ANESTHESIA WELL-BEING AND EFFICIENCY
From Anesthesiology Update 2005, presented by the University of California, San Diego, School of Medicine,
January 5-8, 2005
| CARING FOR THE SUBSTANCE-ABUSING COWORKER —Robin R. Seaberg, MD, Assistant Clinical Professor of
Anesthesiology, University of California, San Diego, School of Medicine
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| Drug of abuse: defined as any substance that alters mood, level of perception, or brain function; includes all forms of administration;
in addition to potent anesthetic agents, includes legal and illegal over-the-counter, prescribed, and recreational
drugs; most common examples include alcohol, opioids, sedative hypnotics, and stimulants
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| Substance abuse: follows strict Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria;
maladaptive pattern of recurrent substance use resulting in clinically significant impairment or distress; manifested
in failure to fulfill major role obligation, use of substance when physically hazardous, or legal problems; person chooses
to continue using substance despite adverse consequences, eg, recurring social and interpersonal problems
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| Substance dependence: includes ≥3 of following occurring over relatively short period (≈1 yr); tolerance; withdrawal; consumption
of larger than intended amounts or over longer period than intended; efforts to cut down or control use unsuccessful;
over time, almost all life force directed toward obtaining substance; forfeiture of social, occupational, or
recreational activities due to use; continued use despite adverse consequences; involves pattern of use leading to significant
impairment or distress; can occur with or without physiologic component; psychologic dependence also occurs
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| Tolerance: defined as need to use higher doses to achieve same effects; involves chemical and physiologic changes in body;
development of tolerance to one drug usually indicates cross-tolerance to other drugs of same class
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| Withdrawal (abstinence syndrome): characterized by appearance of physiologic symptoms when drug stopped too
quickly; clinically significant withdrawal symptom exists only with opioids, depressants, and stimulants; in general,
symptoms opposite of acute effects
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| Physician impairment: defined as inability to practice medicine with reasonable skill and safety by reason of physical or
mental illness; causes include loss of motor skills, mental illness, dysfunctional aging, and drug or alcohol use disorders;
results in temporary period of close supervision
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| Addiction: drugs of abuse affect brain and “change how you feel”; dopamine primary culprit producing good feelings and
brain rewards; all experiences that produce positive feelings cause increased activity in specific area of brain; closely tied
to opioid receptors; drugs of abuse increase reward almost immediately and powerfully; long-term use of substances irreparably
alters natural reward system; in addition to dopamine, serotonin also plays role, particularly with hallucinogens
and alcohol; other neurotransmitters important in specific circumstances; studies support genetic influences in predisposition
to drug dependencies
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| Disease model: substance-abuse disorders are family of chronic diseases with behavioral component; criteria for disease include
recognized definition, ability to be diagnosed reliably using set criteria, known course that disease likely to follow,
and known treatment once diagnosis made; genetic susceptibility to addiction cannot currently be changed, but behavioral
choices and responses can be changed
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| Progression: use of alcohol and other substances usually begins in mid-to-late teens; early onset of use more likely to cause
additional life problems and earlier onset of dependence; dependence on drugs of abuse rarely begins after 40 yr of age;
most dependencies associated with earlier-than-expected death; long-term use of alcohol can shorten lifespan by 10 to 15
yr; leading causes of death for alcohol abusers include cardiovascular disease, cerebrovascular accident (CVA), cancer,
accidents, and suicide; leading causes of death for opioid abusers include accidental death, overdose, chronic liver disease,
cardiovascular disease, and cancer; problems noted first in family, then community associations; may have credit or
financial problems; spiritual and emotional health deteriorates, followed by physical health; deterioration of clinical performance
late sign of problems; with potent opioids, use and dependence escalates so rapidly that fluctuating process unseen
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| Medical professionals: 8% to 14% of physicians become dependent on drugs or alcohol at some point in career; some studies
have shown specific use patterns in different specialties; residents and practicing physicians tend to use various substances
for self-treatment of pain, anxiety, and depression; 1% to 2% prevalence of drug and alcohol use among
anesthesia providers; access to highly addictive opioids, lack of needle phobia, curiosity about drugs, and “our feeling
that we’re smarter than these drugs” all contribute to vulnerability; although only 4% of physician population, anesthesiologists
comprise largest percentage (12%-15%) of physicians in treatment programs; 33% to 50% of people in treatment
programs polydrug users; initial reasons for use include curiosity, fun, to sleep, or to self medicate various ailments; in
late stages, most use just to “stay even” or to avoid pain of withdrawal; those more susceptible to substance abuse disorders
include those with genetic predisposition and family history of substance abuse or mental illness; personality characteristics,
including overconfidence and thrill seeking, may play part, as well as lack of strong family, community, and
religious associations; other health factors, including chronic fatigue and smoking >1 pack of cigarettes daily, also correlated;
stress less important than individual’s mechanism of coping with stress; access affects type of substance used, not
incidence; family members may be first to notice changes in behavior or other warning signs of substance abuse; only
pathognomonic sign is witnessed self-administration of drugs; coma and death unfortunately sometimes first recognizable
sign of potent substance abuse disorder; most signs and symptoms insidious and subtle in their progression, making
them easier to deny; most users feel that as long as they can function at work, there is no problem; colleagues may note
signing out escalating doses of opioids; patients’ complaints of pain out of proportion to that expected from narcotic
record in postanesthesia care unit (PACU), mood swings, depression, anger and irritability alternating with euphoria;
charts may become unreadable; increasing desire to work alone; refusal of lunch relief or breaks; frequent bathroom
breaks but with noticeable change in mood upon return; frequent offers to relieve others, volunteer for extra call and extra
cases; unexplained absences; not answering pager; wearing long-sleeved gowns to hide tracks and to stay warm; pinpoint
pupils (in opioid users); flu-like syndrome noted with opioid withdrawal; other signs of withdrawal include deteriorating
relationships with patients and staff and deteriorating personal hygiene
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| Suspected problem: moral and ethical obligation to protect patients from impaired physician; treatment outcome best
when problem identified early; each department or practice should have designated person with interest and some experience
in this area; do not deny problem, or hide or protect person; attempts to handle problem alone unlikely to be successful;
American Society of Anesthesiologists (ASA) substance abuse hotline can be starting point; all states required to
have physician health program; physician well-being committee necessary
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| Diversion: allows impaired physicians to be diverted to treatment, rather than discipline; all information gathered by diversion
evaluation committee confidential; records destroyed upon completion of program; components of treatment program
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| Intervention: never done one-on-one; set aside time and private place; goal to demonstrate need for treatment; want agreement
to get multidisciplinary medical evaluation; medical leave-of-absence possible with voluntary evaluation; avoids action
against license by securing voluntary agreement to not practice medicine until permitted by diversion evaluation
committee; ideally, person can be escorted directly from intervention to treatment facility
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| Rehabilitation: goals include optimization of physical and mental health, motivatation to achieve and maintain abstinence,
participation in counseling to build substance-free life, and adoption of relapse-prevention techniques; long-
term goal is new lifestyle allowing for emotional and spiritual growth in sobriety; no such thing as cure; acute rehabilitation
may begin as inpatient or outpatient, depending on individual circumstances
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| Aftercare: involves need to continue to use various therapeutic tools available to help maintain sobriety; components of aftercare
program; formal programs last months to years
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| Return to work: decided on case-by-case basis; gradual process designed to maximize chances of successful return to
practice while maintaining sobriety; at first, clinical duty hours strictly regulated; when possible, access to drug-of-
choice restricted or monitored; work site monitor familiar with person’s history serves as point-of-contact and support;
be supportive of person’s return to work; be alert for signs of relapse
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| IMPROVING PERSONAL JOB SATISFACTION —Matthew B. Weinger, MD, Professor of Anesthesiology, Biomedical
Informatics, and Medical Education, Vanderbilt University School of Medicine, Nashville, Tennessee
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| Introduction: people in work situations that are not satisfying often have poor control (little autonomy and independence)
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| Secrets of personal satisfaction: reasonable expectations; accurate perceptions; effective decisions; optimize your relationships;
work as part of larger organization; “do what you love, and love what you do”; happiness comes when perceptions
better than expectations; learn to deal with uncertainty; only things over which we have total control are our
perceptions of world around us
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| Perceptions: influenced by wide range of internal cognitive biases and external contextual factors; affect what we see, hear,
think, and experience; perceptions of world grounded in context of environment
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| Choices: anticipate decisions and optimize ability to choose; decision defined as any act of omission or commission where
individual or group has choice of whether to act or not act; decision to not act most common
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| Decision evaluation: decision can be judged before or after implementation; before implementation, decision may be assessed
as to whether it covers contingencies, displays sound judgment, shows imagination, and demonstrates flexibility;
afterwards, decision almost always judged by how well it achieved its stated objectives; Frankl stated, “no man should
judge unless he asks himself in absolute honesty whether in a similar situation he might not have done the same thing”
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| Elements of decision: recognize problem; generate options; evaluate options; implement decision; “all important decisions
arise in the middle of living everyday life [in which there is] already a present course” that has been challenged; understand
personal goals; important not to confuse long-term goals with means of achieving goals; Winston Churchill said,
“one must act in accordance with what one feels and believes”
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| Thinking about yourself: core beliefs; goals and aspirations; wants and needs; strengths and weaknesses; limitations
(yourself, your family, world around you); biases
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| Influence of core beliefs and attitudes: defines right and wrong; establishes self-worth; significantly affects perception,
interpretation, and judgment of surrounding world; shapes and influences interactions with others; influences expectations
and perceptions of outcomes
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| Decision implementation: more time consuming and requires more effort than making decision; early disappointments or
obstacles inevitable; new information may call into question decided course of action; success often requires commitment
and persistence; “not every battle is worth fighting”
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| Dealing with others: other people will disappoint “if you don’t recognize that everyone’s different and contributes in different
ways”; particularly frustrating are people you perceive as being lazy or unwilling to put out any effort
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| Success in dealing with others: improve yourself; empathy; effective communication; effective negotiation; ability to handle
conflict (without escalating problem); teamwork skills; perhaps most important impediment to success in many professional
and interpersonal situations is failure to consider adequately other person’s perspective; most people only interested in
themselves and listen poorly to others; quote from Dale Carnegie states, “the only way on earth to influence the other fellow
is to talk about what he wants and show him how to get it”; rule change can substantially improve success
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| Trading on differences: involves interests, opinions, risk preferences, and motivation
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| Adjusting perceptions: do not blame others for your problems or situation; discuss each other’s perceptions and needs;
give other person stake in outcome
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| Teamwork: professional success requires team decision making; dysfunctional attributes, particularly in health care, are
competing goals and inability to see bigger picture; successful organization able to establish clear values, vision, and
goals for organization; everyone sees that competing against each other not as effective as working together; five Cs of effective
team include commitment, competence, common goal, communication, and coordination
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| Conflict: arises whenever interests diverge; inevitable in all relationships; often considered dysfunctional, but occurrence
and resolution of conflict promote interpersonal or organizational growth
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| Emotions: do not pass judgment immediately; do not express your interpretation of behavior; do not lose sight of contents
of message; talk about how behavior makes you feel
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| High-performance organizations: strong organizational values, vision, and culture; shared information about goals and results;
active employee participation in decisions; reduced status differences among employees; highly selective recruitment;
substantial investment in training; higher levels of compensation, usually based partially on group performance (not just individual
performance); some degree of employment security
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Educational Objectives
| The goal of this activity is to educate the listener about caring for the substance-abusing coworker and improving personal
job satisfaction. After hearing and assimilating this program, the participant will be better able to:
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 | 1. Identify substance abuse in a colleague.
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| 2. Distinguish between substance abuse, substance dependence, and tolerance.
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| 3. Trace the progression of substance abuse.
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| 4. List the appropriate steps in diversion, intervention, and rehabilitation of the substance-abusing medical professional.
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| 5. Describe the steps to improving personal job satisfaction.
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Discussed on This Program
Diazepam [Diastat, Diazepam Intensol, Valium]
Disulfiram [Antabuse]
Fentanyl [Sublimaze]
Midazolam HCl [Versed]
Morphine sulfate (several trade names)
Naltrexone HCl [Depade, ReVia]
Sufentanil citrate [Sufenta]
Suggested Reading
Alexander BH et al: Cause-specific mortality risks of anesthesiologists. Anesthesiology 93:922, 2000; Berry AJ et al:
Cause-specific mortality risks of anesthesiologists. New evidence for the existence of old problems. Anesthesiology
93:919, 2000; Booth JV et al: Substance abuse among physicians: a survey of academic anesthesiology programs. Anesth
Analg 95:1024, 2002; Duncan PG: Risks and benefits of the practice of anesthesiology. Can J Anaesth 46:R131, 1999;
Jenkins K et al: A survey of professional satisfaction among Canadian anesthesiologists. Can J Anaesth 48:637, 2001;
Kinzl JF et al: Influence of working conditions on job satisfaction in anaesthetists. Br J Anaesth 94:211, 2005; Kluger
MT et al: Job satisfaction, stress and burnout in Australian specialist anaesthetists. Anaesthesia 58:339, 2003; Lederer W
et al: The professional image anticipated by anaesthesiologists. Acta Anaesthesiol Belg 55:355, 2004; Luck S et al: The
alarming trend of substance abuse in anesthesia providers. J Perianesth Nurs 19:308, 2004; May JA et al: Attitudes of anesthesiologists
about addiction and its treatment: a survey of Illinois and Wisconsin members of the American Society of
Anesthesiologists. J Clin Anesth 14:284, 2002; Prislin M et al: Improving education about substance abuse. Acad Med
74:749, 1999; Travis J: Society for Neuroscience meeting. Anesthesia's addiction problem. Science 306:1126, 2004; Wass
CT et al: Recruitment of house staff into anesthesiology: a re-evaluation of factors responsible for house staff selecting anesthesiology
as a career and individual training program. J Clin Anesth 15:289, 2003; Weinger MB et al: An objective
methodology for task analysis and workload assessment in anesthesia providers. Anesthesiology 80:77, 1994; Weinger
MB et al: Multiple measures of anesthesia workload during teaching and nonteaching cases. Anesth Analg 98:1419, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Drs. Seaberg and Weinger spoke in San Diego at Anesthesiology Update 2005, held January 5-8, 2005, and sponsored
by the University of California, San Diego, School of Medicine. The Audio-Digest Foundation thanks the speakers
and the sponsor for their cooperation in the production of this program.
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