Krista L Kaups MD, MSc, FACS Health Sciences Clinical Professor of Surgery UCSF Fresno.
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Krista L Kaups MD, MSc, FACS Health Sciences Clinical Professor of Surgery UCSF Fresno UCSF How common is the problem? What are the risk factors? Signs and symptoms? What are my options as a faculty member/program director? What is the prognosis? Reviews of physicians treated for substance abuse show that alcohol is “drug of choice” for surgeons (probably about 2/3rds, followed by opioids) (Buhl, Arch Surg 2011) Resident-specific data is limited. Surveys of use appear to show alcohol most widely used – and lower use rates of other substance (Hughes, Am J Psych, 1992) An estimated 10-12% of physicians will experience impairment due to alcohol or drug dependency over the course of their careers 2010: Electronic survey of 25,000 ACS Fellows with responses from 7,200 (29%) AUDIT-C tool used to assess alcohol use or dependence Abuse or dependence: Score > 5 for men > 4 for women Problematic (misuse): Score > 4 for men > 3 for women Q1: How often did you have a drink containing alcohol in the past year? Never 0 Monthly or less 1 Two to four times a month 2 Two to three times a week 3 Four or more times a week 4 Q2: How many drinks did you have on a typical day when you were drinking in the past year? None, I do not drink 1 or 2 0 3 or 4 1 5 or 6 2 7 to 9 3 10 or more 4 0 Q3: How often did you have six or more drinks on one occasion in the past year? Never 0 Less than monthly 1 Monthly 2 Weekly 3 Daily or almost daily 4 Overall, 15.4% had scores consistent with abuse or dependence Point prevalence 13.9% for male surgeons, but 25.6% for female surgeons Alcohol abuse or dependence was strongly and independently associated with burnout, depression and recent major medical errors In this survey, alcohol was, by far, the most widely used substance Oreskovich et al, Arch Surg.2012;147(2):168-174 Problems in (pre-)training: disciplinary action, drug use, family history Work demands and access Performance enhancement medications to sleep or stay awake Stress: school, family, burnout Poor coping skills and strategies Poor social support network Robert Alan Bonakdar,MD Personality factors promoting physician success may also predispose to burnout and impairment: Drive for over-achievement Excessive work conscientiousness at the expense of personal and social obligation Ability to deny personal problems Perfectionism Sense of self-worth tied to achievement Work performance is often the last area affected so issue may be long-standing by the time it’s uncovered Impairment: “Inability to practice medicine with reasonable skill and safety” Alcohol on breath Slurred speech Ataxia Erratic performance or decrement in performance Tremulousness “Out-of-control” behavior at social events Problems with law enforcement (e.g., domestic abuse, driving while intoxicated Hidden bottles Poor personal hygiene Failure to remember events, conversations, or commitments (“blackouts”) Tardiness Frequent hangovers Poor early morning performance Unexplained absences Unusual traumatic injuries Mood swings Irritability Sweating Domestic/marital problems Isolation Leaving the workplace early on a regular basis Berge et al, Mayo Clin Proc. 2009;84(7):625-631 Denial is common – by all parties In most states, unless there is evidence of patient harm, doctors can seek treatment for substance use without being reported to the Board of Medicine. Don’t wait for harm to occur! States with mandatory reporting have laws protecting physicians from civil suits Have a plan depending on acuity of situation – but avoid confrontational approach Berge et al, Mayo Clin Proc. 2009;84(7):625-631 42 states currently have PHP’s Goals: “Promote early identification, treatment, documentation, and monitoring of ongoing recovery of physicians prior to the illness impacting the care rendered to patients” May not actually provide treatment but provide referral to appropriate programs Comprehensive treatment program is essential: ◦ ◦ ◦ ◦ ◦ Intervention Evaluation and triage [Usually] residential therapy Family involvement Re-entry with case management, worksite monitor, random drug and alcohol screening, advocacy – 5 year contract is recommended • Mainstream addiction treatment in the general population have shown poor compliance rates during treatment and relapse rates of 40 – 60% within 6 months of treatment. BMJ, 2008: 337, McClellan et al 292 healthcare professionals (1991-2001) University of Washington – WPHP 10 year retrospective cohort study Alcohol 57% Major Opioids 14% All individuals without relapse > 5 years return to the practice of medicine In those with one relapse, 61% returned to medicine JAMA, March 2005, 293: #12, Domino et. 1. Family history of substance abuse 2. Use of major opioid (fentanyl, meperidine) 3. Co-existence of a psychiatric disorder The presence of all three factors markedly increased the risk of relapse (Hazard ratio 13.25) JAMA, March 2005, 293: #12, Domino et. al. Table 6. Risk Factors for Relapse for Alcohol Users. Domino, K. B. et al. JAMA 2005;293:1453-1460 Copyright restrictions may apply. 5 year retrospective cohort study 904 physicians with substance use disorders 16 Physician Health Programs (PHP) Study represents the first long term outcome study for surgeons being monitored for SUD 144 surgeons compared to 634 non-surgeons Surgeons included General, Ob-Gyn, Ophthalmology, Orthopedics, ENT, Plastic, Thoracic, Urology 5 medical specialties represent 70% nonsurgeons (FP, internal medicine, psychiatry, ER, anesthesia) Buhl, Oreskovich, et al, Arch. Surg. 2011 20% of all participants had at least one positive screen (drug or alcohol) 5 year follow up (completed program) ◦ 63% surgeons ◦ 65% non-surgeons 16% contracts extended (attendance, relapse) At 5 years: 67% of surgeons licensed and practicing surgery, 25% did not return to medicine Buhl, Oreskovich, et al, Arch. Surg. 2011, in press Significant number of surgeons are impaired – alcohol appear to be the drug of choice Denial and compensatory mechanisms are powerful A single DUI may reflect poor judgment; more than one almost certainly indicates a problem Have a plan – and written policies and procedures in place BEFORE you need them Know your local resources Prognosis is very good with appropriate treatment, support and monitoring State Medical Boards/Medical Society Physician Health Programs Federation of State Health Programs www.fsphp.org Hospital: Physician wellbeing/wellness committee (mandated by Joint Commission)