (p. 2, referenced in the article) recommendation to regard each dimension as separate and distinct. Furthermore, a recent review of longitudinal studies 4 suggested that one of these dimensions, emotional exhaustion, predicted the other, depersonalization, across time and study samples. 3. The use of an arbitrary cutoff point for discriminating between "cases" and "non-cases" of burnout is conceptually problematic 3. It is not justified in a study designed to predict medical errors. Furthermore , the practice of dichotomizing a continuous variable like emotional exhaustion is problematic 5 ; in this study, it probably resulted in reduced power because of the small sample size of the "not burned-out" group. Arie Shirom, Ph.D. Tel-Aviv University ashirom@post.tau.ac.il 1. Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ, Lewin D, Chiang VW, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. British Medical Journal 2008;336(7642):488-491. 2. Melamed S, Shirom A, Toker S, Berliner S, Shapira I. Burnout and risk of cardiovascular disease: Evidence, possible causal paths, and promising research directions. Psychological Bulletin 2006;132(3):327-353. 3. Schaufeli WB, Enzmann D. The burnout companion to study and practice: A critical analysis. Washington, DC: Taylor & Francis, 1998. 4. Taris T, Le Blanc PM, Schaufeli WB, Schreurs PJG. Are there causal relationships between the dimensions of the Maslach Burnout Inventory? A review and two longitudinal tests. Work & Stress 2005;19(3):238-256. 5. Royston P, Altman DG, Sauerbrei W. Dichotomizing continuous predictors in multiple regression: a bad idea. Statistics in Medicine 2006;25(1):127- 141. Competing interests: None declared |
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Partha Pratim Das, Senior Resident PGIMER, Chandigarh, Sec-12, 160012, Sandeep Grover
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To the editor, The article by Amy et al 1 brings out an important under researched area to the forefront and adds to what is already perhaps known. The research was a prospective, multi-site study with more than 100 respondents, with 50% participation rates, and it used validated reliable instruments. The burnout was assessed using Maslach Burnout Inventory (Version 1996), which is perhaps the most effective way of diagnosing burnout.2 Further, the data collectors for medication errors were trained and unaware about the aims, and blinded reviewers categorized medication errors with high inter rater reliability (κ = 0.88), all of which provide credence to the findings. Depression and burnout was not related to postgraduate years of study indicating perhaps the vulnerability of all the years. However, there are some of issues which makes the reader to take the findings cautiously, some of which we would like to discuss. First, the paper confuses the reader with jargon of numbers without actually giving details as to whether it refers to the sample of 2 centers (N=101) or three centers (N=123). If the aim of the study was to assess the relationship between depression, burnout and medication errors, the study results could have been better understood, if the authors would have restricted themselves to sample of 2 centers. Another important issue in the study is confidentiality versus ethics. When we look at the type of errors, most of the errors were categorized as ‘potential adverse events’, which are defined as “medication errors that has major potential to cause harm if not intercepted before reaching the patient or because the patient has sufficient physiological reserve to absorb the error without apparent injury”. What is understood from this is that although the researchers were aware of the errors, these were not intercepted and possibly harm would have been passed on the patients. In the same line, the authors maintained the confidentiality and allowed the further errors to continue after the study, with patients at the receiving end. Third, it is also interesting to note that although equal numbers of residents were grouped as participants and non-participants, the non-participants carried out nearly twice the number of errors than the participants. This could be perhaps due to ‘Hawthorne effect’, which states that there can be temporary change in behavior or performance in response to a change in the environmental conditions, with the response being typically an improvement.3 If such could be the case then the medication errors reported in the study, perhaps don’t reflect the true picture reported. Fourth, as per the authors the study was ‘advertised’. It is well know fact that advertising a study about burnout and depression, could bias the sample selection and response of subjects. Fifth, is an important issue about prevalence of depression. The authors used a screening questionnaire, which have high false-positive rates, and could have given the higher figures. It would have been better if the authors would have gone for a second stage interview, and confirmed the “caseness”, before concluding about the prevalence of depression. Another important issue which could have influenced the prevalence of depression was predominance of females in the participants. Sixth, is the issue of linking medication errors and depression. Although the authors try to highlight the findings that the depressed residents committed six times more errors than non- depressed subjects, but they have ignored the important issue about the type of errors. When we look at the type of errors, the percentage of “potential adverse events” was more in non-depressed group (16 out of 21, 76%) compared to (12 out of 24, 50%) depressed group. We feel that it is important to minimize the “potential adverse events”, which could be perhaps more dangerous, rather than the actual number of medication errors. In view of lack of proper diagnostic schedule for depression, it would premature to link the medication errors to depression. In spite of all the above, this was a good endeavor to bring forth an important issue of mental health of residents whose psychological well- being is paramount to ensure better physicians of future and quality health care services. Dr. Partha Pratim Das, MD Dr. Sandeep Grover, MD Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India. Email: drparthapratimdas@yahoo.com References: 1.Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ, Lewin D, Chiang VW et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study BMJ 2008; 336:488-491 2.Prins JT, Gazendam-Donofrio SM, Tubben BJ, van der Heijden FMAA, van de Wiel HBM, Hoekstra-Weebers JEHM. Burnout in medical residents: a review. Medical Education 2007: 41: 788–800 3.Norman, D. A. The psychology of everyday things. New York: Basic Books, 1988. Competing interests: None declared |
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Christopher L. Manning, CEO Primhe Twickenham TW11 9HG
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Dear Editor, In the same week as the publication of the DH's Report on Mental Health and Mental Ill Health in Doctors(1), this paper is itself most timely. In all the worthy rhetoric about workforce development, the reality is that many front-line professionals and staff are still being completely forgotten and/or being actively discriminated against for having a formal mental illness or being plainly distressed or acopic. We sum up our approach to all this with the warm, empathic and supportive term - "performance management". This paper is yet another wake-up call to the World's largest employer that it has a Duty of Care to its own. It is to be hoped that through the Improving Access to Psychological Therapies Programme and the opportunities for facing inwards to contemplate its own systemic navel, rather than solely acting as deliverer of the Health of the Nation, that the NHS itself will increasingly itself become far more psychologically minded and aware. The issues of mental health and illness are riven through all the NHS's core business and the principles of how, as people first and foremost, we are all "wired for health". This plain biological fact needs to be reflected both in the interventions provided to patients and the support and continuing personal and professional development of the workforce. All NHS employees should be able to access supportive assessment of their psychological state and should be registered with their own GP, as well as there being anonymous, confidential and trustworthy help - the Third Sector has a lot to offer here, with such organisations as the Doctors Support Network. Further, whilst the talk is often about teams, many face the daily grind of disintegrative uncertainty and endless systemic writhings. Once again, we have mountains of evidence about the effect that this has on all people. And why do we not have regular and confidential emotional support meetings for the NHS's highly pressed staff - and especially look after those with high levels of caring and empathy who may not find it so easy to distance themselves from the heat of the kitchen. The paper on alcohol misuse(2) mentions the use of random drugs testing as part of suggested strategy for tackling this form of self-harm. Does the NHS dare to introduce that too? To say nothing of an anti-stigma event or week when everyone working in the NHS who wishes too can self- declare (perhaps with a ribbon?) a personal lived experience of a mental illness? People support breast cancer, AIDS etc in this way - why shouldn't the brainmind have some good music too? Yours Sincerely, Dr Chris Manning Refs: 1. Mental Health and Ill health in doctors; DH 20th Feb 2008. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_083066 2. Tackling alcohol misuse in the UK Babor BMJ.2008; 336: 455 Competing interests: None declared |
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nicholas a ware, Final year medical student St George's University of London
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Despite several limitations to this study, many of which the authors themselves highlight, the study's conclusions are extremely worrying. If depressed doctors really are making six times as many errors as their non- depressed peers while over half of them are unaware they may be depressed then perhaps there is an argument to be made for employee screening. If depression amongst certain doctors is as prevalent and potentially dangerous as this study suggests then there should be a process put in place to ensure that it is screened for and dealt with by employers, ie- the NHS in this country, who surely have a responsibility both to their employees and to their patients. Competing interests: None declared |
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John M Davies, Retired Consultant Paediatrician DN33 3NA
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I was not clear what role computers played in the prescription errors described. It is not surprising that depressed residents made more errors than did control doctors. The processes of neonatal and indeed paediatric prescribing are generally much more complex than for adults, whatever the health status of the doctor. The tolerance of errors may be less in children and babies. Drug injections for adults often use a half to a whole standard ampoule, but sick or premature neonates frequently require only a tiny proportion of the phial, which increases the scope for accidental and possibly lethal overdosage caused by medical or nursing error. A sequence of calculations may be required to obtain the correct dose: the weight of the drug in milligrams or micrograms must be chosen according to the baby's weight and then adjusted according to factors such as age, gestation, or renal function. The displacement volume of dissolved powder or crystals may be relevant when small proportions of a phial are required. Once the weight of the dose is known, the correct volume of the solution must be chosen and the dose diluted to obtain a manageable volume, bearing in mind that a 0.02 ml injection cannot be practically given and that in multiple drug treatment minimal volumes must be used to avoid fluid overdose. Each of these stages adds scope for error, however accurate or user friendly the compendium or formulary, in spite of the use of an electronic calculator. In 1996 I reported a computerised system (Reference) that took care of all these issues, though not of course the state of the prescriber's health. The system called up all the relevant variables and avoided the use of a decimal point after a zero. It is obviously obsolete now but could have been refined at the time by someone more adept than I was. Nevertheless computerised prescribing could reduce some of the pressures on healthy and depressed doctors, should increase the safety of paediatric and neonatal prescribing, and it is worthy of more research. REFERENCE. Program calculates doses for neonates J M Davies BMJ.com 1996;312:446 (17 February) Competing interests: None declared |
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KHALID ALKHOULY, General Surgeon 10 Woodland Hill, Perth Andover, NB. E7H 5H5
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The majority of healthcare staff is highly motivated individuals who work together as a team to achieve the best outcomes for their patients. Health professionals have put in place a range of systems and checks to prevent medication errors. Periodic healthcare system review limits the incidence of error, so that if an error occurs its damaging effects are minimized. However, recent experience has shown that in certain situations those safeguards have not been adequate and have failed to prevent serious error and harm to patients. Errors occur when both human and system factors interact in a chain of events. Too often it is only the actions of individuals. Trigger factors within the workplace should also be considered as important causes of error e.g. time pressure, understaffing, fatigue and inexperience. Many healthcare organizations have developed their own systems for reporting and reviewing errors to raise awareness of risks. However, these developments have not been integrated to establish disseminating the lessons learnt and changes implemented. A number of barriers which prevented active learning from taking place may be summarized in developing unified priority mechanisms for reporting and analysis when things go wrong. Too often, incident enquiries have been characterized by passive learning –where lessons are identified but not carried through into practice. Some barriers to the reporting of adverse events are lack of awareness that an error has occurred, perception that the patient is unharmed by the error, lack of awareness of the need to report, lack of familiarity with reporting mechanisms, staff feeling they are too busy to report, fear of disciplinary action or litigation, and lack of feedback when errors are reported. Ideally all the defenses should be intact at our standards on prescribing, dispensing and administration of therapeutics. Since we have the safe and effective use of therapeutics, our projects should focus on education. The Education and clinician training in therapeutics increase their awareness of the benefits and risks of new, existing, and combined uses of therapeutics. Audiences include patients, providers, and policymakers. A more open culture, in which errors can be reported and discussed, mechanisms for ensuring the lessons are put into practice. Mistakes do occasionally occur and in the great majority of cases the causes of serious errors stretch far beyond the actions. Improving medication safety must be locally driven by health professionals and managers at the front line of patient care. Competing interests: None declared |
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