Addiction and substance abuse in anesthesiology

Despite substantial advances in our understanding of addiction and the technology and therapeutic approaches used to fight this disease, addiction still remains a major issue in the anesthesia workplace, and outcomes have not appreciably changed. Although alcoholism and other forms of impairment, such as addiction to other substances and mental illness, impact anesthesiologists at rates similar to those in other professions, as recently as 2005, the drug of choice for anesthesiologists entering treatment was still an opioid. There exists a considerable association between chemical dependence and other psychopathology, and successful treatment for addiction is less likely when comorbid psychopathology is not treated. Individuals under evaluation or treatment for substance abuse should have an evaluation with subsequent management of comorbid psychiatric conditions. Participation in self-help groups is still considered a vital component in the therapy of the impaired physician, along with regular monitoring if the anesthesiologist wishes to attempt reentry into clinical practice.     

Measurement of individual clinical productivity in an academic anesthesiology department

BACKGROUND: The ability to measure productivity, work performed, or contributions toward the clinical mission has become an important issue facing anesthesiology departments in private practice and academic settings. Unfortunately, the practice and billing of anesthesia services makes it difficult to quantify individual productivity. This study examines the following methods of measuring individual productivity: normalized clinical days per year (nCD/yr); time units per operating-room day worked (TU/OR day); normalized time units per year (nTU/yr); total American Society of Anesthesiologists (ASA) units per OR day (tASA/OR day); and normalized total ASA units per year (ntASA/yr). METHODS: Billing and scheduling data for clinical activities of faculty members of an anesthesiology department at a university medical center were collected and analyzed for the 1998 fiscal year. All clinical sites and all clinical faculty anesthesiologists were included unless they spent less than 20% of their time during the fiscal year providing clinical care, i.e., less than 0.2 clinical full-time equivalent. Outliers, defined as faculty who had productivity greater or less than 1 SD from the mean, were examined in detail. RESULTS: Mean and median values were reported for each measurement, and different groups of outliers were identified. nCD/yr identified faculty who worked more than their clinical full-time equivalent would have predicted. TU/OR day and tASA/OR day identified apparently low-productivity faculty as those who worked a large portion of their time in obstetric anesthesia or an ambulatory surgicenter. tASA/OR day identified specialty anesthesiologists as apparently high-productivity faculty. nTU/yr and ntASA/yr were products of the per-OR day measurement and nCD/yr. CONCLUSION: Each of the measurements studied values certain types of productivity more than others. By defining what type of service is most important to reward, the most appropriate measure or combination of measures of productivity can be chosen. In the authors' department, nCD/yr is the most useful measure of individual productivity because it measures an individual anesthesiologist's contribution to daily staffing, includes all clinical sites, is independent of nonanesthesia factors, and is easy to collect and determine.     

Substance abuse among physicians: a survey of academic anesthesiology programs

Efforts to reduce controlled-substance abuse by anesthesiologists have focused on education and tighter regulation of controlled substances. However, the efficacy of these approaches remains to be determined. Our hypotheses were that the reported incidence of controlled-substance abuse is unchanged from previous reports and that the control and accounting process involved in distribution of operating room drugs has tightened. We focused our survey on anesthesiology programs at American academic medical centers. Surveys were sent to the department chairs of the 133 US anesthesiology training programs accredited at the end of 1997. There was a response rate of 93%. The incidence of known drug abuse was 1.0% among faculty members and 1.6% among residents. Fentanyl was the controlled substance most often abused. The number of hours of formal education regarding drug abuse had increased in 47% of programs. Sixty-three percent of programs surveyed had tightened their methods for dispensing, disposing of, or accounting for controlled substances. The majority of programs (80%) compared the amount of controlled substances dispensed against individual provider usage, whereas only 8% used random urine testing. Sixty-one percent of departmental chairs indicated that they would approve of random urine screens of anesthesia providers. IMPLICATIONS: This survey indicates that the frequency of controlled substance abuse among anesthesiologists has changed little in the past few years, despite an increase in the control and accounting procedures for controlled substances as well as increased mandatory education.     

Effect of subspecialty organization of an academic department of anesthesiology on faculty perceptions of the workplace

BACKGROUND: Many large academic practices have accepted the notion that subspecialization provides certain benefits-more consistent care, a higher degree of state-of-the-art knowledge, improved teaching, and better working relationships and communication among the subspecialty anesthesia faculty and their surgical and nursing colleagues. But a rigid subspecialty grouping is rarely done in the main body of an academic faculty. STUDY DESIGN: To evaluate if subspecialization provides greater satisfaction for an academic general services anesthesia faculty, a survey about work conditions and perceptions was undertaken before and after reorganization of a large academic practice. Scores for each question were on a scale of 1 to 5. RESULTS: Although there was a sense that excellent expert care was more often delivered after subspecialty reorganization, the overall faculty impression of their workplace was not markedly changed (prereorganization 3.52 +/- .56; postreorganization 3.60 +/- .34 [mean score +/- SD]; p = NS). CONCLUSIONS: The faculty did not perceive an overall benefit from a move to greater subspecialization in the organization of the anesthesia department, despite the leadership's opinion that the workplace had become much more functional and productive.     

Managing intergenerational differences in academic anesthesiology

PURPOSE OF REVIEW: Common definitions for workplace generations are the silent generation (born 1925-1945), the baby boomer generation (1946-1962), generation X (1963-1981), and generation Y (1982-2000). Distinct motivational and value perceptions stereotype generations. This review defines the characteristics of workplace generations today and provides insight into how differences influence the workplace environment. RECENT FINDINGS: Senior faculty members are mostly boomers, whereas residents and junior faculty members tend to belong to generation X. Medical students and incoming interns are from generation Y. When compared with boomers, generation X is more savvy with technology, more independent, less loyal to the institution, and seeks balance between work and lifestyle. The 80-h resident working week restriction has reinforced differences between older and younger physicians. Generation Y exhibits traits that are similar to those of generation X. Their increased interest in anesthesiology may reflect, in part, their assumption that it affords better control of lifestyle. SUMMARY: Understanding, improved communication strategies, mentorship, and flexibility in methods employed to achieve common goals are most likely to capture the interest and cooperation of members of generation X and possibly Y. Future studies should test effects of particular interventions on outcome in terms of recruitment and performance milestones.     

Status of women in academic anesthesiology

The authors compared anesthesia faculties with the rest of medical school faculties at each of four academic ranks and found a significant difference in proportion of men and women anesthesia faculty members at the assistant professor rank only (P less than 0.001). When the faculty status of women and men academic anesthesiologists was examined a significant difference was found in rank distribution in age groups 40 to 44 (P less than 0.005) and 45 to 49 (P less than 0.001), where there was a deficit of professors and a surfeit of instructors among women. Significant differences in distribution continued at age 50-54 (P less than 0.01), 55-59 (P less than 0.001), and 60-64 (P less than 0.005), primarily at professor and assistant professor ranks. In addition, there was significantly lower prevalence of board certification (P less than 0.001) and level of responsibilities for women (P less than 0.001). There was no significant difference in tenure status.     

Clinical assessment of malpractice case scenarios in an anesthesiology department.

STUDY OBJECTIVE: To determine whether anesthesiologists agree with each other when assessing actual malpractice clinical scenarios, whether their assessments comport with the actual malpractice verdicts, and whether they can accurately guess jury verdicts. DESIGN: Survey study requesting anesthesiologists to review 12 malpractice case scenarios, administered twice. SETTING: Academic medical center department of anesthesiology. MEASUREMENTS AND MAIN RESULTS: Mean interphysician agreement, mean Likert values assessing relative negligence, mean agreement with jury verdicts, mean success at predicting actual jury verdicts for 12 actual jury verdict case scenarios. Respondent anesthesiologists appeared homogeneous by training and years of experience. They showed high (> 80%) agreement among themselves in their assessments of the malpractice case scenarios over the two administrations (p = 0.13). In addition, mean Likert values as to relative negligence assessments by respondent anesthesiologists were not significantly different between administrations by case (p = 0.09 to 1.00). However, of the eight cases with complete or virtually complete agreement between respondent anesthesiologists, three (37.5%) disagreed with the verdict rendered by the actual juries. In addition, anesthesiologists showed significant disagreement (> 30%) among themselves in four of the case scenarios, indicating there may not be agreement regarding the standard of care in these clinical circumstances. Finally, anesthesiologists predicted jury verdicts poorly, with success rates of 50% or less in seven of the 12 case scenarios. CONCLUSIONS: For this sample of homogeneous anesthesiologists who demonstrated high clinical agreement, it appears that the malpractice system may not be able to function on its own terms in adjudicating malpractice claims. Although there was agreement among respondent anesthesiologists, these assessments were in direct opposition to actual verdicts, a significant percentage of cases resulted in disagreements as to the appropriate standard of care, and anesthesiologists could not successfully predict jury verdicts. The malpractice system appears to be operating far from its theoretical ideal if these results could be applied more generally. Thus, in practice, the legal system, which is to provide an optimal level of injury deterrence, may be a poor method to limit patient injury, improve patient safety, and provide compensation to negligently injured patients in the health delivery system.     

A microcomputer-based relational database for an academic department of human genetics

Recent advances in microcomputer technology have made it possible for academic departments to establish their own discrete databases. This is in keeping with the modern tendency towards distributed processing on smaller systems as opposed to depending on large shared remote centralized mainframes. A database that had been implemented on a mainframe for the Department of Human Genetics of the University of Cape Town has been successfully transferred to a microcomputer system, resulting in a redesigned relational system with several significant advantages. These include faster data capture, enhanced consistency, greater computer awareness, improved economy and increased confidentiality.     

Application of a critical incident reporting and analysis system in an anesthesiology department

OBJECTIVES: To ascertain the changes in anesthesia-related morbidity and mortality after application of a scheme for reporting critical incidents and to assess the effect of implementing preventive measures against the detected errors. PATIENTS AND METHODS: We defined a critical incident to be any situation in which the margin of safety for the patient was reduced or might have been reduced. We analyzed data from the period between January 1999 and December 2004. RESULTS: The number of critical incidents was 547 (0.79% of 68627 anesthetic procedures). Human error was identified in 279 incidents (51%). The most frequent factors underlying errors were wrong diagnosis of the situation, communication problems, and failure to check equipment and drugs. The patient suffered no adverse effect in 81.8% of the incidents; 78.9% were considered preventable. Introducing an equipment checklist before anesthesia reduced the number of incidents from 90 events in 21809 cases in 31 months to 34 events out of 22064 cases in 29 months; chi2 test, P < 0.05; odds ratio (OR), 2.68; 95% confidence interval (CI), 1.80-3.98). Labeling syringes reduced errors in the administration of medications from 45 errors in 21 809 cases in 31 months to 27 in 22064 cases in 29 months; chi2, P < 0.05; OR, 1.68; 95% CI, 1.04-2.72. CONCLUSIONS: Corrective measures were adopted as a result of the incident reporting scheme. Some of the measures led to a statistically significant reduction in equipment and drug administration errors.     

Interventions to promote retention in substance abuse treatment

Objectives: Compare two methods of improving retention in substance abuse treatment for persons with traumatic brain injury.

Design: Randomized clinical trial with control group comparison.

Interventions: Provision of a financial incentive and reduction of logistical barriers.

Outcome measures: Treatment attendance, perceived therapeutic alliance, premature termination.

Results: Provision of a financial incentive was highly effective for facilitating early attendance and appeared to promote eventual successful treatment completion. Reduction of logistical barriers did not significantly improve attendance or successful discharge. The hypothesized role of improved therapeutic alliance as a consequence of intervention and a mediator for preventing premature termination was not supported. However, results suggested that intervention, particularly financial incentives, promoted congruence between counsellor and client perceived therapeutic alliance.

Conclusions: For clients with traumatic brain injuries, provision of a financial incentive at an early point in substance abuse treatment substantially improves attendance and reduces the likelihood of premature termination. The basis for this effect appears to involve more than enhancement of the therapeutic alliance. We posit that concrete incentives can provide an opportunity for successful rule-governed behaviour that may generalize to other areas of improved impulse control.     

A departmental policy addressing chemical substance abuse

Substance abuse is a major socioeconomic problem. However, the ready availability of potent narcotic and sedative drugs probably constitutes a unique risk for anesthesiologists. Until recently, few anesthesia departments were prepared to recognize or safely manage afflicted colleagues. Because we felt it important to educate our staff and residents and to have a response mechanism established prior to the advent of a substance abuse problem, a departmental committee was formed to develop a Substance Abuse Policy. The policy has served to increase our general awareness and to direct our actions effectively when dealing with physician impairment. It is presented here in the belief that other departments might find it useful in tailoring their approach to this problem.     

A case of unusual substance abuse causing myeloneuropathy

STUDY DESIGN: Case report. OBJECTIVES: Examine an unusual drug related case of myeloneuropathy as well as the pathophysiology of nitrous oxide induced subacute combined degeneration. SETTING: Major metropolitan teaching hospital - Princess Alexandra Hospital, Queensland, Australia. METHODS: Review case notes, investigations, relevant medical literature and epidemiological data. RESULTS: A 23-year-old female developed a myeloneuropathy and encephalopathy after an 8-month history of nitrous oxide abuse. Her presentation was complicated by acute renal failure, deep vein thrombosis (DVT) and pulmonary embolism (PE) as well as severe cognitive deficits. After eight months of multidisciplinary rehabilitation the patient is able to walk short distances with mobility aids and is able to manage self cares. However, she still requires a wheelchair for long distances and will have significant residual neurological deficits. CONCLUSION: The abuse of nitrous oxide has potentially serious outcomes that require discussion of issues related to harm minimisation and health promotion.