The Facts on Substance Abuse in Anesthesiology

In the April 2005 ASA NEWSLETTER, Michael Scott, J.D., provided an excellent and timely report on the complex issue of legal aspects of drug testing. However, a few points need some clarification. Mr. Scott states that anesthesiologists and anesthesiology residents are “among those at greater risk to become chemically dependent on alcohol or drugs.”¹ There is no evidence that anesthesiologists are at greater risk of becoming dependent on alcohol than physicians in other specialties of medicine.²

The author mentions a commonly cited observation that anesthesiologists are represented in drug addiction recovery programs at three times the percentage that anesthesiologists exist in the physician population. This higher percentage was observed in a few subspecialized, tertiary care, referral treatment programs in the early 1980s, not at “any given time” across all treatment facilities. Paris et al.³ reported that, in the New Jersey Physician Health Program, 6.1 percent of the physicians were anesthesiologists. An Illinois program reported that 4.6 percent of physicians in its study were anesthesiologists.⁴ Hughes et al.² found a prevalence of any abuse or dependence among anesthesiologists to be 7.8 percent, while that of emergency medicine physicians was 12.4 percent and psychiatrists 14.3 percent.

Mr. Scott discusses data from a study by Booth et al. stating that “almost 20 percent of chemically dependent anesthesiologists die or require resuscitation.” Booth reported that 18 percent of individuals died or almost died “before any substance abuse was suspected.” I suspect that in many of these cases, there were other symptoms prior to the identifying event. Another finding in Booth’s study, stating that 24 percent of faculty in anesthesiology residency programs did not receive any education on addiction in anesthesiologists, would partially explain how the diagnosis could be delayed or missed.

The article also touches on the very complicated issue of recidivism. The author states, “Among those addicted anesthesiologists who do not die, I understand, the recidivism rate is very high.” The results from 1995’s ASA COOHORP Study published an overall relapse rate of about 14 percent per year for residents and practitioners.⁶ This may be considered too high, but studies by the state physician monitoring programs for New Jersey² and California⁷ that follow physicians in all specialties for several years found that the “relapse rates” for anesthesiologists is not higher than for nonanesthesiologists.

Jerry S. Matsumura, M.D.
Reno, Nevada

References:
1. Scott M. Legal aspects of drug testing. ASA Newsl. 2005; 69(4):25-28.
2. Hughes PH, Storr CL, Brandenburg NA, et al. Physician substance use by medical specialty. J Addict Dis. 1999; 18:23-37.
3. Paris RT, Canavan DI. Physician substance abuse impairment: Anesthesiologists vs. other specialties. J Addict Dis. 1999; 18:1-7.
4. McGovern MP, Angres DH, Leon S. Characteristics of physicians presenting for assessment at a behavioral health center. J Addict Dis. 2000; 19:59-73.
5. Alexander BH, Checkoway H, Nagahama SI, Domino KB. Cause-specific mortality risks of anesthesiologists. Anesthesiology. 2000; 93:922-930.
6. Arnold WP. 1995 substance abuse survey in anesthesiology training programs: A brief summary. ASA Newsl. 1995; 59(10):12-13,18.
7. Pelton C, Ikeda RM. The California Physicians Diversion Program’s experience with recovering anesthesiologists. J of Psychoactive Drugs. 1991; 23:427-431.

Awakening Laryngospasm Debate in Pediatric Patients

This letter is in response to a comment made in the August 2005 ASA NEWSLETTER (letter to the editor titled “Laryngospasm: A Preventable Cause of Cardiac Arrest”) regarding laryngospasm as a preventable cause of cardiac arrest. The authors of this letter suggest that intravenous access should be obtained on all pediatric patients and, furthermore, should be obtained prior to induction of anesthesia. Their concerns were that this would reliably prevent cardiac arrest, as neuromuscular blockers could be readily given in case laryngospasm were to occur. 

I have two comments to make regarding this issue. As a practicing pediatric anesthesiologist for over eight years, I can attest that it is extremely rare to have such a severe laryngospasm in a patient where there is no intravenous (I.V.) access. The final point I want to state concerns the last comment made by the authors: “If our specialty is truly interested in minimizing the risks of anesthesia in all patients, is it not time to reassess the issue of intravenous access in pediatric anesthesia?” I wonder if the authors perform awake fiberoptic intubation in all of their patients, regardless of age, as to avoid that “can’t intubate, can’t ventilate” scenario that may occur after induction of general anesthesia.

Yashesh R. Savani, M.D.
Grand Rapids, Michigan

Reply to Dr. Savani From Drs. Norman and Daley

We agree entirely with the letter from Yashesh R. Savani, M.D., that laryngospasm leading to cardiac arrest is very rare. Indeed, cardiac arrest from any cause during an anesthetic is rare, and we anesthesiologists are privileged to work in a field with such good outcome rates. We must not, however, become complacent with these rates and should be continually striving to explore ways to improve the safety of anesthesia.

The real questions regarding this issue are: Will adequate intravenous (I.V.) access prevent cardiac arrest due to laryngospasm, and is it practical to obtain I.V. access on all pediatric patients? The answer to the first question is a definite “yes.” The answer to the second may be less clear. One needs to look at the reasons for avoiding or delaying (until after induction) I.V. access in pediatric patients and then decide if this outweighs the benefit. Having trained as residents at the major pediatric hospital in Canada, we have seen routine I.V. access pre-induction in action and know that it is both practical and acceptable.

If our own children were to undergo general anesthesia of any kind, we would insist on an I.V. being inserted prior to induction. Is it not better to stay out of trouble than to get out of trouble?

Peter H. Norman, M.D.
M. Denise Daley, M.D.
Houston, Texas

The Price of Privilege

The August 2005 “From the Crow’s Nest” describing ASA’s ongoing congressional lobbying efforts contained two incongruous statements that speak volumes about the current American political process. The first inspires a sense of national pride: “[W]e as individual citizens have the right to directly contact our representatives and express our opinions without penalty… a privilege that most of the world still dreams about.”

The second, however, revealed the repulsive reality about our current democratic process: “[M]oney in the form of contributions to campaigns… means access to politicians who will hear the message about an important issue.” The bottom line is that the Golden Rule — he who has the gold, makes the rules — is alive and well in American politics. This may explain why there are not more regulations unfavorable to anesthesiologists, yet there are over 45 million Americans without health insurance because they do not have the “means” to access their representatives. I feel privileged … do you?

Sam R. Sharar, M.D.
Seattle, Washington

Editor’s Note: As Dr. Sharar has noted the oft-quoted “Golden Rule” — he who has the gold rules — he has inadvertently given the best reason for contributing significantly to ASAPAC. It is our PAC’s contributions that often get the attention of the elected official, candidate or staffer who gives access for our message to be heard. If we don’t speak with our elected officials, more and more regulations will come down that adversely affect anesthesiology. Each year, each ASA member ought to write a check to the ASAPAC. I’ve written mine — Dr. Sharar, have you written yours?

— D.R.B.

Helping Pain Patients Bear Their Burden

“Men need the truth dinned into their ears over and over again.”

— Rene Laennec

I heartily support Stephen P. Long, M.D., on the issue of opioids (September ASA NEWSLETTER). The articulate landscape you put forth is indeed a remarkable journey of our collective failure to provide relief for the suffering.

From the early days of John J. Bonica, M.D., of beloved memory, we were and still are the guardians of the gates of pain.

Unfortunately, as Dr. Long clearly points out, we have been weakened on all sides.

The never-ending horde of referrals to pain clinics unfortunately reflects sadly on the lack of teaching and understanding of the patient in pain. The element of fear of “Big Brother” looking over their shoulders is without question a major incentive to be rid of the patient in pain.

Our hospice involvement over many years and the ongoing care of patients in pain could not have been accomplished without the beacons of knowledge and compassion. The tragedy of the pain patient reflects our mainstay of teaching over the past 40 years. The easiest pain to bear is someone else’s.

Keep up the good work, Stephen.

Sheldon L. Burchman, M.D.
Milwaukee, Wisconsin

One Vote for All

I must confess that I have come to anticipate the arrival of the ASA NEWSLETTER as it has become more interesting and informative. This impression was confirmed in the September 2005 issue when I read the announcement of the candidacy of 13 ASA members running for elected office. Evidently, August 1 was the deadline for those planning to run to announce their intention.

My joy was elicited as I remembered that about 10 years ago, I submitted a letter of concern noting that every November issue the portrait of the president-to-be appeared in page 2 of the NEWSLETTER announcing that he/she had moved from the president-elect to the presidency for the next 12 months. A short biography followed. On page 4, we were notified of who was to be the president-elect; an even shorter biography followed. The membership had not been informed how they stood on the issues that bewildered us then (some of which still remain a threat today). In other words, we knew very little how they performed in the administrative positions they held, nor was their intended agenda announced. I received some excuse, and my letter was never published.

If this information was given to the House of Delegates, they failed to pass it on to their respective state society memberships, in detail and before the election. The result has been that our presidents function as “responding executives,” only acting on the issues that threaten our practice, our Society or our position in the medical forum. Seldom have we heard “I am going to change this” or “I am going to look into that,” and only recently we heard, “I’m going to form a commission that will study … ” No platform or plan had been announced so the membership could make a selection of our leaders. This form of election and the lack of responsive representation have resulted in apathy among the membership and an undetermined number of anesthesiologists who deserted ASA.

We, the Membership, would like to:

• Have clarity and transparency in the organization’s functions;

• Change the electoral process;

• Hear from each of the candidates running for office, before the election, and hear what their position is in every issue that affects our practice;

• Know, in advance, what plans candidates have for their tenure; and

• Have one-member-one-vote.

Hopefully we will be able to elect the one candidate who has new ideas, original proposals and sound judgment while facing adversity with sufficient knowledge of the issues and able to express him/herself well enough to debate them with other candidates.

We not only want to know who is running, we also want to know why we should give him/her our vote. Using Internet communication, after posting the candidates’ profile, a debate can be conducted nationwide; some members could ask questions to them. Every active member could then vote, having been well-informed and without having to leave their homes. The democratic dream of one-member-one-vote will come true. May the best candidate win.

J. Antonio Aldrete, M.D.
Birmingham, Alabama

Miller Time

The article by R. Dennis Bastron, M.D., in the October 2005 ASA NEWSLETTER on “Albert Miller: Anesthesiology Pioneer,” evoked the words of the immortal Yogi Berra, “It’s like déjà vu all over again.”

It was some 53 years ago that my mentor, Meyer “Mike” Saklad, M.D., escorted me from the Rhode Island Hospital to the then Providence Lying-In Hospital to witness an anesthetic administered by this same Dr. Albert Miller for an emergency cesarean section. Despite the fact that a half century has elapsed, that scenario in time is as vivid today as then. There a 70-something-year-old physician demonstrated the use of his (unpatented!) Miller ether cone. With his head close to the patient’s ear, sotto voce, he induced anesthesia with no indication of the excitement phase we were accustomed to. The procedure continued to be uneventful, not the usual complaints from the surgeon about relaxation. The baby screamed at birth, and if we had had the Apgar Score available, it would have been at least a “10.”

At a meeting of the so-called “Friday Night Club,” Dr. Miller discussed his proposed use of “Constant Pressure Nitrous Oxide-Oxygen Anesthesia.” He subsequently used it successfully in a series of diaphragmatic hernias heralded in the press at the time as the “upside down stomach.”

One seldom finds reference to his many original anesthesia contributions, ranging from probably the first detailed anesthesia record to, and including, his description of the ascending intercostal muscle paralysis that develops as the depth of anesthesia increases.

The anesthesiologist of this era often found him/herself in the incongruous and frustrating position of, despite being at the head of the (operating) table, seldom receiving the respect or the recognition usually accorded this position. When Albert Miller sat at the head of the table, there was no question as to who was the “captain of the ship.”

Dr. Saklad, mentioned in the article, was one of the early directors of the American Board of Anesthesiology. He was a pioneer in respiratory physiology and developed a ventilator with the capability of supplying CPAP and PEEP.

One can only surmise that if both these men, these icons, had chosen that Mecca of Medicine, Boston, some 45 miles away, as their milieu of practice rather than the hinterlands of Providence and Fall River, their undertakings, their innovations, would not have been relegated to obscurity and antiquity.

Herbert Ebner, M.D.
Grand Cayman

Who Will Pay the Price for P4P? Our Patients

At the Annual Meeting in Atlanta, ASA leadership expressed its perceived obligation, despite reservations, to participate in the process to define performance targets for anesthesiologists to protect its members from being excluded from future positive updates to Medicare, as threatened by some in Congress. Many ASA members articulated a distrust of the motivations of those who have created this pay-for-performance (P4P) monster and see it as a misguided attempt by well-intentioned intellectuals and a brilliant strategy by savvy businessmen to reign in medical spending. P4P may well provide a ruse for Congress and/or the Centers for Medicare & Medicaid Services to institute essentially nonpayment for bureaucratic performance (“NP4BP”).

The Institute of Medicine has recognized the specialty of anesthesiology for its seminal contributions to patient safety. Medical liability insurers have corroborated this with their lowering the insurance risk class for the specialty. Despite all this, Medicare persists in treating our specialty egregiously concerning payment for services, both with a preposterously low conversion factor and an oppressive teaching rule. If we are treated like this in the face of recognition for our improved performance, until these evils have been redressed, how can we as a specialty possibly participate in Medicare P4P?

All around us there is discussion concerning P4P: in our hospitals, in our other medical societies, in our newspapers. It does not seem possible to push this evil genie back into the bottle, but we may and we must, if we make enough noise, change the framework of the debate concerning how P4P might be applied to our specialty. As the one specialty that has proven its commitment and success in improving performance, we need to demand that we lead the way: Give us the tools (i.e., the funding) to measure performance, allow ASA to mine the data in a scientific manner, and then have ASA set goals that facilitate patient care. We must refuse to take the intellectually dishonest route of producing check-off boxes that facilitate nothing except a justification for Medicare and then private insurers to pay less for what really may not be less at all. We must not abdicate our professional scientific responsibility to do what is logical, coherent and beneficial for our patients and our profession.

Moreover, Medicare is unique in prohibiting any payment (even payment to the patient) for noncontracting physician services. If payment for noncontracted commercial services is to be preserved, as it must be to prevent private insurers from just setting the payment rates (as they basically do in Massachusetts and other states that prohibit so called “balance billing”), consider what will happen if payments to physicians are reduced by P4P and patients are then left with a larger share of cost. There are repercussions here that go far beyond trying to include anesthesiologists in some nebulous future potential Medicare rate updates. This is so important that we must now contemplate, if we cannot derail this train and if we are unable to change its course, laying down on the tracks in a way that the American Medical Association will not and cannot do, when push comes to shove, because of its basic principles to protect patient access to care at all costs, no matter what.

Kenneth Y. Pauker, M.D.
Laguna Niguel, California

NEWSLETTER Editor Needs to Be More Agreeable

It is always wonderful to open the ASA NEWSLETTER each month and see your smiling face! But, increasingly, these “Ventilations” are becoming more and more difficult to read.

First, may I recommend a book to you? It is titled The Four Agreements, written by Don Miguel Ruiz. It is somewhat kitschy, but well meaning.

The first agreement: Be impeccable to your word.

The second agreement: Don’t take anything personally.

The third agreement: Don’t make assumptions.

The fourth agreement: Always do your best.

Now, I cannot tell you how these simple statements can be applied to your life, but I can tell you how they can be applied to your editorial in November 2005. First, the Chair of the SUNY at Buffalo Department of Anesthesiology (where we both trained), John I. Lauria, M.D., was a formidable presence both in and out of the operating room. No, he was not the author of any well-known texts of anesthesiology nor did he have a National Institutes of Health grant, but he took several independent, struggling, lackluster anesthesia programs within the city of Buffalo and combined them into a powerful training entity. He empowered every resident who trained in the program to not be a faceless entity at the head of the operating table. Believe me, no one then or since has referred to Dr. Lauria or myself as “Hey, Anesthesia.” John Lauria was and still is a true mentor to many of us who trained with him. Also our training program did have tenured professors, examiners for the ASA boards and a member of the Association of University Anesthesiologists. Even in the early to mid-1980s when we trained, graduates of our program were given all the tools they needed to become perioperative physicians.

That brings us to the third agreement … the assumption that anesthesia should always be on the lookout to expand its role in and outside of the operating room. Has anyone thought about the fact that the majority of anesthesiologists actually enjoy being in the operating room passing gas, left to the sole pursuit of caring for a single patient at a time? Frankly I never felt that I became an anesthesiologist to supervise nurse anesthetists or otherwise spend my day. A naïve thought, but what if anesthesiologists only delivered anesthesia themselves …would we then be on the lookout to grab another piece of the pie? Maybe the operating rooms would only run the amount of rooms that anesthesiologists themselves could cover.

Doug, I have known you since you began your residency in anesthesia. I know you always do your best and always have. I also know your heart is in the right place, but please take a look at The Four Agreements and see how you can apply it to all that you do!

Amy B. Alvarez, M.D.
Buffalo, New York

‘Hey, Anesthesia’ and Proud of It

I am writing in response to your “From the Crow’s Nest” in the November 2005 ASA NEWSLETTER. While anesthesiology does tend to be an anonymous specialty, I am not convinced that wholesale changes in our specialty are warranted merely to prevent being addressed as “Hey, Anesthesia.”

I was never referred to as “anesthesia” when I practiced primary care or as a hands-on anesthesiologist at a small community hospital. While I cannot say the same is true in my current academic anesthesiology position at the University of Pittsburgh, my experience as a comparatively high-profile physician in my past practice has made my current name, “anesthesia,” while not optimal, certainly tolerable.

The truth of the matter is that anesthesiologists tend to possess the following characteristics: an interest in short-term critical care, desire for immediate gratification as a result of our interventions, fondness of performing interventional procedures and enough self-assuredness so as not to require outside recognition for our abilities. These characteristics contribute to our being occasionally addressed in generic terms.

While I agree with the vision of Ronald D. Miller, M.D., of our specialty in managing the perioperative experience, and believe we should take a greater role in preoperative and postoperative care, I have not seen much interest in making the transition to hospitalist. The number of empty critical care anesthesiology slots speaks volumes.

The bottom line is that anesthesiology is a great profession as is: We perform an invaluable service that nobody else is remotely qualified to provide, we make a difference in our patients’ lives (whether they realize it or not), and we have colleagues who can competently carry on when we go home (a huge perk, although we are loathe to admit it). If occasionally being addressed as “Hey, Anesthesia” is the price we have to pay, I will pay it happily.

Joseph F. Talarico, D.O.
(a.k.a. Anesthesia)
Pittsburgh, Pennsylvania