No one shows up to work intending to make errors. People drawn to work in clinical laboratories are highly conscientious and responsible, and they are devastated when an error occurs. Yet of course, errors occur, even in the most prestigious institutions. The seriousness of what is at stake—our patients’ safety—naturally compels us to examine every possible external, systematic problem that increases the risk of errors. But sometimes it’s also necessary to be introspective: What can lead to our co-workers, or ourselves, making serious mistakes that we do not intend to make?

One often overlooked risk in the lab is burnout. Burnout has previously been raised as a possible cause of errors in the laboratory by Michael Astion, MD, PhD, in CLN Patient Safety Focus (1). In addition, I have advanced Just Culture as a framework for understanding human behavior as a cause for errors and a tool to address them (2).

But even though many articles in the literature describe burnout in other medical professionals, very few identify burnout among laboratorians as a cause of errors in pathology and laboratory medicine (3-7).

Making the Diagnosis

Burnout, a syndrome characterized by exhaustion, cynicism, and reduced effectiveness, does not spare us. Though a recent Medscape survey showed that burnout among pathologists was lower compared to other physician specialists, there were alarming signs that demonstrated a discernible gender and generational gap. Women reported burnout more than men in almost all medical specialties. And burnout rates in pathologists 35 years of age or younger were equal to the rate of burnout among emergency medicine physicians, who have some of the highest rates of burnout among specialties (8).

Burnout is insidious because it often goes unrecognized due to gradual onset and symptoms that are nonspecific and often attributed to another cause.

In the absence of rigorous studies from peer-reviewed journals, it is reasonable to presume that the rates of burnout among other healthcare professionals in the laboratory, including doctoral level scientists, clinical laboratory scientists, and phlebotomists, are likely similar to that of pathologists, as they face similar stressors.

In laboratory medicine, we have made extensive progress understanding the causes of error in our operations. However, none of the previous studies of preanalytical, analytical, or post-analytical errors specifically called out burnout as a cause, and not an effect, of mistakes. Yet Astion and I strongly believe that burnout is an underrecognized and underappreciated cause of errors in laboratories, based on our experiences as laboratory medical directors.

It is important to acknowledge that burnout among other physician specialists and nurses likely impacts all lab personnel. In many ways, it becomes a negative feedback loop: Burned-out clinicians and nurses may drive burnout in laboratory staff, and vice versa.

So if we accept that burnout is a cause of errors, how can we prevent burnout in our laboratories?

Building Resiliency

Tait Shanafelt, MD, and his colleagues have studied burnout and resiliency for decades. Previously at Mayo Clinic in Rochester, Shanafelt is the first chief physician wellness officer to direct the newly established Stanford WellMD Center. He recommends both individual and system-wide remedies to prevent burnout and build resiliency. In particular, he points out that the quality of physician leadership has a dramatic effect on the rates of burnout among followers (9-11).

What Drives Burnout?

Problems in any of these seven domains can lead to exhaustion, cynicism, and inefficiency:

  1. Workload and job demands
  2. Efficiency and resources
  3. Meaning in work
  4. Culture and values
  5. Control and flexibility
  6. Social support and community at work
  7. Work-life integration

Source: Shanafelt and Noseworthy (12)

No one can control all the factors that lead to burnout. Laboratory leaders need to work with institutional leaders to build healthier systems that recognize burnout among all of the professionals within their organizations. Healthcare systems can help all staff address those factors over which individuals have control, increasing the chances for more engagement—the opposite of burnout. John Noseworthy, MD, CEO of Mayo Clinic, regularly encourages everyone to “take care of the patients, take care of ourselves, and take care of each other.”

Building Resilience in a VUCA World

We live in a VUCA world: one that is volatile, uncertain, complex, and ambiguous (13). It is especially important for laboratory leaders to set good examples of resiliency and to cultivate a resilient system of healthy working relationships. In many ways, it is as if we in our laboratories are all in submarines. Since we live and work in close quarters, why would we ever want to poke someone else in the ribs, or worse yet, in the eyes?

In addition to underscoring the need for strong leaders, our VUCA world also requires that we understand and embrace something very difficult: that to be successful we must nurture a positive attitude while also being clear-eyed about the problems we face. This challenge is illustrated by the Stockdale paradox, described by former vice presidential candidate Adm. James Stockdale to Jim Collins in his book, Good to Great (14).

Adm. Stockdale—who was held captive for 7 years during the Vietnam War—said that we must believe that things will turn out fine in the end, but that we must have the courage to face the facts as they are, not as we wish them to be. It is not optimism alone that helps people survive and thrive. Resilient leaders demonstrate grit, grace, and humor.

We each are responsible for teaching and coaching ourselves to be more resilient. In essence, we must learn to forgive mistakes if we are to avoid future ones. Perfectionism is not the goal; excellence is. Laboratory leaders can build resilience by reminding ourselves of the Stockdale paradox to deal with future events, guarding ourselves against the “what ifs” that we may encounter.

In the end, we must live mindfully in the present—neither preoccupied about the past nor tormented about future events that we cannot control.

James S. Hernandez, MD, MS is an associate professor of laboratory medicine and pathology, and medical director and chair of the division of laboratory medicine at Mayo Clinic in Scottsdale and Phoenix, Arizona. +Email: hernandez.james@mayo.edu

References

  1. Astion M. Burnout, a new frontier in patient safety? Clinical Laboratory News 2013;(10)39.
  2. Hernandez J. Responding to laboratory errors, how not to lose your cool. Clinical Laboratory News 2012;(10)38.
  3. Hernandez J and Wu R. Burnout in pathology: Suggestions for individual and system-wide solutions. J Am Soc Cytopathol 2018; doi.org/10.1016/j.jasc.2018.01.002.
  4. Schrijver I. Pathology in the medical profession?: Taking the pulse of physician wellness and burnout. Arch Pathol Lab Med 2016;140:976-82.
  5. Hollensead SC, Lockwood WB, Elin RJ. Errors in pathology and laboratory medicine: Consequences and prevention. J Surg Oncol 2004;88:161-81.
  6. Hammerling JA. A review of medical errors in laboratory diagnostics and where we are today. https://academic.oup.com/labmed/article/43/2/41/2505001 (Accessed February 2018).
  7. Van Der Linden D, Keijsers GPJ, Eling P, et al. Work stress and attentional difficulties: An initial study on burnout and cognitive failures. http://www.tandfonline.com/doi/abs/10.1080/02678370500065275 (Accessed February 2018).
  8. Peckham C. Physician burnout: It just keeps getting worse. http://www.medscape.com/viewarticle/838437_4 (Accessed February 2018).
  9. Shanafelt TD and Noseworthy J. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. http://www.mayoclinicproceedings.org/article/S0025-6196(16)30625-5/pdf (Accessed February 2018).
  10. Shanafelt TD, Gorringe G, Menaker R, et al. Impact of organizational leadership on physician burnout and satisfaction. http://www.sciencedirect.com/science/article/pii/S0025619615000713 (Accessed February 2018).
  11. In a first for U.S. academic medical center, Stanford Medicine hires chief physician wellness officer. https://med.stanford.edu/news/all-news/2017/06/stanford-medicine-hires-chief-physician-wellness-officer.html (Accessed February 2018).
  12. Shanafelt TD and Noseworthy J. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. http://www.mayoclinicproceedings.org/article/S0025-6196(16)30625-5/pdf (Accessed February 2018).
  13. Hernandez JS, Allen TC.Transformation of pathologists: Responding in a volatile, uncertain, complex, and ambiguous environment. Arch Pathol Lab Med 2013;137:603-5.
  14. Collins J. Good to great: Why some companies make the leap... and others don’t. Harper Collins 2001.

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