Prevention of medical errors and malpractice: Is

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a Eastern Virginia Medical School, Norfolk, VA 23501-1980, United States b Central State Hospital, ... E-mail address: parksas@evms.edu (A. Parks-Savage).
International Journal of Law and Psychiatry 60 (2018) 35–39

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International Journal of Law and Psychiatry

Prevention of medical errors and malpractice: Is creating resilience in physicians part of the answer?☆ Agatha Parks-Savage a,⁎, Linda Archer a, Heather Newton a, Elizabeth Wheeler b, Shaun R. Huband c a b c

Eastern Virginia Medical School, Norfolk, VA 23501-1980, United States Central State Hospital, Petersburg, VA 23803, United States Virginia Indigent Defense Commission, Petersburg, VA 23803, United States

a r t i c l e

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Article history: Received 24 March 2018 Received in revised form 12 June 2018 Accepted 9 July 2018 Available online xxxx Keywords: Resilience Physician burnout Physician stress Malpractice Medical errors

a b s t r a c t In this article, we present key concepts regarding physician and resident resilience and burnout, the legal and educational context for these distinctions, and the effects of improved physician resilience through self-care on a reduction in medical errors and malpractice. Resilience here indicates the mental processes and behaviors that enable an individual to overcome the potential negative effects of stressors. In order to explore the multiple factors that contribute to physician resilience, the authors approached the topic from a variety of perspectives, including the current ways of thinking about medical malpractice in the United States, physician resilience and medical errors, and building resilience during postgraduate medical education. The authors review steps taken and in process to mitigate physician burnout and enhance physician resilience. © 2018 Published by Elsevier Ltd.

1. Introduction In this article, we present key concepts regarding physician and resident resilience and burnout, the legal and educational context for these distinctions, and the effects of improved physician resilience through self-care on a reduction in medical errors and malpractice. Physicians and residents work in a complicated and stressful environment, and abundant medical literature has correlated physician burnout with lowered quality of care, medical errors, and medical malpractice suits, as well as lowered patient compliance and satisfaction. For example, in 2000, the US Institute of Medicine released its landmark report, To Err Is Human: Building a Safer Health System, which stated that medical errors occur in as many as 5%–18% of all hospital admissions and accounted for 98,000 deaths annually (Institute of Medicine 2000). By 2013, medical errors were the third leading cause of death in the United States and accounted for 440,000 fatalities annually (James 2013).

☆ This paper was presented at the 35th International Congress on Law and Mental Health in Prague (July 9–14, 2017). The presenters included Dr. Linda Archer, Vice Dean for Graduate Medical Education, Dr. Agatha Parks-Savage, Assistant Dean of Graduate Medical Education, and Dr. Heather Newton, Director of Graduate Medical Education (Eastern Virginia Medical School, Norfolk, Virginia, USA); Dr. Elizabeth Wheeler, a licensed psychologist (Central State Hospital, Petersburg, VA); and Mr. Shaun R. Huband, Esq., Virginia Indigent Defense Commission. ⁎ Corresponding author. E-mail address: [email protected] (A. Parks-Savage).

https://doi.org/10.1016/j.ijlp.2018.07.003 0160-2527/© 2018 Published by Elsevier Ltd.

Ethical considerations likely preclude clinical trials that would compare the performance of impaired vs. nonimpaired caregivers, but a 2008 study involving approximately 7900 physicians found that major medical errors were strongly related to physicians' degree of burnout (Shanafelt et al. 2010). A later report found that 45% of study physicians reported feeling at least one of the three principal symptoms of burnout: emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment (Shanafelt et al. 2012). Medical school and residency training years seem to be the peak time for physicians to experience distress, and, compared with their nonphysician peers, physicians experience burnout more frequently (Dyrbye et al. 2014; Marmon & Heiss 2015). What is more, compared with similarly aged college graduates who pursued other careers, 10% of medical students in one study experienced suicidal ideation during medical school (Dyrbye et al. 2008). In contrast to burnout, resilience here indicates the mental processes and behaviors that enable an individual to overcome the potential negative effects of stressors—resilience is not a static, innate condition but rather can be developed or learned and, over the course of an individuals life, can be ameliorated or degraded (Fox et al. 2018). Zwack and Schweitzer (2013) succinctly defined physician resilience as the ability to deploy personal resources despite stressful working conditions. Eley et al. (2013) operationalized resilience as “a process of adaptation to adversity and stress.” Further, the UK's Medical Research Council has defined resilience as the process of negotiating, managing, and adapting to significant sources of stress or trauma (Medical Research Council

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2014). Functionally, it is the capacity to bounce back after facing adverse situations. In 2016, 32 experts in the study of burnout in health professionals gathered to create the Joy of Medicine, a program sponsored by the American Medical Association, to develop a national agenda for research in this field. The group identified five top-priority ideas for this research agenda: medical errors, malpractice suits, physician turnover, decreased clinical hours, and lower patient satisfaction as a consequence of burnout (Dyrbye et al. 2017). Here we discuss physician resilience via explorations of related legal frameworks; what we currently know about resilience and reduced medical errors and malpractice; current actions in the US medical community to understand and foster this relationship; assessment of resilience in physicians; and finally, we present current activities at Eastern Virginia Medical School to enhance physician self-care and development of resilience. (Note: The main author of each section is identified by initials.)

may have different outcomes and damage awards. However, all share the same basic common elements of duty, breach, actual and proximate cause, and damages (A.L.R. 3d n.d.). Each of these essential elements is discussed below:

2. Medical malpractice in the United States (S.R.H.)

2.2. Breach of duty

Medical malpractice in the United States includes alleged patient injury related to surgical malpractice, misdiagnosis, robotic surgery malpractice, anesthesia malpractice, medication errors, and hospital malpractice. The extent of the issue is indicated by the finding that 1 in 14 physicians practicing in the United States faces a malpractice suit each year, and an estimated 210,000 and 400,000 people die each year from hospital-related medical errors (James 2013). In many cases, the alleged injury involves the provision of care by more than one physician and other allied health care professionals. This section provides a brief overview of medical malpractice law in the United States, describes how medical malpractice law functions, and explores the relation of medical malpractice law and tort law in the United States. This discussion necessarily includes the components of Medical malpractice, including the physician–patient relationship, the standard of care, the relationship of standard of care provided vs the actual alleged injury, and, if malpractice is determined, the awards to the injured party. Because our comments address the legal system in the United States as it relates to medicine, a few definitions are in order (Johnson 2016; Pegalis 2017; Speiser, Krause, & Gans 2003): Civil law, as compared with criminal law, is concerned with the rights and duties of individuals and organizations toward each other. A civil case is an action brought by one person against another in order to seek restitution for some form of wrongdoing. Torts are a specific subset of civil law in which one party claims that another party acted negligently toward them and caused some sort of injury. Medical malpractice is a type of tort in which a healthcare professional, who is responsible for using reasonable judgment in making medical decisions and rendering care, fails to act reasonably under the circumstances. If the patient is injured as a result of this failure to act reasonably, the healthcare professional may be liable to compensate the patient for the injury suffered. A plaintiff is a person who brings a legal action. A defendant is a person, company, or other legal entity against whom a claim or charge is brought in court. A verdict is the finding made by a judge or a jury whether the healthcare provider is liable to the patient for the alleged injury sustained as a result of medical malpractice. The plaintiff must demonstrate by a preponderance of evidence— that is, that it is more likely than not—that medical malpractice has occurred. A preponderance of the evidence essentially means there is a greater than 50% chance that the plaintiff's claim of medical malpractice is correct (Medical malpractice in diagnosis and treatment of breast cancer n.d., A.L.R. 6th 379). The goal of a medical malpractice claim is to make the plaintiff as close to whole as she was before the injury occurred. Nearly universally, the remedy for a medical malpractice claim is monetary damages. In the United States, torts are defined and regulated by the individual states, which means that medical malpractice cases in different states

Breach of this duty occurs when the treating doctor fails to adhere to the standards of the profession. The physician's conduct is compared with the conduct of other physicians in similar situations: In other words, to determine whether there is a breach of duty, the defendant's actions are compared with the normal or expected actions of other providers in the same or similar circumstances. Was the level of competency and professionalism consistent with the specialized training, experience, and care a “reasonably prudent” physician would have provided? Typically, expert witnesses are engaged on both sides to support their contention of negligence or lack of negligence. If the physician's actions are egregious (e.g., amputating the wrong leg), expert witnesses may not be necessary (Johnson 2016).

2.1. Existence of a legal duty A fundamental principle of medical malpractice law is the existence of a legal duty on the part of the physician to provide care or treatment to the patient. Duty results from the development of a professional relationship between the patient and the physician at the time when a doctor–patient relationship is established. The physician then owes the patient the duty of care and treatment with the degree of skill, care, and diligence possessed by or expected of a reasonably competent physician in that community (Liability of Hospice in Tort n.d., in Contract, or Pursuant to Statute, for Maltreatment or Mistreatment of Patient, 95 A.L.R. 6th, 749).

2.3. Actual/proximate cause A causal relationship must be established between the breach of duty and injury the patient suffers. Actual cause, also referred to as the cause in fact, asks whether the physician's actions or lack thereof resulted in the patient's injury. Proximate cause asks whether the law recognizes the doctor's actions as being legally responsible for the injury. Proximate cause can act as a limitation on liability (Van Arsdale, Larsen, & Levin 1936). For example, say that Dr. Jones negligently prescribes the wrong medication for a patient. As a result of taking the medication, the patient has an allergic reaction and goes to an urgent care center for further treatment. Dr. Smith, the physician at the urgent care center, inadvertently causes the patient's death due to his own negligent medical care. Although Dr. Jones was the cause in fact of the patient's original injury, it is quite possible in this scenario that he will not be held liable for that injury. Instead, Dr. Smith's negligence may be seen to legally supersede Dr. Jones' negligence (Pegalis 2017). In this way, Dr. Jones is no longer the proximate cause of the patient's injury. Unfortunately for Dr. Smith, that honor now falls to him. 2.4. Damages The existence of damages that result from the injury and appropriate compensation for them are routinely adjudicated by the legal system. Damages may be economic (past and future medical expenses, loss of income) or noneconomic (pain, suffering, inconvenience) (Speiser et al. 2003). In rare instances, when a physician's conduct is grossly reckless, wanton, or even malicious, punitive damages may be assessed as a punishment for the physician's conduct (Vaeth 1996). Absent a showing of damages, a plaintiff cannot maintain a cause of action for medical malpractice (Van Arsdale et al. 1936). For example, if a fractured tibia was treated using a closed reduction and case application when the

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standard of care would call for open fixation, then the treatment would constitute negligence if the fracture did not heal correctly and required further surgeries for correction. However, if the fracture healed appropriately even though the treatment was nonstandard, there would be no actual damages and thus nothing for the court to award. In summary, in the United States, as in other countries, physicians, physicians in training, and patients are bound by complex legal and social requirements. Damages caused by provider burnout or lack of resilience can be considerable, and an important portion of medical education should involve instilling strategies to promote physician and resident resilience and to inculcate strategies to avoid burnout. 3. Medical education, burnout, and resilience in the United States (L.A.) 3.1. Medical education and burnout US medical schools attempt to address physician burnout and resilience, but first an overview of the medical education system is in order. To be eligible to apply to medical school, students must first complete four years of academic training at a college or university. In the past, this required a specialized curriculum in preparation for medical school; however, in recent years medical schools are commonly considering students with backgrounds in many academic fields. Students then must take and pass the Medical School Admissions Test before applying to medical school. The four-year medical school curriculum focuses on learning the science of medicine, its clinical applications, normal and abnormal functions of the body, and other relevant areas such as problemsolving and concepts of community health. At the end of this training, the individual receives the MD degree but cannot independently practice medicine. For independent practice, physicians must complete three to five years of training in a residency accredited by the Accreditation Council for Graduate Medical Education (ACGME). Residencies provide training in specialties such as Pediatrics, Surgery, or Internal Medicine. At the end of residency, the physician may sit for the Board examinations and go into practice or may pursue specialty-specific training called a fellowship in an area such as Pediatric Cardiology, Internal Medicine Cardiology, and others. Residency and fellowship programs jointly are called Graduate Medical Education. In this context, we can return to burnout and resilience. Graduate Medical Education residency and fellowship programs are accredited via the ACGME, which is a private, nongovernmental nonprofit organization that sets standards for US graduate medical education (residency and fellowship) programs and the institutions that sponsor them (www.acgme.org). In academic year 2016–2017, approximately 800 ACGME-accredited institutions sponsored 10,700 residency and fellowship programs in 154 specialties and subspecialties (www. acgme.org/about-us/overview). ACGME also has championed efforts to mitigate physician burnout, stress, and depression by promoting physician resilience. 3.2. Avoiding burnout and building resilience Since its founding in 1982, the ACGME has addressed issues related to the balance of education and service vs. the need for time for educational and personal pursuits. Initially, the interest in well-being focused solely on duty hours and fatigue. In 1988, an ACGME task force provided recommendations for duty hour limits; these were updated in the Common Program Requirements that became effective July 1, 2011 (ACGME 2010). These recommendations were adopted by several specialties, but it was not until 2003 that Common Program Requirements, which apply to all specialties, were enacted. These stipulated that, on average over four weeks, residents must not work more than 80 h per week, must have at least one day in seven free from clinical duty, must be on call in the hospital no more than every third night, and must have adequate

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backup. The Common Program Requirements were revised again in 2010 and further restricted duty hours. In 2014, the highly publicized suicides of two resident physicians in New York spurred a national discussion about physician suicide. In 2015 and again in 2016, ACGME convened national Symposia on Physician Well-Being and, in 2017, issued further revisions to the Common Program Requirements (effective July 1, 2017) (ACGME 2010). For the first time, requirements for addressing well-being were developed, including a requirement for a process for self-assessment of well-being. These revisions extend beyond concerns about duty hours and fatigue mitigation and additionally emphasize resident well-being and self-care. In addition, the Common Program Requirements call for limiting residents' nonphysician responsibilities, educating and monitoring faculty and residents about burnout, depression, and suicide, and providing tools for self-screening and ready access to confidential mental health services (ACGME 2010). Other efforts to mitigate burnout include the National Academy of Medicine's promotion of a national collaborative platform to support and improve clinician well-being and resilience (National Academy of Medicine 2017b). The ACGME and the Association of American Medical Colleges (AAMC) joined forces with the National Academy of Medicine and established the Action Collaborative to assess and understand the underlying causes of clinician burnout and suicide and to advance solutions to reverse the trends in clinician stress, burnout, and suicide (Dzau, Kirch, & Nasca 2018; National Academy of Medicine 2017a).

4. The relationship between physician errors and resilience (A. P.-S.) What, then, is the connection between physician errors and resilience? We hypothesize that physicians who engage in self-care or well-being strategies on a regular basis concurrently buttress their resilience when they manage complex patient-care decisions. Resilient physicians are less likely to make errors in patient care because they are less distracted and can clearly focus on the tasks before them. Resilience, in fact, is the central element of physician well-being—it is a person's ability to respond to stress in a healthy, adaptive way so goals are achieved at minimal physical and psychological costs. Resilient people do not just bounce back from adversity, but they also grow stronger in the process (Zwack & Schweitzer 2013). From January 2010 to March 2011, these investigators conducted 200 semistructured interviews with physicians of different ages, specialties, and leadership positions across Germany. Analysis revealed 30 subcodes in three dimensions. The reported strategies and attitudes helped physicians to develop mental, physical, and social resources that fostered effective decision-making. When physicians felt that they were successfully coping, they maintained their resilience. Epstein and Krasner (2013) reiterated these points and further suggested that healthcare institutions must support the efforts of the healthcare work force to enhance the latter's capacity for resilience. These are worthwhile efforts because resilient physicians increase the quality of patient care while reducing errors, burnout, and attrition. When we think of building more resilient physicians, we can usefully consider the paradigm of military training, which is founded on the concept of resilience during exceptional crisis. Airlines and pilots offer a more mundane but important reminder about the feasibility and necessity of resilience and high performance in everyday life. Not surprisingly, the business world rewards high performers with significant monetary incentives. Professional athletes are motivated to be the best—for them, distractions can ruin careers. In reality, preparing professionals for sustaining high performance with minimal error is not a novel concept. In medical education, inculcating resilience must be an ongoing activity.

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5. Measuring resilience (B.W.) Enhancing physician resilience is a laudable goal, but questions remain, notably, How do we measure resilience in this population? Several instruments are available, and the discussion here is neither a recommendation nor an endorsement of tools used to evaluate resilience. Eley et al. (2013) studied the relationship between resilience and personality traits in physicians and reported that physician wellbeing is crucial for activities that include professional effectiveness, personal resilience, and their own longevity and safe practice. Three key traits—resilience and self-directedness, cooperativeness, and harm avoidance—characterized physicians who were judged best able to cope with challenges, stresses, and adversity (based on a cross-sectional cohort of 479 family practitioners in Australia who completed a temperament and character inventory) (Eley et al. 2013). The authors of this report note that previous literature has shown that resilience is a key component of health and healthy coping with trauma. In terms of physicians in training, many measures of resilience are available; many involve self-reports. Wagnild helped develop The Resilience Scale (available at www. resiliencecenter.com). The Resilience Scale version II is a 25-item selfrating scale with prompts such as “I am determined even if the odds are against me” and “My life has purpose.” The scale is based on a five-factor model of resilience: perseverance, purpose, self-reliance, authenticity, and equanimity are associated with greater resilience. The Brief Resilience Scale was developed by Smith et al. (2008), and its outcomes are positively related to personal characteristics, social relations, coping, and health and negatively related to anxiety, depression, negative affect, and physical symptoms. The Brief Resilience Scale is a reliable means of assessing resilience as the ability to bounce back or recover from stress and may provide unique and important information about people who are coping with health-related stressors. In summary, several measures are available to measure resilience (see, e.g., Connor & Davidson 2003); the tools just mentioned are not the only—or necessarily the best—measures available. Because graduate medical educators can choose among available options, the choice of instrument may depend on how one wants to define resilience and the specific characteristics that may be desired in a particular setting. In addition, because no single consensus instrument exists, researchers should review the development of specific instruments and the traits used to define resilience in order to determine if a particular instrument is a good fit for the real-world population. A satisfactory discussion of such instruments would include validity, reliability, effectiveness measures, and other metrologic aspects and is beyond the scope of the present study. 6. Educating physicians to be resilient (H.N.) We have established that being resilient allows residents to bounce back from the challenges of life and to endure and flourish in their work environment. Although resilience is helpful in all professions, it is particularly useful in medicine because of the demanding workloads that physicians face and their exposure to suffering, death, and uncertainty. Physicians must respond to challenges in their practice, and resilient individuals are better equipped to meet these challenges, learn from them, and develop their resilience. 6.1. Common stressors Many common medical-school stressors have been identified by physicians and staff; a comprehensive listing is beyond the scope of this discussion, but the primary causes include the following: • Rapidly expanding medical knowledge base. The time required for medical knowledge to double in 1950 was 50 years; in 2020 it will be 0.2 years; and medical students who graduate in 2020 will

• • • • • •

experience four such doublings during the course of their training (Densen 2011). Problems with work–life integration and balance (Shanafelt, Dyrbye, & West 2017). Excessive workload (Shanafelt et al. 2017). New regulatory requirements (e-prescribing, medication reconciliation) (Shanafelt et al. 2017). Unprecedented level of scrutiny (quality metrics, patient satisfaction scores, measures of cost) (Shanafelt et al. 2017). Increasingly time-consuming maintenance of certification requirements (Rassolian et al. 2017). Working on electronic medical records tasks at home. Although variables related to electronic medical records may not be significantly associated with burnout, insufficient time for the actual documentation can be significant (Rassolian et al. 2017).

Many of these stressors co-exist, which increases the probability of burnout. As medical educators, we must not only recognize these stressors but also help the physician to recognize the stressors as well. Then we can help orient physicians toward strategies and techniques to mitigate the stressors or cope with them in a healthy manner. 6.2. Collateral damage caused by stressors Without seeking to be comprehensive or quantitative, we note that burnout may also cause a variety of untoward events for not just the resident but also those in the work and study environments, including patients. Among these suboptimal outcomes, a physician's lack of resilience can: • • • • • •

Erode professionalism Contribute to broken relationships Promote suicidal thoughts Contribute to problematic alcohol or drug use Increase the risk of medical errors Promote early retirement.

6.3. Developing resilience Graduate medical education programs are charged with developing resilience as a critical component of the physician's professional development. To this end, the American Medical Association (AMA) provides a Steps Forward curriculum that includes modules that promote physician and resident resilience and preventing burnout (AMA 2017): • • • •

Reduce burnout and identify signs of burnout early Increase compassion and empathy Reconnect with the joy and purpose of practice Improve physical and mental health.

Practice benefits such resilience-building programs for residents and physicians include the following: less staff turnover; reduced costs to recruit and replace burned-out physicians; increased patient satisfaction; fewer medical errors; improved work environment; and less need for disciplinary action (AMA 2017). 6.4. Resident wellness programs—examples from Eastern Virginia Medical School The purpose of the resident wellness program at the authors' institution is to promote the well-being of residents and fellows during their training at EVMS. This is a resident-driven program that includes members from the EVMS Resident and Fellow Association and from focus group participants who helped develop this program. The goal of the wellness program is to provide residents with practical stress coping strategies that involve 1:1, small-group, or large-group experiences.

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Table 1 Some components of the resident wellness programs at Eastern Virginia Medical School (EVMS). Program title

Description

Couples support group

Builds community and support for spouses and significant others whose partner is a resident or fellow. The group is co-facilitated by the partner of a resident or fellow. More than just residents and fellows running together, this group builds richer social and collegial connections among residents and fellows compared with routine clinical interactions. Two residents coordinate the running schedules. This electronic wellness newsletter focuses on hot topics related to residents' and fellows' health and well-being during their time at EVMS. It includes activities around town and healthy recipes. RAFA members annually recommend a speaker to invite to address topics related to well-being and stress management. A recent speaker was J Dahle, author of the White Coat Investor. This pilot leadership coaching program is available to all residents and fellows. Five sessions (average) of individual coaching provide trainees with effective personal and professional coping strategies while they address a new range of challenges during their training. The BBN Foundation changes the culture of medicine by training healthcare professionals to effectively communicate with compassion, providing patients and family members greater support during challenging times. BBN provides training programs about compassionate and effective communication in healthcare for every resident physician, senior physician, nurse, and healthcare worker. EVMS was named a Center of Excellence in 2016. These 1-h sessions are facilitated by a licensed clinical social worker and a physician advisor and provide a safe environment for residents and fellows to talk about their experiences caring for a patient who has died. Half- or full-day program retreats are facilitated by doctoral educators and are based on the content or topic identified by the program. For example our GME Office conducted a retreat for Internal Medicine after participants did a group “escape room” activity. Three different days of training, one at the beginning of the assignment and two before the end of their first quarter of training. Reviews what chiefs have learned and facilitates sharing of experiences. Mindfulness strategies emphasize breathing, body language, giving oneself a periodic time-out. SNGH Gym is open 24/7. Zumba is open to all staff, not just physicians. RAFA is a useful resource for social gatherings, couples support groups, the running club, training needs, and others. RAD is the rape aggression defense system. The Weight Watchers program is greatly discounted and includes time on campus for monthly meetings and a support group.

Running club Residents and Fellows Association (RAFA) newsletter Annual wellness presentations Leadership coaching Breaking Bad News (BBN) Foundation

Final rounds Program retreats Chief training Special interest group activities

Table 1 lists and briefly describes some components of our resident wellness programs. 7. Conclusions Greater awareness of factors that contribute to physician burnout and implementation of strategies that promote physician resilience are both positive developments that will help reduce medical errors. From a somewhat broader perspective, however, we are in the early phases, on the one hand, of reporting and measuring outcomes and, on the other hand, of implementing programs for effectiveness. Both activities are ongoing, of course, but a potential limitation of most studies of burnout and resilience is the lack of standardized instruments that can reliably and reproducibly assess these conditions. Clinical trials that attempt to do so may be required to use simulations or surrogates rather than outcomes in clinical practice, but the design and conduct of such studies is of considerable interest. A concurrent challenge—and one that we must not overlook—involves moving from resilience in individuals and programs to the creation of resilient institutions. References Accreditation Council for Graduate Medical Education (2010). Common program requirements. Retrieved from http://www.acgme.org/What-We-Do/Accreditation/ClinicalExperience-and-Education-formerly-Duty-Hours/History-of-Duty-Hours. American law reports 3d. American Medical Association (2017). Steps forward. Retrieved from www.stepsforward. org/modules/improving-physician-resilience. Connor, K. M., & Davidson, J. R. (2003). Development of a new resilience scale: The Connor–Davidson resilience scale (CD-RISC). Depression and Anxiety, 18, 76–82. Densen, P. (2011). Challenges and opportunities facing medical education. Transactions of the American Clinical and Climatological Association, 122, 48–58. Dyrbye, L. N., Thomas, M. R., Massie, F. S., Power, D. V., Eacker, A., Harper, W., ... Shanafelt, T. D. (2008). Burnout and suicidal ideation among U.S. medical students. Annals of Internal Medicine, 149, 334–341. Dyrbye, L. N., Trockel, M., Frank, E., Olson, K., Linzer, M., Lemaire, J., & Sinsky, C. A. (2017). Development of a research agenda to identify evidence-based strategies to improve physician wellness and reduce burnout. Annals of Internal Medicine, 166(10), 743–744. Dyrbye, L. N., West, C. P., Satele, D., Boone, S., Tan, L., Sloan, J., & Shanafelt, T. D. (2014). Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Academic Medicine, 89(3), 443–451. Dzau, V. J., Kirch, D. G., & Nasca, T. J. (2018). To care is human—Collectively confronting the clinician-burnout crisis. New England Journal of Medicine, 378(4), 312–314.

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