Stress in medicine: Strategies for caregivers, patients, clinicians—Addressing the impact of clinician stress

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The impact of clinician stress on the health care system is significant. It can adversely affect the patient experience, compromise patient safety, hinder the delivery of care in a manner that is inconsistent with producing quality outcomes, and increase the overall cost of care.


Models of health care that restore human interaction are desperately needed. Clinicians today are overwhelmed by performance assessments that are based on length of stay, use of evidence-based medication regimens, and morbidity and mortality outcomes. Yet clinicians have few opportunities to establish more than cursory relationships with their patients—relationships that would permit better understanding of patients’ emotional well-being and that would optimize the overall healing experience.

Shanafelt et al1 surveyed 7,905 surgeons and found that clinician stress is pervasive: 64% indicated that their work schedule left inadequate time for their personal or family life, 40% reported burnout, and 30% screened positive for symptoms of depression. Another survey of 763 practicing physicians in California found that 53% reported moderate to severe levels of stress.2 Nonphysician clinicians have significant levels of stress as well, with one survey of nurses finding that, of those who quit the profession, 26% cited stress as the cause.3


In the Shanafelt et al study, high levels of emotional exhaustion correlated positively with major medical errors over the previous 3 months.1 Nearly 9% of the surgeons surveyed reported making a stress-related major medical mistake in the past 3 months; among those surgeons with high levels of emotional exhaustion, that figure was nearly 15%. This study also found that every 1-point increase in the emotional exhaustion scale (range, 0 to 54) was associated with a 5% increase in the likelihood of reporting a medical error.1

In a study of internal medicine residents, fatigue and distress were associated with medical errors, which were reported by 39% of respondents.4


Stress can damage the physician-nurse relationship, with a significant impact not only on clinicians, but also on delivery of care. The associated breakdowns in communication can negatively affect several areas, including critical care transitions and timely delivery of care. Stress also affects morale, job satisfaction, and job retention.5

Figure. An analysis by the Agency for Healthcare Research and Quality concluded that communication was the most frequent contributor to 3,548 sentinel clinical events (eg, wrong-site surgery, medication errors) that occurred from 1995 through 2005.6

In an examination of sentinel events in US health care, the Agency for Healthcare Research and Quality determined that a communication breakdown was the most common root cause of sentinel events in wrong-site surgery, delays in treatment, and medication errors, and the second most common cause (behind orientation/training) of adverse postoperative events.6 When root causes of all clinical categories of sentinel events were tallied, communication was found to be the most frequent contributor (training, patient assessment, and staffing were next) (Figure).6 The quality of the communication among physicians and nurses is a major influence on overall patient satisfaction and a patient’s willingness to recommend the hospital to others.


The traditional response to complaints registered by patients has been behavioral coaching, disruptive-behavior programs, and the punitive use of satisfaction metrics, which are incorporated into the physician’s annual evaluation. These approaches do little to address the cause of the stress and can inculcate cynicism instead.

A more useful approach is to define and strive for an optimal working environment for clinicians, thereby promoting an enhanced patient experience. This approach attempts to restore balance to both the business and art of medicine and may incorporate biofeedback and other healing services to clinicians as tools to minimize and manage stress.

The business of medicine may be restored by enhancing the culture and climate of the hospital, improving communication and collaboration, reducing administrative tasks, restoring authority and autonomy, and eliminating punitive practices. The art of medicine may be restored by valuing the sacred relationship between clinician and patient, learning to listen more carefully to the patient, creating better healing environments, providing emotional support, and supporting caregivers.

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