Health of Specialists and Trainees

Doctors are generally:

Anaesthetists:

Impairment:

Personal Care

Doctors should:

  • Have their own GP
  • Not self-prescribe
  • Avoid corridor consultations
  • Not prescribe, treat, or consult close family members

Professional Care

Doctors and departments should:

  • Facilitate access to GPs and other health professionals
  • Maintain a list of resources to help doctors with health issues
  • Provide orientation programs to:
    • Reduce stress
    • Provide support
  • Regularly discuss personal health topics at training and CME events
  • Establish systems for professional support
  • Develop rostering practices that minimise fatigue and ill-health
  • Establish a welfare officer
    Should be present if department is >5 people. Responsibilities:
    • Resolve issues
    • Respond to issues
    • Promote resources and supports
    • Intervene when patient safety is at risk

Chemical Dependence

Definitions:

  • Substance abuse
    Related, excessive, or inappropriate use of a mood-altering substance resulting in negative consequences in one or more life areas, and where addiction cannot be diagnosed.
  • Addiction
    Primary, chronic disease of brain reward… leading to a pathological pursuit of reward or relief by substance use. Characterised by an inability to consistently abstain, impaired behavioural control, craving, and impaired recognition of problems with behaviours and interpersonal relationships.

Risk Factors

General:

  • Family history of drug abuse
  • Childhood abuse
  • Family dysfunction
  • Mental health disorder
  • Male
  • Experimenting with drugs/alcohol
  • Peers who use drugs
  • Sense of professional immunity from addiction

Specific:

  • Direct contact with drugs
  • Immediate availability
  • Easy to divert

Clinical Manifestations

Disease process usually well-advanced by the time physical and behavioural changes become noticeable

Inside the hospital:

  • Behavioural
    • Deteriorating relationships
    • Mood swings
    • Poor reliability
    • Frequent change of jobs
  • Clinical
    • Poor administration and record keeping
      • Unaccounted for drugs
    • Disproportionate post-operative pain compared with anaesthetic record
    • High doses of narcotic used in anaesthesia
    • Preference for working alone
    • Difficult to find between cases or when on call
    • At hospital when not on call
    • Requesting extra shifts
    • Unusually willing to take on additional work commitments
    • Carrying syringes and ampoules in clothing
    • IV equipment in non-clinical places
    • Wearing of long-sleeved gowns

Outside of hospital:

  • Withdrawal from family, friends, and hobbies
  • Neglect and deterioration in appearance
  • Mood swings
  • Fatigue, lethargy
  • Poor concentration, memory
  • Frequent unexplained illnesses
  • Legal problems
  • Financial problems

Mandatory Notification

Law mandates reporting:

  • Practicing whilst intoxicated
  • Sexual misconduct
  • Placing patient at risk through impairment
  • Patient at risk through practice which constitutes a significant departure from accepted professional standard

Investigation

Process will vary:

  • Sufficient evidence will usually mandate immediate investigation
  • Lack of evidence may need a period of monitoring
  • Interviews with senior staff (e.g. nurses)
  • Police involvement if criminal activity

Meeting with the person:

  • Needs to be planned in advance
  • Have suitable contacts available:
    • Occupational medicine
    • Psychiatry
    • ANZCA Welfare officer
  • Notification to provider needs to be followed immediately by meeting
    Support person should be available.
    • Family
    • Friend
    • Colleague
  • Explain concerns raised about their behaviour
  • Present any evidence
    Factual and unemotional way.
  • A non-judgmental approach facilitates a more productive interaction
  • Responses:
    • Relief
      • Usually compliant with suggestions for treatment options
    • Anger
      • Common in those with denial
      • Should be offered assessment and opportunity to consent to urine or hair testing
  • Person should be accompanied from this point on
    Significant risk of self-harm.

Intervention

Three major considerations:

  • Patient safety
    • Remove person from list
    • Review patients to ensure they are adequately cared for
    • Find alternative staff
  • Colleague health
    • Private and confidential
    • Significant reputation and career risk with allegation
  • Statutory reporting obligations

Recovery

In general:

  • Sustained abstinence occurs in 74-90%
    Anaesthetists similar to general doctors.
  • Median time time to relapse is 2.6 years.
    • Mortality of 13%

Re-entry:

  • Assessment by medical board
  • Requires supervision
  • Limitation of practice
  • Restricted access to drugs
  • Drug testing
    • Blood
    • Urine
    • Hair
      Hair testing is preferable to verify abstinence due to longer lead time.

Angres Criteria

Used to stratify likelihood of returning to anaesthesia:

  • Category I
    Return immediately after treatment.
    • Tremendous love for/commitment to anaesthesia
    • Accepts and understands the disease
    • Bonding with AA (or narcotics anonymous) and has a sponsor
    • Strong family support
    • Committed to recovery
    • Balanced lifestyle
    • No evidence of dual diagnosis, for example, bipolar disorder
    • Treatment team, anaesthetic department, and employer support return
  • Category II
    Possibility of return.
    • Relapsed with recovery underway
    • Dysfunctional but improving family situation
    • Involved, but not bonded with AA/NA
    • Improving recovery skills
    • Some denial remains
    • Mood swings without other psychiatric diagnosis
  • Category III
    Redirection to another specialty.
    • Prolonged i.v. use
    • Prior treatment failure and relapses
    • Disease clearly remains active
    • Went into anaesthesia for drug access
    • Dysfunctional family
    • Non-compliant with regulatory bodies
    • Poor recovery skills and no bonding with AA/NA, no sponsor
    • Severe co-morbid psychiatric diagnosis

Resources

In Australia, resources include:

  • Welfare of Anaesthetists Special Interest Group Documents
    Covering:
    • RD 1: Personal Health Strategies
    • RD 3: Depression & Anxiety
    • RD 5: Critical Incident Support
    • RD 13: Impairment in a Colleague
    • RD 16: Welfare Issues in the Anaesthetic Dept
    • RD 20: Substance Abuse
    • RD 24: Mandatory Reporting
      • Doctors’ Health Advisory Service
  • GP
  • Mentor/buddy system
  • Psychiatrist/staff counsellor
  • AHPRA

References

  1. ANZCA. PS49: Guidelines on the Health of Specialists and Trainees.
  2. Occupational hazards of anaesthesia | BJA Education | Oxford Academic [Internet]. [cited 2019 Nov 2]. Available from: https://academic.oup.com/bjaed/article/6/5/182/336915
  3. Mayall R. Substance abuse in anaesthetists. BJA Education. 2016 Jul;16(7):236–41.