Clinician wellbeing, fatigue and sustainable practice

Overview & Definition

A paediatric registrar has slept four hours in two days. On a night shift she nearly gives ten times the intended opioid dose. She is exhausted, withdrawn, and beginning to doubt whether she is cut out for medicine. Your job is to keep that registrar — and every child she cares for — safe. That is the territory of clinician wellbeing, fatigue and sustainable practice: the personal and system conditions that let a doctor practise well across a career, and the failure modes — fatigue, burnout, impairment, the second-victim response — when those conditions are not met. [1] [11]

Burnout is a work-related syndrome, not a personal weakness or a medical diagnosis. Maslach defines it along three dimensions: overwhelming emotional exhaustion, depersonalisation (a cynical, detached, sometimes callous response to patients and colleagues), and a reduced sense of personal accomplishment. Fatigue is the state of reduced mental or physical capacity caused by sleep loss, prolonged wakefulness, circadian disruption, or workload that exceeds recovery. An impaired clinician is one whose performance is compromised by fatigue, illness, substance use or psychological distress. The second victim is a clinician who is traumatised by involvement in an adverse event, medical error, or patient harm — Wu's term for the doctor who "makes the mistake" and then needs help too. Holding these four ideas apart is half the viva. [10] [11]

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1. [1]Landrigan CP Effect of reducing interns' work hours on serious medical errors in intensive care units N Engl J Med, 2004.PMID 15509817
2. [2]Lockley SW Effect of reducing interns' weekly work hours on sleep and attentional failures N Engl J Med, 2004.PMID 15509816
3. [3]Philibert I Sleep loss and performance in residents and nonphysicians: a meta-analytic examination Sleep, 2005.PMID 16335329
4. [4]Shanafelt TD Burnout and satisfaction with work-life balance among US physicians relative to the general US population Arch Intern Med, 2012.PMID 22911330
5. [5]Shanafelt TD Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014 Mayo Clin Proc, 2015.PMID 26653297
6. [6]Shanafelt TD Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout Mayo Clin Proc, 2017.PMID 27871627
7. [7]West CP Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis Lancet, 2016.PMID 27692469
8. [8]West CP Physician burnout: contributors, consequences and solutions J Intern Med, 2018.PMID 29505159
9. [9]Panagioti M Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction: A Systematic Review and Meta-analysis JAMA Intern Med, 2018.PMID 30193239
10. [10]Maslach C Understanding the burnout experience: recent research and its implications for psychiatry World Psychiatry, 2016.PMID 27265691
11. [11]Wu AW Medical error: the second victim. The doctor who makes the mistake needs help too BMJ, 2000.PMID 10720336
12. [12]Scott SD The natural history of recovery for the healthcare provider second victim after adverse patient events Qual Saf Health Care, 2009.PMID 19812092