Chemical Dependency Treatment Outcomes of Residents in Anesthesiology: Results of a Survey

Chemical Dependency Treatment Outcomes of Residents in Anesthesiology: Results of a Survey Gregory B. Collins, MD, Mark S. McAllister, MD, Mark Jensen, DO, and Timothy A. Gooden, MD Alcohol and Drug Recovery Center, Department of Psychiatry and Psychology, Cleveland Clinic Foundation/P48, Cleveland, Ohio Substance abuse is a potentially lethal occupational hazard confronting anesthesiology residents. We present the results of a survey sent to all United States anesthesiology training programs regarding experience with and outcomes of chemically dependent residents from 1991 to 2001. The response rate was 66%. Eighty percent reported experience with impaired residents and 19% reported at least one pretreatment fatality. Despite this familiarity, few programs required preemployment drug testing or used substance abuse screening tools during interviews. The majority of impaired residents attempted reentry into anesthesiology after treatment. Only 46% of these were successful in completion of anesthesiology residency. Eventually, 40% of residents who underwent treatment and returned to medical training entered another specialty. The mortality rate for the remaining anesthesiology residents was 9%. Long-term outcome was reported for 93% of all treated residents. Of these, 56% were successful in some specialty of medicine at the end of the survey period. We hypothesize that specialty change afforded substantial improvement in the overall success rate and avoided significant mortality. Redirection of rehabilitated residents into lower-risk specialties may allow a larger number to achieve successful medical careers. (Anesth Analg 2005;101:1457 62) Substance abuse disorders among physicians are a major health and societal concern. Up to 14% of all physicians become chemically dependent at some point in their careers (1 3). Anesthesiology appears to be the specialty with the largest percentage of impaired physicians (4,5). Despite constituting 4% of the United States physician population, anesthesiologists represent up to 13% of physicians treated for chemical dependency (1,4). Anesthesiology residents endure substantial risk, as the largest morbidity and mortality from substance abuse in physicians occurs within the first 5 yr after medical school (6). Substance abuse among anesthesiology residents is now well recognized. Talbott et al. (4) reported that while anesthesiology residents represented only 4.6% of the US resident physician population at the time of their study, 33.7% of all residents presenting to the Medical Accepted for publication May 12, 2005. Address correspondence and reprint requests to Gregory B. Collins, MD, Section Head, Alcohol and Drug Recovery Center, Department of Psychiatry and Psychology, Cleveland Clinic Foundation/P48, 9500 Euclid Avenue, Cleveland, OH 44195. Address e-mail to colling@ccf.org. DOI: 10.1213/01.ANE.0000180837.78169.04 Association of Georgia s Impaired Physicians Program were residents training in anesthesia. Only a few studies have examined treatment outcomes and the feasibility of reentry into anesthesia training by impaired residents. In general, these studies have produced conflicting results. A survey of residency program directors in 1989 found that the rate of successful reentry into anesthesia residency, as defined by completion of training without relapse after rehabilitation, was only 34% for parenteral opiateabusing residents compared to 70% for non-opiate abusers (7). Twenty-six deaths were reported, with over half of these occurring as a consequence of relapse. Twenty-five percent of the parenteral opiate abusers who relapsed died as a result. The authors concluded that reentry of the parenteral opiateabusing resident into training, with the expectation that two thirds will relapse and one in four of these will die, represents too large a risk for all involved. They suggested that redirection into another specialty may be the most prudent course of action. Less discouraging outcomes have been observed by others. A 1999 report found no significant difference in the rate of sustained recovery, defined as longer than 2 yr of abstinence, between impaired anesthesiologists (41% of whom were residents) and randomly selected 2005 by the International Anesthesia Research Society 0003-2999/05 Anesth Analg 2005;101:1457 62 1457

1458 ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH COLLINS ET AL. ANESTH ANALG TREATMENT OUTCOMES OF IMPAIRED RESIDENTS 2005;101:1457 62 impaired physician controls (81.3% and 86.1%, respectively) over a 12-yr period (8). Similar relapse rates were noted as well (40.6% versus 44.6%, respectively). Rates of sustained recovery and relapse for the subset of anesthesiology residents did not differ significantly from the parent or control groups (88.9% and 38.5%, respectively). The authors noted that anesthesiologists were encouraged to change specialty more frequently than controls. In an earlier report, similar rates of sustained abstinence were found among anesthesiologists and physicians of other specialties (69% and 73%, respectively) referred to the California Physicians Diversion Program (9). More than half of the successfully treated anesthesiologists were parenteral opiate abusers. Although only six residents were studied, four eventually did well and the remaining two were still enrolled at study completion. The authors did not consider a single relapse as a treatment failure, noting that it often served as a stepping stone towards long-term recovery. Both reports concluded that recovery rates for reentering anesthesiology professionals are similar to their medical counterparts. These reports suggest improved outcomes based on the trend towards highly structured monitoring and long-term follow-up of recovering physicians. Outcomes for anesthesiology residents were not the primary focus of these studies. Therefore, we conducted a nationwide survey of anesthesiology residency programs to examine current treatment outcomes, feasibility of successful reentry, and long-term career stability of these individuals. Methods An anonymous 20-question survey (Appendix) was developed to obtain data regarding the extent of substance abuse in anesthesiology residents, treatment outcome, and the existence of specific substance abuse policies from 1991 to 2001. There were 176 anesthesiology residency training programs identified using the American Medical Association (n 160) and American Osteopathic Association (n 16) graduate medical education registries as of January 2001. In August 2001, a copy of the survey and a cover letter, along with a self-addressed stamped envelope, were sent to each residency program director. In September 2001, a second letter was sent to increase compliance. All returned surveys were reviewed and scored by hand. Data were compiled and analyzed with Origin 6.1 (OriginLab Corporation, Northampton, MA). Continuous variables were described as mean sd, and categorical variables were described with frequencies and percentages. Results Of the 176 residency programs initially identified, 7 no longer existed. Responses were received from 111 of the 169 active programs yielding a response rate of 66%. The duration of program directorship ranged from 1 yr to 30 yr, with a mean of 7.1 6.2 yr. One-hundred-ten responding programs provided current resident roster data at the time of survey completion, yielding an active population of 3569 active residents. The first part of the survey elicited responses regarding the use of proactive substance abuse screening in the resident selection process as well as preemployment urine toxicology testing. Among the 111 responding programs, 18 (16%) routinely performed substance abuse screening in the selection process and 17 (15%) required pre-employment urine toxicology testing. Once having identified a resident as potentially impaired, 92% of responding programs initiate evaluation and treatment. Three fourths of the responding programs have some form of on-site chemical dependency treatment and monitoring. The second portion of the survey investigated training program experience with chemically dependent residents. At least one fatality before intervention, manifest as either drug overdose or suicide, was reported by 21 (19%) of the program directors. Eighty percent of the responding programs identified at least one resident as chemically dependent within the period from 1991 to 2001. A total of 230 cases of impairment were reported from the 111 responding programs, giving an average of 2.1 1.8 residents per program over the 10-yr reporting period. Among the 230 residents identified, 199 received treatment within the reporting interval and 31 were enrolled in an active treatment program at the time of completion of the survey. Thus, the prevalence of known active chemical dependency in anesthesiology residents among the reporting programs was 0.87% (31/3569). The final portion of the survey ascertained the outcome of rehabilitation of impaired residents, as evidenced by reentry into medicine and specialty pursuit, level of career attainment, and long-term well-being. A flow chart demonstrating the ultimate outcome of all treated residents is shown in Figure 1. Among the 199 residents receiving treatment, 32 (16%) left medicine entirely, whereas 167 (84%) continued to pursue postgraduate training after rehabilitation. Of those remaining in medicine, 153 (92%) initially returned to anesthesia whereas 14 (8%) pursued a different specialty. The distribution of initial career pursuit among all individuals after rehabilitation is depicted in Figure 2. Of those returning to residency in anesthesia, 127 (83%) were allowed to return to their original residency program and the remaining 26 (17%) residents

ANESTH ANALG ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH COLLINS ET AL. 1459 2005;101:1457 62 TREATMENT OUTCOMES OF IMPAIRED RESIDENTS Figure 1. Ultimate outcome of 199 impaired anesthesiology residents after chemical dependency treatment. Figure 3. Distribution of career pursuit in the 199 chemically dependent anesthesiology residents at the end of the survey period. Less than half of all treated residents were successful in completing anesthesiology training and there was significant associated mortality. Those who chose a different specialty immediately after treatment (early group) were followed by a significant proportion that left anesthesia after an initial attempt to return (late group). Figure 2. Distribution of career pursuit in the 199 chemically dependent anesthesiology residents immediately after rehabilitation. The majority of residents who remained in medicine after treatment attempted to return to anesthesiology training. transferred to a different program. Eventually, however, 53 of the cohort of 153 reentering anesthesiology residents also pursued a different specialty. Therefore, 67 of the 167 (40%) residents who returned to medicine after treatment ultimately trained in a different specialty. Of the 199 chemically dependent residents who completed treatment, at the time of survey completion only 91 (46%) successfully reentered and completed training in anesthesia. Six of the residency programs reported 9 relapse-related fatalities. The distribution of ultimate career pursuit among all treated individuals is shown in Figure 3. Finally, the surveyed residency programs were asked to identify the number of successfully treated residents who were in stable recovery and actively practicing in any medical specialty at the time of survey completion. Responses were received from 101 (91%) of the 111 programs completing the survey covering 185 (93%) of the original cohort of 199 treated residents. Among this group, 104 (56%) were chemically abstinent and professionally stable in any medical specialty after completion of residency training. Discussion We performed this study to determine if improvement has been made in the treatment outcomes of residents in anesthesiology compared with earlier studies (5,7). Previous surveys of anesthesiology residency programs have documented that most programs have experience with chemically dependent residents. Our finding that 80% of responding programs have had at least one impaired trainee is the largest reported percentage. Published incidences of impairment among anesthesiologists in the US over the past 3 decades range between 1% and 2% (1,10,11). The results of our survey demonstrated an average of just over 2 residents per reporting program being identified as chemically dependent over the 10-year period. Despite recommendations for substance abuse policies (12) and narcotic control systems (13) in anesthesia departments across the country, chemical impairment remains a major occupational hazard. Although the focus of many reports has been on the increasing recognition of substance abuse among anesthesiology professionals, no recent reports have examined the long-term impact of rehabilitation, particularly concerning successful reentry of residents into training. The most recent report on this topic included only 13 residents (8). Our results indicate that 92% (153/167) of those returning to medicine after treatment for chemical dependency attempted to resume their training in anesthesia, with 83% (127/153) of those returning to their original residency program. Previous reports have demonstrated that 61% to 83% of anesthesiology professionals similarly attempt to

1460 ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH COLLINS ET AL. ANESTH ANALG TREATMENT OUTCOMES OF IMPAIRED RESIDENTS 2005;101:1457 62 reenter anesthesia (5,7 9). We did not attempt to determine how many of these individuals were counseled regarding redirection into another specialty. It has been our institutional experience that most residents do return to their original program, as it offers the path of least resistance in terms of familiarity and avoidance of the stigma a history of substance abuse may bring when reapplying for training positions in a different specialty. Only 59% (91/153) of those returning to residency in anesthesia were ultimately successful in completing training. This equates to a failure rate of approximately 40%. We were unable to determine from our data how many individuals relapsed after resuming anesthesia training, but six programs reported at least one relapse-related death. Only 42% of chemically dependent anesthesiology residents overall were successful in completing training in a previously mentioned report (7). Moreover, 14% of all reentrants in this report died as a result of relapse. Equally discouraging was a similar survey of anesthesiology training programs in Australia and New Zealand, which revealed that only one of 13 impaired trainees ultimately completed residency, although follow-up data in this study were limited (14) We were able to gather long-term data on 93% (185/199) of the study residents and we found that 56% (104/185) of these who underwent rehabilitation and returned to medicine were doing well in the practice of any specialty at the end of the survey period. We were unable to determine what proportion of these 104 individuals were successful in anesthesiology. However, the loss of 16% (32/199) of treated residents who leave medicine entirely after treatment is cause for concern. Perhaps this reflects a flawed selection process for students entering medical training. The additional loss of 67 of the 167 remaining trainees who left anesthesia for other specialties either immediately or subsequent to an initial attempt at reentry likely reflects the difficulty in returning successfully to anesthesiology training. Finally, the substance-related deaths of 9 of the remaining 100 anesthesiology residents after treatment is a grim reminder of the risks and mortal consequences of an ill-advised return to the specialty. It is likely that such mortality could be decreased or avoided with redirection to lower risk specialties. Very few anesthesiology programs were found to perform screening for substance abuse during the resident selection process (16%) or pre-employment toxicology testing (15%) of new house staff hires. This was surprising considering both the increased overall awareness of physician impairment and the higher risk of development of chemical dependency attributed to the practice of anesthesia. Of particular concern are the observations of Talbott et al. (4) and Gallegos et al. (15) that anesthesiology residents undergoing treatment for dependency cited drug availability as a major determinant of their choice of career. Both suggested that preventative measures against addiction should be implemented earlier, i.e., during the resident selection process. According to a survey of academic anesthesiology programs, current efforts to reduce controlled substance abuse, namely increased mandatory education and tighter narcotic accounting procedures, appear largely ineffective (10). Detection of the impaired resident is frequently difficult. Rarely are these individuals caught red handed. A number of observational signs have been suggested as suspicious for substance use among anesthesia providers (1). Unfortunately, a conspiracy of silence often exists despite observance of these workplace symptoms. Moreover, addicted individuals are extremely unlikely to admit to their abuse. Although the addition of focused substance abuse screening and toxicology testing to the resident selection process does not constitute foolproof mechanisms for prevention, in light of the potential devastating consequences, additional means of early detection with the purpose of cautioning those at risk are warranted. The Association of Program Directors of Internal Medicine suggests that pre-employment drug testing provides a clear deterrent to addicted individuals from entering programs where such screening is mandated (16). Currently, no studies have examined the impact of pre-employment drug testing on the incidence of resident substance abuse. Selection of high-risk individuals into anesthesiology residency programs may have contributed to the observed persistence in the rate of substance abuse. In a longitudinal study of a single midwestern medical school class, validated screening tools were used to assess the degree of substance abuse among these students (17). Approximately 20% of the students interviewed during their fourth year of medical school met the criteria for substance abuse or dependence in the 12 months before the interview. The development of prevention strategies for the anesthesiology profession should consider the use of similar risk assessment tools during the resident selection process. Indeed, others have cited risk factors, including a family history of chemical dependency and substance abuse (particularly marijuana) at an early age, as significant predictors of future substance abuse in residents (17,18). These factors, combined with the occupational stress and the ready availability of potent narcotics, may produce an extremely high-risk environment for predisposed individuals. Although the results of such screening instruments should not be used as absolute indications for denial or acceptance into training, we believe that broader use of these tools may prove

ANESTH ANALG ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH COLLINS ET AL. 1461 2005;101:1457 62 TREATMENT OUTCOMES OF IMPAIRED RESIDENTS useful in discouraging high-risk individuals and augmenting overall substance abuse prevention in this population. Finally, we suggest that redirection of the recovering anesthesiology resident into other specialties of medicine by rehabilitation providers may be an important step in the management of these individuals. As a provider approved by the state licensing board, our institution receives many impaired physician referrals. It is generally our practice to recommend specialty change to anesthesia residents because of the frequent recidivism rate. As our survey demonstrates, however, most do choose to return to anesthesia. Based on personal accounts of those we have treated, including that from one of the authors, the temptation encountered on returning to the candy store often makes continuing in anesthesia a futile endeavor despite structured monitoring and follow-up. Those who do change specialty based on recommendation often demonstrate greater insight into their disease. Although we do not suggest that relapse necessarily foretells long-term failure, it has been shown, in this report and others, that in the setting of reentry into anesthesia, relapse is associated with significant mortality. Relapse is most common in the early period of recovery. Therefore, it would seem imprudent to place the newly recovering resident back into a stressful operating room environment where potent narcotics are readily available. It is clear that prospective studies are needed to assess novel prevention strategies as well as the success of impaired resident reentry in terms of continued abstinence, completion of residency training, and long-term career stability. Some limitations to this study deserve mention. First, this retrospective study relies completely on the recall of 10 years of data, a period longer than the average tenure of the respondents. To facilitate this and the overall compliance, our survey instrument was designed to be brief and general. Given an average of just over 2 impaired residents per reporting program and the often notable nature of these cases, it is likely that if surveys were returned, they were indeed accurate. On the other hand, many details of the individual, the rehabilitation, and the residency that may have influenced the outcome were not solicited. Second, to what extent the data reflect the true magnitude of the problem and the true population at risk is a point of concern. As mentioned, detection of these individuals is often difficult and delayed, with a significant proportion undiscovered until after training. In this regard, the true scope of the problem may be understated. Conversely, over-representation of the problem may have occurred because a significant proportion of the true population at risk was not represented based on our response rate. One reason for lack of response may be the absence of the perceived target data on behalf of the nonrespondents. Despite nearly 30 years of increased awareness, education and monitoring of controlled substances, as well as the treatment of affected individuals, our survey suggests that little progress has been made in improving the prevalence, mortality, or feasibility of successful reentry of impaired anesthesiology residents. Increased use of substance abuse screening of prospective house staff coupled with pre-employment drug testing may allow for identification of high-risk individuals and, where appropriate, direction into other fields of medicine. The effectiveness of such measures should be the topic of future research. Present strategies of monitoring and aftercare, intensive counseling and mandatory self-help meetings have not lead to improved outcomes. Our data would support a more proactive approach. Appendix Text of the survey that was sent to the directors of all United States anesthesiology residency programs in August and September 2001. Please answer the following questions in regards to the past TEN years (1991 2001): 1. How many years have you served as residency program director? 2. What is the total number of residents in your residency program? 3. On average, how many residents graduate per year? 4. Are standardized tools or other forms of assessment for chemical dependency in individuals utilized during your residency candidate interviewing process? 5. Does your program require urine drug testing of residency candidates prior to acceptance? Prior to employment? 6. In the past 10 years, how many residents in your program have been identified as chemically dependent? (Including alcohol, street drugs, anesthesia and prescription medications) 7. How many of those residents identified as chemically dependent received evaluation and treatment? 8. How many residents are currently undergoing chemical dependency treatment or monitoring? 9. How many substance-related fatalities or suicides have there been among residents in your program prior to intervention/treatment for substance abuse? Following treatment? 10. Do residents in your program unconditionally receive treatment if found to be substance abusers? 11. Do residents receive continued benefits while undergoing treatment for chemical dependency in terms of: Continued salary? Y/N Time off for treatment? Y/N Reentry assurance? Y/N

1462 ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH COLLINS ET AL. ANESTH ANALG TREATMENT OUTCOMES OF IMPAIRED RESIDENTS 2005;101:1457 62 12. Does your institution have a chemical dependency treatment and monitoring program for residents in place? Is it on site? 13. Of those residents receiving treatment, how many were allowed to return to your training program? 14. Of those residents receiving treatment, how many successfully completed your training program? 15. Of those residents receiving treatment, how many returned to a different anesthesiology residency program? 16. Of those residents receiving treatment, how many left medicine completely? 17. Of those residents receiving treatment, how many immediately left anesthesiology for another specialty of medicine? 18. Of those residents receiving treatment, how many initially returned to anesthesiology but subsequently left for another specialty? 19. Of those former residents receiving treatment, how many are currently doing well in practice in any specialty of medicine? 20. How many residents were arrested? Convicted? Jailed? References 1. Farley WJ. Addiction and the anaesthesia resident. Can J Anaesth 1992;39:R11 3. 2. Farley WJ, Talbott GD. Anesthesiology and addiction. Anesth Analg 1983;62:465 6. 3. Herrington RE. The impaired physician-recognition, diagnosis, and treatment. Wisc Med J 1979;78:21 3. 4. Talbott GD, Gallegos KV, Wilson PO, Porter TL. The Medical Association of Georgia s Impaired Physician s Program. Review of the first 1000 physicians: analysis of specialty. JAMA 1987; 257:2927 30. 5. Ward CF, Ward GC, Saidman LJ. Drug abuse in anesthesia training programs. A survey: 1970 through 1980. JAMA 1983; 250:922 5. 6. Alexander BH, Checkoway H, Nagahama SI, Domino KB. Cause-specific mortality risks of anesthesiologists. Anesthesiology 2000;93:922 30. 7. Menk EJ, Baumgarten RK, Kingsley CP, et al. Success of reentry into anesthesiology training programs by residents with a history of substance abuse. JAMA 1990;263:3060 2. 8. Paris RT, Canavan DI. Physician substance abuse impairment: anesthesiologist vs. other specialties. J Addict Dis 1999;18:1 7. 9. Pelton C, Ikeda RM. The California Physicians Diversion Program s experience with recovering anesthesiologists. J Psychoactive Drugs 1991;23:427 31. 10. Gravenstein JS, Kory WP, Marks RG. Drug abuse by anesthesia personnel. Anesth Analg 1983;62:467 72. 11. Booth JV, Grossman D, Moore J, et al. Substance abuse among physicians: a survey of academic anesthesiology programs. Anesth Analg 2002;95:1024 30. 12. Lecky JH, Aukburg SJ, Conahan TJ 3rd, et al. A departmental policy addressing chemical substance abuse. Anesthesiology 1986;65:414 7. 13. Adler GR, Potts FE 3rd, Kirby RR, et al. Narcotics control in anesthesia training. JAMA 1985;253:3133 6. 14. Weeks AM, Buckland MR, Morgan EB, Myles PS. Chemical dependence in anaesthetic registrars in Australia and New Zealand. Anaesth Intensive Care 1993;21:151 5. 15. Gallegos KV, Browne CH, Veit FW, Talbott GD. Addiction in anesthesiologists: drug access and patterns of substance abuse. QRB Qual Rev Bull 1988;14:116 22. 16. Aach RD, Girard DE, Humphrey H, et al. Alcohol and other substance abuse and impairment among physicians in residency training. Ann Int Med 1992;116:245 54. 17. Flaherty JA, Richman JA. Substance use and addiction among medical students, residents, and physicians. Psych Clin N Amer 1993;16:189 97. 18. Yarborough WH. Substance use disorders in physician training programs. J Oklahoma State Med Assoc 1999;92:504 7.