The Healthy Anesthesiologist

1. Introduction

Anesthesiologists have an ethical duty to strive to stay healthy. The Canadian Medical Association’s Code of Ethics1 states that a physician has "Responsibilities to Oneself", namely:

10. Promote and maintain your own health and well-being.

53. Seek help from colleagues and appropriately qualified professionals for personal problems that might adversely affect your service to patients, society or the profession.

54. Protect and enhance your own health and well-being by identifying those stress factors in your professional and personal lives that can be managed by developing and practicing appropriate coping strategies.

The American Society of Anesthesiologists’ Guidelines for the Ethical Practice of Anesthesiology2 states:

IV. Anesthesiologists have ethical responsibilities to themselves.

1. The achievement and maintenance of competence and skill in the specialty is the primary professional duty of all anesthesiologists. This responsibility does not end with completion of residency training or certification by the American Board of Anesthesiology.

2. The practice of quality anesthesia care requires that anesthesiologists maintain their physical and mental health and special sensory capabilities. If in doubt about their health, then anesthesiologists should seek medical evaluation and care. During this period of evaluation or treatment, anesthesiologists should modify or cease their practice.

All physicians experience occupation-related stress to some degree; however, this may be particularly significant for anesthesiologists3. The provision of anesthesia has become safer over the years, and the public expects a successful outcome even though many patients undergoing anesthesia are older, sicker, and subjected to more and more complex procedures than in the past. Anesthesiologists practice in a high-stress environment, with multiple demands from patients, families, other physicians, co-workers, and administrators.

The practice of anesthesiology is characterized by the motto of the Canadian Anesthesiologists’ Society – "Science, Vigilance, Compassion". The anesthesiologist of the 21st century is expected to be up-to-date on the latest literature and practice evidence based medicine, to be vigilant at all times when a patient is under his/her care, and to maintain a compassionate demeanor throughout – no small demands on any human being. The anesthesiologist is also subjected to additional stressors – such as long and unpredictable working hours, minimal relief breaks, exposure to chemical and radiation hazards, noise pollution, and a lack of natural light.

One area of potential stress for anesthesiologists, fortunately rare, is the occurrence of a death or other catastrophic event while the patient is under the care of the anesthesiologist. This is particularly stressful when the event is unexpected and the patient was previously healthy. Anesthesiologists may handle such crises in a variety of ways. The training of the anesthesiologist includes the medical aspects of these situations (resuscitation, invasive procedures, etc.), but may not prepare the anesthesiologist for the emotional stress that ensues. All too frequently the impact of these events become internalized by the anesthesiologist4, and may lead to long term sequelae, such as anxiety or depression. In many institutions there are limited systems in place to support the anesthesiologist, either immediately, or in the longer term.

Fatigue is a major issue for anesthesiologists. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) states that: "Every anaesthetist carries a personal obligation to provide a safe and effective service and should be aware of the problem of fatigue" 5. Many comparisons have been drawn over the years between the practice of anesthesiology and the airline industry, but, unlike pilots, there has been no standardized approach to limit the number of working hours of anesthesiologists. In Canada, legislation restricts the number of hours that pilots and truck drivers may work, but no such law exists for physicians. For the present, it is up to the individual anesthesiologist, supported by his department and institution, to ensure that he/she is able to work without undue fatigue.

Anesthesiologists, like everyone, get older inevitably bringing on a diminution of faculties ­– physical, mental, and special sensory. This may be counterbalanced to some degree by the wisdom that comes with experience. There is much variation between individuals in the ageing process. Furthermore, a senior anesthesiologist may be highly capable of functioning in some arenas, e.g. elective anesthesia or education, yet be excessively stressed in others, e.g. managing the 2 a.m. ruptured aortic aneurysm. The AAGBI recommends that: "there should be a review of on-call responsibilities for anaesthetists over 55 years of age" 5.

Anesthesiologists are at particular risk for certain illnesses. They are more prone to addictions and suicide than other physicians 6-10. They represent about 3% of physicians, yet they account for 20 – 30% of drug-addicted physicians4. The addiction rate in anesthesiologists and other anesthesia providers (e.g. CRNAs) has been estimated in the 10 – 20% range8. Compared with internists, anesthesiologists have been shown to have a higher incidence of suicide (RR 1.45)7.

The ethical responsibilities to promote and maintain the health of anesthesiologists can be considered in three main areas: personal responsibilities, institutional responsibilities, and individual responsibilities towards other healthcare workers, trainees and colleagues.

2. Personal Responsibilities of the Anesthesiologist

The ethical requirement to promote and maintain one’s own health and well-being must address physical, mental, and emotional health. The anesthesiologist should strive to stay healthy, but most will be faced with health and wellness challenges over many years in practice. As noted, anesthesiologists are particularly prone to stress in the workplace, are subject to fatigue, and are at higher risk for addictions and suicide.

Anesthesiologists should:

2.1. be aware of the general and specific health issues that may impact their professional life.

2.2. be aware of their own issues with health and wellbeing.

2.3. seek appropriate help if concerned about their own physical, mental, emotional, or special sensory health.

2.4. be particularly aware of the issue of fatigue, and if this is leading to unsafe practice, this should be addressed with the department and institution.

2.5. avoid commitment to such a quantity of clinical work that they are affected by excessive fatigue.

2.6. agree to limit or modify their practice if patients or co-workers are being placed at risk until significant personal health care issues are resolved.

2.7. maintain adequate disability insurance so that they may attend to personal health or wellbeing without major financial penalty.

3. Responsibilities of the Institution

For the purposes of this document, the term "Institution" refers to the Health Authority, Hospital, Faculty and/or Departmental Administration that has jurisdiction over the provision of anesthesia and the practice of anesthesiologists.

It is recognized that there are other authorities, such as regulatory authorities, that have jurisdiction over the anesthesiologist and that have a stake in promoting physician wellness.

 Institutions have multiple responsibilities relating to anesthesia and the practice of anesthesiologists. First and foremost, they have a duty to ensure that anesthesia is delivered in a safe, ethical and caring fashion. All of these elements may be influenced by the health and wellbeing of the anesthesiologist, and all are essential. For example, an anesthesiologist capable of delivering safe anesthesia, but who, as a result of personal stresses, is consistently rude to patients and disruptive to co-workers is not acceptable.

Institutions also have responsibilities to their employees and to the anesthesiologists that practice in their facilities. In particular, the institution has a duty to promote a healthy work environment. With very rare exceptions, support must be provided to anesthesiologists and other employees who seek help with health and wellness issues.

3.1. Institutions should have a formal policy and approach to promoting wellness of physicians, that takes into account the special needs of different practitioners, including anesthesiologists.

3.2. Institutions should be supportive of any anesthesiologist who seeks help with health or wellness issues, whether they be physical, mental, or emotional.

3.3. Institutions should have a formal policy addressing alcohol and drug abuse amongst employees and physicians, including anesthesiologists.

3.4. Anesthesiologists seeking support or help from the institution should be treated in a confidential manner.

3.5. Institutions should refer the support of the unwell anesthesiologist to another agency, such as a physician support group administered by a provincial medical association.

3.6. Notwithstanding the above, institutions should consider the safety of patients and staff as their first priority, and may be required to place limits on the practice of an anesthesiologist until the health issue has been resolved.

3.7. Institutions should not be obliged to continue to support an anesthesiologist who consistently declines to seek help with a well-documented health or wellness problem that is preventing consistent delivery of safe, ethical, and caring anesthesia.

3.8. A healthy work environment for anesthesiologists should be supported by institutional policies, e.g. by the provision of adequate rest breaks, availability of healthy nutrition, provision of comfortable on-call sleep rooms , and an on-call schedule that does not lead to excessive fatigue.

3.9. Institutions should have a protocol in place to support staff, physicians, and anesthesiologists who are involved in the care of patients who die or experience some other catastrophic event in the operating room or related areas.

3.10. Institutions should provide a flexible working schedule for anesthesiologists, that takes into account the physiological stresses that affect anesthesiologists of different ages.

3.11. Anesthesiologists with disabilities who are able to function safely and effectively within a defined scope of practice should be supported by the institution.

4. Individual Responsibilities towards Health Care Workers, Trainees, and Colleagues

Many of the above recommendations apply to other health care workers, trainees, and colleagues. The ethical anesthesiologist has a role in helping such individuals who have significant health or wellness problems that are impacting the safe, ethical, and caring delivery of medical services to patients. The American Society of Anesthesiologists states2:

II. Anesthesiologists have ethical responsibilities to medical colleagues.

4. Anesthesiologists should advise colleagues whose ability to practice medicine becomes temporarily or permanently impaired to appropriately modify or discontinue their practice. They should assist, to the extent of their own abilities, with the re-education or rehabilitation of a colleague who is returning to practice.

Anesthesiologists are not, with a few exceptions, experts in providing the care that a colleague with health or wellness issues may require. They do have a role, however, in being aware of these concerns as they may relate to a colleague, in encouraging the colleague to seek appropriate help, in reporting unsafe conditions, and in supporting a colleague who is in a recovery phase from an illness or wellness issue.

4.1. Anesthesiologists should be broadly aware of the warning signs of significant illness, addiction, or excessive stress in a health care worker, trainee, or colleague.

4.2. Anesthesiologists should approach a colleague if seriously concerned about health or wellness. The colleague should be encouraged to seek help and advice from an appropriate source.

4.3. Notwithstanding the above, if the anesthesiologist is aware that patients and/or staff are being placed at risk, there is a duty to report such conditions to the appropriate authority, such as a Department Head.

4.4. For other health care workers and trainees, such concerns are often best addressed by communication between the Department Head of Anesthesia and the appropriate authority (e.g. residency training coordinator).

4.5. Anesthesiologists should be supportive of health care workers, trainees, or colleagues who have sought help with a health or wellness problem, and are recovering, or undergoing treatment or rehabilitation for that problem.

4.6. Anesthesiologists should respect the confidentiality of health care workers, trainees, or colleagues who have health or wellness issues.

5. References

  1. http://policybase.cma.ca/PolicyPDF/PD04-06.pdf
  2. http://www.asahq.org/publicationsAndServices/standards/10.pdf (N/A)
  3. Jackson SH. The role of stress in anaesthetists' health and well-being. Acta Anaesthesiol Scand 1999; 43: 583-602.
  4. Soto RG, Rosen GP. Pediatric death: guidelines for the grieving anesthesiologist. J Clin Anesth 2003; 15: 275-7.
  5. http://www.aagbi.org/publications/guidelines/docs/webversionfatigue04.doc
  6. Lutsky I, Hopwood M, Abram SE, Jacobson GR, Haddox JD, Kampine JP. Psychoactive substance use among American anesthesiologists: a 30-year retrospective study. Can J Anaesth 1993; 40: 915-21.
  7. Alexander BH, Checkoway H, Nagahama SI, Domino KB. Cause-specific mortality risks of anesthesiologists. Anesthesiology 2000; 93: 922-30.
  8. Luck S, Hedrick J. The alarming trend of substance abuse in anesthesia providers. J Perianesth Nurs 2004; 19: 308-11.
  9. Taub S, Morin K, Goldrich MS, Ray P, Benjamin R; Council on Ethical and Judicial Affairs of the American Medical Association. Physician health and wellness. Occup Med 2006; 56: 77-82.
  10. http://www.aagbi.org/publications/guidelines/archive/docs/drugabuse.pdf