SA members frequently contact the Committee on Occupational Health with questions related to disability. The concerns can be grouped into one of three general categories: 1) an anesthesiologist who has suffered an injury or illness and wants to return to practice; 2) an anesthesiologist with an established impairment who is seeking support in his/her attempt to receive disability insurance benefits; or 3) colleagues who are questioning whether an anesthesiologist with particular limitations should be permitted to continue practicing. These issues are invariably complex, and resolution frequently involves subjective determinations with profound personal, professional and societal ramifications.

What makes these issues even more challenging is that a condition that is disabling to an individual in one circumstance might be a mere inconvenience to another or even the same individual under different conditions. For example, to many in the general public, confinement to a wheelchair is the epitome of disability. Wheelchair users, however, do not frequently consider themselves disabled. Indeed several of the leaders in our own specialty have required wheelchairs for ambulation. Identification of an individual as disabled can be so contentious that final resolution requires a decision by the U.S. Supreme Court.

Definitions
Impairment is any loss, loss of use or derangement of any body part, organ system or organ function. An impairment is considered permanent once it has become stabilized with little chance of substantial change in the next year, with or without medical treatment.

Disability as defined by the Americans With Disabilities Act (ADA) (42 U.S.C. § 12101) is “a physical or mental impairment that substantially limits one or more major life activities of such individual; a record of such impairment; or being regarded as having such a condition.” Disabling conditions can be subdivided into those that arise from physical, mental, emotional, sensory or developmental etiologies. Some disabilities are congenital in origin, others acquired. Disabilities can have an acute onset, as occurs with injury or acute illness, or a more gradual, progressive onset, as occurs with many chronic diseases. Some are ultimately fatal while others do not affect life expectancy. Some disabling diseases elicit feelings of blame and stigmatization while others evoke compassion and sympathy.

Work disability is a specific subgroup in which employment problems resulting from health conditions impair the individual’s ability to perform a work role in a manner that is considered normal. The etiologic basis of work disability is a complex interaction between the characteristics of the individual and the work environment. A disabled physician (commonly referred to as an impaired physician) is one who is unable to practice medicine with reasonable skill and safety because of mental illness, a physical illness or condition, or the habitual or excessive use or abuse of alcohol or other substances that impair ability.

Legal Considerations: Disability is one of the protected classes under federal nondiscrimination law. The pertinent federal laws that directly bear on disability discrimination for anesthesiologists are the Rehabilitation Act of 1973 (29 U.S.C. § 794 et seq.) and the ADA.

The Rehabilitation Act prohibits covered employers from discriminating against employees and applicants solely because of disability. The act applies to three categories of employers: 1) federal executive branch employers, 2) federal contractors and 3) employers accepting federal funds (e.g., Medicare).

The ADA extends these same protections to other classes of employees. All aspects of employment are encompassed, including hiring and firing, training, advancement, compensation and benefits. The law goes further by requiring that employers proactively offer equal opportunity to disabled employees by providing reasonable accommodations that do not cause them “undue hardship.” The definition of “employer” under the ADA is broad-based and includes a hospital’s powers in granting professional privileges.

Title II of the ADA prohibits state and local governments and their agencies from excluding a disabled individual from any government program such as medical licensure or renewal. Title III further extends the law to protect applicants to both public and private institutions, e.g., medical schools.

There are certain notable exceptions to protection by the ADA. An individual who poses a direct threat to the health and safety of others is not considered a qualified person with a disability. For example more than one court decision has ruled that a surgeon who is seropositive for HIV poses a significant health risk to his/ her patients, is not “qualified” for his/ her job and is not covered by the ADA. Neither is current illegal use of drugs a protected category. On the other hand, the status of being addicted to an illegal drug may be protected as long as the individual is in recovery and not a current user.

Professional Competence:* Medical schools, postgraduate training programs, and licensing and specialty certification bodies each set standards to ensure the competence of current and/or future practitioners of medicine. Each is focused upon a different stage in a physician’s career, has unique goals and establishes its own cognitive, physical, emotional and technical standards to prove competence.

Historically most medical schools sought to produce an “undifferentiated graduate” with the knowledge and skills necessary to enter any residency. More recently the ideal that each medical graduate should possess all the technical skills to succeed in any specialty has been questioned. Nevertheless the Association of American Medical Colleges (AAMC) still requires of a graduating medical student that he or she have “somatic sensation and the functional uses of senses of vision and hearing” and “of equilibrium, smell and taste” (see www.aamc.org/medicalschools.htm). The graduate must have sufficient exteroceptive and proprioceptive sense and motor function to carry out activities “necessary for the education of the physician.” They also must be able to consistently, quickly and accurately integrate all information received by whatever sense(s) employed, and they must have the intellectual ability to learn, integrate, analyze and synthesize these data.

The physical and cognitive capabilities required of a graduate of a residency program are similar to those of a medical school graduate. The American Board of Anesthesiology (ABA) requires that each resident “must possess knowledge, judgment, adaptability, clinical skills, technical facility and personal characteristics sufficient to carry out the entire scope of anesthesiology practice …. They must be able to manage emergent life-threatening situations in an independent and timely fashion …. Adequate physical and sensory faculties, such as eyesight, hearing, speech and coordinated function of the extremities are essential …. Freedom from the influence of or dependency on chemical substances that impair cognitive, physical, sensory, or motor function also is an essential characteristic …” (see www.theaba.org).

The Accreditation Council for Graduate Medical Education (ACGME) similarly requires that residents must demonstrate the following competencies: “gather essential and accurate information about their patients … develop and carry out patient management plans… and perform competently all medical and invasive procedures considered essential for the area of practice” (see www.acgme.org).

It is less clear what skills and competencies must be maintained in the years of practice subsequent to residency. As a generalization, the health care industry has not kept pace with many other industries in ensuring the continuing competence of its personnel. Unlike many other professionals whose conduct impacts public safety, physicians are not required to undergo annual physical and performance examinations or random drug screening. Few health care organizations utilize programs to monitor clinical performance of individual physicians. Many recredentialing and relicensing organizations rely only on self-selected continuing education attendance as proof of clinical competence. The problem with this approach is that physicians are inaccurate in self-evaluation of their performance and learning needs. Continuing medical education (CME) attendance, in particular, is a poor surrogate for professional proficiency.

Thorough and fair testing for competency has proven to be difficult among attending anesthesiologists. Experts in the field continue in the attempt to distinguish a “good” anesthesiologist (one who meets the demands of the job) from one who is incompetent. Part of the difficulty arises from the fact that there are no universally accepted core competencies or a “job description” for an attending anesthesiologist. Each practice, and each anesthetizing location, imposes unique demands that render elements of any universal catalog incomplete or irrelevant.

Many specialty boards, including ABA, are in the process of improving their recertification procedures by adding a mechanism to test clinical skills in addition to the traditional demonstrations of medical knowledge. The goal is to identify specialty-specific competencies and means to measure these competencies among practicing physicians as part of maintenance of certification.

Common Scenarios
It is predictable that all individuals, if they work long enough, will suffer a disability for some period during their lives. Below are some common situations in which anesthesiologists’ ability to practice have been questioned.

Loss of Vision: Adequate visual acuity is necessary for most of the professional activities of an anesthesiologist. Severely impaired central vision, markedly restricted visual fields, color blindness or failed stereopsis (three-dimensional vision) could make it difficult to perform many of the tasks that are integral to the safe practice of anesthesiology. Several research reports have shown that the impaired vision created by wearing ophthalmologic goggles rendered anesthesiologists vulnerable to frequent medication sorting errors and deterioration in intubating skills. It is important to point out that these studies artificially created acute visual loss and do not necessarily apply to anesthesiologists with chronic visual impairment.

Hearing Loss: Hearing loss, especially in high-frequency ranges, is common among older physicians. These losses often go undetected until they have reached an extreme degree.

Hearing deficits appear to be especially prevalent among anesthesiologists. In one study, 66 percent of anesthesiologists had abnormal audiograms measurable over all audible frequencies.¹ High-frequency hearing loss can be especially problematic for anesthesiologists because of several characteristics specific to the operating room. Masks worn in operating rooms can muffle voices and hide facial cues that are helpful in interpreting language. Also, the operating room has a high level of background noise, with intermittent bursts from sources such as music, suction apparatus, beepers, alarms, surgical saws and drills, and the clanging of instruments. The combination of high-frequency hearing loss and elevated levels of ambient noise can interfere with an anesthesiologist’s ability to discern conversational speech and to hear equipment alarms that are commonly set to the higher range of audible frequencies.

Anesthesiologists Infected With Blood-borne Pathogens: In 1991 the Centers for Disease Control and Prevention (CDC) published recommendations to prevent transmission of blood-borne pathogens from health care workers (HCWs) to patients (see www.cdc.gov). These recommendations included an admonition that HCWs with hepatitis B virus (HBV) or HIV should not perform exposure-prone procedures unless they have sought counsel from experts to determine if they may continue to perform those procedures. Also included was the requirement that these HCWs disclose their serologic status to their patients before engaging in exposure-prone procedures.

Shortly afterward the American Medical Association issued an amendment to its Code of Medical Ethics (E 9.131 HIV-Infected Patients and Physicians): “A physician who knows that he or she is seropositive should not engage in any activity that creates a significant risk of transmission of the disease to others. A physician who has HIV disease or who is seropositive should consult colleagues as to which activities the physician can pursue without creating a risk to patients” (see www.ama-assn.org).

It is unlikely that many anesthesiologists are at risk of transmitting a blood-borne disease to their patients. Except in unusual circumstances, anesthesiologists do not perform “exposure-prone” procedures. That being the case, neither the CDC guideline nor the AMA Code of Ethics should require an HIV- or HBV-positive anesthesiologist to restrict his or her routine practice or disclose his/her serologic status.

In addition to ethical considerations, however, there also are significant medico-legal concerns. The doctrine of medical malpractice imposes a strict duty to avoid patient injury and to protect the welfare of the community. It would be difficult to avoid the conclusion that the transmission of an infectious agent from physician to patient violates the standard of care. This would be especially true if adequate infection control guidelines were not followed. All anesthesiologists, regardless of serologic status, should adhere to universal precautions and recommendations for sterilization/disinfection.

Neurologic and Psychiatric Illness: A number of chronic neurological diseases that impair motor function (such as multiple sclerosis and Parkinson’s disease) can adversely affect the ability to practice anesthesiology. In most cases, the patient (anesthesiologist in this case) and his/her physician can monitor the progression of these diseases and ensure that safe practice is not imperiled.

The situation is more complicated with conditions such as Alzheimer’s disease that primarily affect cognitive and executive functioning and can impair medical reasoning. Frequently this kind of mental impairment is unappreciated by the patient and is first identified by a colleague or spouse. Physicians suffering from this type of disease also are unlikely to benefit from efforts at remediation.

A seizure disorder can be a particularly vexing situation for an anesthesiologist. Many variables associated with the seizure disorder — for example, etiology, frequency and severity of seizures and adequacy of medical control — will determine the advisability of continued and/or restricted practice. In general those rules that apply to driving restrictions (six months seizure-free in many states) represent a reasonable requirement before resuming unrestricted practice. Where sleep deprivation or disturbances in circadian rhythm exacerbate the seizures, it is advisable to eliminate night work.

Psychiatric disease, including anxiety, depression, personality disorders and disruptive behavior, is at least as common among physicians as in the general population. The overall prevalence of psychiatric disease among anesthesiologists is unreported. The relatively high prevalence of chemical dependence and suicide, however, suggests that underlying psychiatric disease is at least as common as that seen among other physicians. Severe unmanaged neurosis or psychosis is incompatible with safe anesthetic practice. On the other hand, well-monitored and controlled illness should not be a contraindication to safe practice. The potential cognitive or motor effects of potent psychotropic medications also require close monitoring.

Fatigue can act independently or contribute toward exacerbation of any of the conditions discussed above. There is increasing awareness of the patient safety issues resulting from sleep deprivation and fatigue among anesthesiologists.

Substance-Related Disorders: Substance-related disorders are those diseases that result from taking a substance of abuse, the side effects of a legally prescribed and administered medication, and toxin exposure. Included in this category are substance use and substance-dependence disorders.

It is debatable whether or not substance-related disorders are more prevalent among physicians than the general population. The National Institute on Drug Abuse² reported that health care professionals suffer from substance-related disorders (including alcohol abuse) at a rate roughly equivalent to that of the general population (8 percent to 12 percent).

The rate of substance-related disorders varies among specialties, with the highest rates commonly reported among anesthesiologists, psychiatrists and emergency physicians and the lowest rates among surgeons and pediatricians. Other authors have questioned whether there is an excessive prevalence of substance-related disorders among anesthesiologists, with the notable exception of illicit use by anesthesiologists of major opiates.³

Considerable controversy exists surrounding the question of re-entry into practice for a resident or attending anesthesiologist in recovery. A number of reports have documented encouraging rates of rehabilitation and successful return to practice. On the other hand, a recent report by Collins et al.4 reveals a failure rate approaching 50 percent for residents attempting successful re-entry into anesthesiology residency. Relapse in this setting can be lethal, with an alarmingly high incidence of suicide or lethal overdoses.

The Aging Anesthesiologist: The population of anesthesiologists is aging. In 1994, 22.8 percent of ASA members were age 55 years or older (ASA personal communication). As of 2006, 27.7 percent were age 55 or older (ASA, personal communication). Although each individual ages differently, there are certain common, general processes that will ultimately impact an anesthesiologist’s ability to practice: a broad spectrum of progressive and irreversible deteriorative changes, a reduced ability to respond adaptively to environmental changes, increased vulnerability to many diseases and increased mortality.

Cognitive changes associated with aging can significantly impact an anesthesiologist’s performance. The overall decrease in the complex processes involved in cognition result in a consistent age-dependent decline in physicians’ current knowledge base and in performance on recertification examinations.

One’s ability to perform effectively in a stressful environment, to adapt to new and quickly changing conditions and to process incoming information and rapidly make complex decisions all deteriorate with age. Also impacted is the ability of an anesthesiologist to perform a number of attention-related tasks and to sustain the vigilance and monitoring tasks that are so integral to safe anesthetic practice.

On the other hand, performance in the operating room relies on additional skills, including technical agility, experience and judgment that can compensate for mild cognitive deterioration and in some situations provide an advantage to older professionals. In one study that examined operative mortality, surgeon age over 60 years was not an important predictor of operative risk in five of the eight procedures studied.⁵ Even in those procedures where older surgeons did have a higher mortality rate, the effect of age was largely restricted to surgeons with low procedure volumes.

Psychosocial changes also challenge the aging anesthesiologist’s ability to practice. Physicians in high-intensity specialties such as anesthesiology who are in the middle and late stages of their careers are particularly vulnerable to psychological morbidity such as increased anxiety, depression, stress and burnout.

A number of physical changes that accompany normal aging can interfere with the safe practice of anesthesiology. Age-related deterioration in vision and hearing has been discussed above. Also important are decrements in manual dexterity, strength and stamina. Older anesthesiologists are particularly vulnerable to the detrimental effects of fatigue. Increasing age is associated with a decreased tolerance of shift-work cycles and a greater tendency to late-night errors. Extended work hours and night call are among the most stressful aspects of anesthetic practice and the most important reasons for retirement among older anesthesiologists.

Disability Insurance: Private disability insurance policies for health care providers and disability clauses in life insurance policies became readily available during the early part of the 20th century. By the mid-1980s, marketing of disability insurance for health care professionals was extremely competitive with a resultant liberalization of underwriting and pricing structures.

As a result of a number of cultural and socioeconomic changes in the 1990s (including the impact of managed care on physician work pressure and job satisfaction), the economics of disability insurance reversed dramatically. From 1980 to 1992, the number of claims almost doubled.⁶ The increase was greatest among five specialties — anesthesiology being among those five.

As a result of these changes, many companies have abandoned the disability marketplace, while the remaining few have tightened the terms of policies. In most cases, underwriters have eliminated “own-occupation” coverage, eliminated lifetime and reduced maximum benefits, and imposed more stringent documentation for the claimed disability. It is not unusual for the claim of a physician seeking disability payments to be ultimately resolved in a court of law.

Conclusion
Questions about disability frequently arise from individual anesthesiologists or their colleagues. Decisions about the advisability of suspending anesthetic practice are complicated and frequently require third-party input.

Disclaimer: The opinions expressed are those of Jonathan D. Katz, M.D. They do not necessarily represent the views of ASA.

References:
1. Wallace MS, Ashman MN, Matjasko MJ. Hearing acuity of anesthesiologists and alarm detection. Anesthesiology. 1994; 81:13-28.
2. Prescription Drugs: Abuse and Addiction. Bethesda, M.D: National Institute on Drug Abuse; 2001.
3. Lutsky I, Hopwood M, Abram SE, et al. Use of psychoactive substances in three medical specialties: Anaesthesia, medicine and surgery. Can J Anaesth. 1994; 41:561-567.
4. Collins GB, McAllister MS, Jensen M, Gooden TA. Chemical dependency treatment outcomes of residents in anesthesiology: Results of a survey. Anesth Analg. 2005; 101:1457-1462.
5. Waljee JF, Greenfield LJ, Dimick JB, Birkmeyer JD. Surgeon age and operative mortality in the United States. Ann Surg. 2006; 244:353-362.
6. Wall BW, Appelbaum KL. Disabled doctors: The insurance industry seeks a second opinion. J Am Acad Psychiatry Law. 1998; 26:7-19.

Jonathan D. Katz, M.D., is Clinical Profesor of Anesthesiology, Yale University School of Medicine, and Attending Anesthesiologist, St. Vincent Medical Center, Bridgeport, Connecticut.