- THE TEN MOST SIGNIFICANT ADVANCES IN ANESTHESIOLOGY IN THE PAST DECADE - 14 Jan 2021
- HOW DO PANDEMICS END?EXAMINING THE 1918 SPANISH FLU PANDEMIC - 17 Dec 2020
- SUFFOCATING ALONE - 10 Dec 2020
An 60-year-old man has a heart attack in the middle of an emergency abdominal surgery at 11:00 pm and dies two hours later. Should the anesthesiologist submit to a drug test to seek out alcohol or drug ingestion that could have made her performance impaired?
Discussion: In the 2012 movie Flight, Denzel Washington stars as a commercial airline pilot addicted to alcohol and cocaine, who crashes his airplane while he is intoxicated. Analogies between aviation and anesthesia are commonplace. Both involve takeoffs, landings, and varying cruising times between the two. Both are generally quite safe, but on occasion disastrous accidents occur.
Pilots are required to submit to random drug testing and to testing following accidents. The Federal Aviation Administration (FAA) mandated drug and alcohol testing of safety-sensitive aviation employees in the Omnibus Transportation Employees Testing Act of 1991 to help protect the public and keep the skies safe.
Proposition 46 was a 2014 California legal initiative that proposed similar random drug testing of physicians and drug testing following critical sentinel events. Prop 46 was on the ballot for the November 2014 general election, and was soundly defeated. This proposition was noteworthy for bundling the drug-testing proposal with an additional proposal that would increase the maximum pain and suffering malpractice reward from $250,000 per case to $1,100,000 per case. Prop 46 was funded and supported by trial lawyers who sought to raise the ceiling on pain and suffering awards they could win in medical malpractice suits in California.
This malpractice award increase proposed by trial lawyers was viewed as a money grab, and was unpopular with voters. Because of concerns with increasing malpractice costs and health care costs, Prop 46 was defeated.
But what if Prop 46 had solely been about drug-testing physicians? Would it have a better chance of passing? I have no crystal ball, but my guess is that yes, it would have had a better chance of passing. According to the September 13, 2014 edition of the Los Angeles Times, the component of Prop 46 that required random drug and alcohol testing of doctors was popular among those surveyed: 68% of likely voters were in favor of it, while 25% were opposed.
In the August 1, 2014 issue of the New York Times, Adam Nagourney wrote “At a time when random drug testing is part of the job for pilots, train operators, police officers and firefighters—to name a few—one high-profile line of work has managed to remain exempt: doctors. That may be about to change. California would become the first state to require doctors to submit to random drug and alcohol tests under a measure to appear on the ballot this November. The proposal, which drew approval in early focus groups, was inserted as a sweetener in a broad initiative pushed by trial lawyers that also includes an unrelated measure to raise the state’s financial cap on medical malpractice awards for the first time since 1975, to $1.1 million from $250,000.”
The same New York Times article states, “Backers of Proposition 46 have begun putting out a steady stream of news releases about cases involving doctors with a history of drug and alcohol abuse…. ‘It’s crucial: I can’t believe we haven’t done this already,’ said Arthur L. Caplan, a medical ethicist at New York University. ‘But the idea that we wouldn’t be screening our surgeon, our anesthesiologist or our oncologist when we are going to screen our bus drivers and our airline pilots strikes me as ethically indefensible.’” In the same article, Daniel R. Levinson, the inspector general for the Department of Health and Human Services, opines that there should be random drug testing across the medical profession, given the access in hospitals to controlled substances. “I don’t think that a carve-out when it comes to the medical field is sensible public policy,” he said. “No one should be above suspicion or below suspicion. I think we all need to play by similar rules.”
In a recent commentary published in the Journal of the American Medical Association (JAMA), Dr. Julius Pham of Johns Hopkins wrote, “Patients and their family members have a right to be protected from impaired physicians…. Why is there such a difference among high-risk industries, which all pledge to keep the public safe? First, medicine is underregulated compared with other industries. The fiduciary patient-physician relationship is generally considered to be governed by the profession, not to be tampered with by regulatory bodies. While some state and individual health system regulations exist, they tend to be weak. Second, self-monitoring is the essence of medical professionalism. Peer review is the accepted modality to identify physicians with impaired performance. Most states now have a designated physician health program to detect and assist potentially impaired physicians before those physicians cause patients harm. However, these programs vary in their mandate, authority, reporting requirements, and activities. For instance, California has the largest number of US physicians, but its physician health program was recently discontinued. In states without proactive programs, it seems, by default, that patient harm has to occur before a review process occurs. In many cases, an overwhelming amount of data (i.e., harmed patients) must be available before a hospital or state initiates an investigation.”
Dr. Pham goes on to say, “What might a model of physician impairment regulation look like? First, mandatory physical examination, drug testing, or both may be considered before a medical staff appointment. This already occurs in some hospitals and has been successful in other industries. Second, a program of random alcohol-drug testing could be implemented. Random testing is required for most federal employees and has been successfully implemented in several medical settings. Random testing in the military has resulted in a decrease in illicit drug use. Third, a policy for routine drug-alcohol testing could be initiated for all physicians involved with a sentinel event leading to patient death. Fourth, a national hospital regulatory/accrediting body could establish these standards to maintain consistency across states.”
It’s estimated that approximately 10% to 15% of all healthcare professionals misuse drugs or alcohol at some time during their career. Although rates of substance abuse and dependence are no different than those in the general population, the stakes are higher because healthcare professionals are caregivers responsible for the general health and well-being of our population. It’s known that specialties such as anesthesiology, emergency medicine, and psychiatry have higher rates of drug abuse, possible due to the stress level associated with these specialties, the baseline personalities of these healthcare providers, and easy access to drugs in these specialties.
As physicians, do we have any compelling arguments to deflect the notion of MD’s being drug tested? Physicians decry the intrusion into their privacy. There is the ethical question whether the risk of patient injury by the 10% of physicians who use drugs and/or alcohol merits that the other 90% of physicians should be subjected to drug testing. There is also the specter of false-positive tests, which could wreak havoc with a doctor’s reputation. The details of any proposed drug and alcohol screening programs will be crucial, and any screening program will require careful consideration of a physician’s rights and privacy.
Two prominent hospitals—Massachusetts General Hospital in Boston and the Cleveland Clinic in Ohio—implemented random urine drug testing in their anesthesia residency teaching departments. A 2005 survey by the Cleveland Clinic estimated that 80 percent of anesthesiology residency training programs reported problems with drug-impaired doctors, and an additional 19 percent reported a death from overdose. “The problem is that we are exposed to, and we have the use of, very highly addictive and potent medications,” said Dr. Michael G. Fitzsimons, administrator for the substance abuse program of the department of anesthesia and critical care at Massachusetts General Hospital in Boston. Dr. Gregory B. Collins, section head of the Alcohol and Drug Recovery Center, at the Cleveland Clinic Foundation, said, “The first thing you often realize in these cases, it’s a kid dead in the bathroom with a needle in his arm.” Dr. Arnold Berry, an anesthesiologist and a member of the Committee on Occupational Health of the American Society of Anesthesiologists, said estimates of anesthesiologists who are addicted to medication range from only 1 to 2 percent. “The most recent study in training programs suggests the (addiction) rate has stayed the same for 20 years,” he said. Dr. Berry said the American Society of Anesthesiologists (ASA) has decided to use other tactics to stave off addiction, rather than recommending urine testing. The ASA is implemented a “wellness initiative” to help anesthesiologists deal with stressors in their lives.
While doctors and organized medicine may delay the notion of drug testing for themselves, public opinion and lawmakers may lead the way toward making physicians “pee in the cup.” Citizens don’t want their airline pilots, firemen, and police officers under the influence of alcohol or drugs, and patients don’t want their doctors under the influence of alcohol or drugs either.
Our patients always come first. It will be an arduous task for MD’s to forever oppose a mandate for clean and sober physicians. Hugh Laurie was a fascinating character as the opiate-popping junkie doctor in “House,” but what patient wants the TV persona of Dr. Gregory House at their bedside?
The most popular posts for laypeople on The Anesthesia Consultant include:
The most popular posts for anesthesia professionals on The Anesthesia Consultant include:
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: