Doctors In Need

The rate of substance abuse amongst anaesthetists is thought to be similar to the rest of the population but their knowledge of drugs and ease of access makes their situation more dangerous. Meaghan Shaw explores this and other welfare issues facing anaesthetists.
Dr Ray Hader was a typical, high-achieving anaesthetic trainee.
Like other high-achievers, he did everything full-on, from his medical studies (graduating with honours), to sport (representing Victoria in volleyball). Unfortunately, this was also his approach to drug taking.
He was a likeable trainee working at Western Health in Melbourne when he succumbed to his addiction. His friend, Dr Brandon Carp, says he claims his drug-taking began when he was assaulted at another hospital by a patient who broke his teeth and he took panadeine forte for the pain.
From panadeine forte, he progressed to midazolam, while also using alcohol and other drug cocktails, which steadily got out of control to the point where he was getting deliveries of midazolam at home.
“He didn’t have a drug of choice, really,” Dr Carp says. “But it seemed that midazolam was what anaesthetised him to death – it was an accident.
“He was a clever guy. I don’t know why it seems to happen with anaesthetists. But he knew the dosages, he understood, he was smart. He just got caught.”
Unfortunately, the case of Dr Hader is not uncommon, with figures showing that up to a quarter of anaesthetists abusing substances will die from overdose or suicide due to their pharmacological knowledge and ease of access to drugs.
Doctors in general also have been found to have higher rates of depression and anxiety, stress-related illness and alcoholism.
To help anaesthetists and pain medicine specialists in need, the Welfare of Anaesthetists Special Interest Group (SIG) reviewed and updated resource documents that outline the more common professional and personal stresses and give suggested references and strategies to deal with them.
The support is crucial.
Dr Carp says at the time of Dr Hader’s addiction, which was for about five years leading to his death in 1998, he was frustrated by a lack of support services and a sense that Dr Hader’s colleagues knew he had a problem but didn’t act while he looked ok.
“I felt incredibly helpless to do anything, both as a doctor and as a friend, because he was actually working and getting away with it,” he says. “He was sort of functional. And I really struggled to find any support mechanisms through the profession that could assist him.”
Finally, Dr Carp reported him to the medical board after he used another doctor’s script pad.
“The reality was it was best for him because (working in the anaesthetic department) was just like giving candy to a little kid,” he says. “And second of all, he could possibly do something to a patient and that would have really destroyed him to know that he had endangered someone else.
“So he understood. He was just waiting for it, really.”
Phillip*, a former trainee anaesthetist, also hit a downward spiral of drug abuse, self-loathing and reckless usage.
Starting as a recreational drug user as a junior doctor to “see what all the fuss was about”, he infrequently used “anything and everything” including ketafol, opportunistically taking medicines home from work to use them.
But after about five years, he went through a stressful period where he changed jobs, got a mortgage and started a family, and his drug-taking got out of control.
Blaming exam preparation, he became withdrawn, wouldn’t answer the phone or knocks on the door, obtained drugs at work, and went home to lock himself in a room to use them with “quite marked feelings of self-loathing”.
“Basically I thought I was worthless and couldn’t find any way out of it,” he says. “I tried stopping on numerous occasions but couldn’t. Every last time was going to be the last time, but I found it more and more difficult (to stop) and I was completely out of control.
“The problem was I would never have asked anyone for any help. And the reason for that was, although there was help available, I was completely blinkered into not being prepared to ask for it because I was terrified about losing my livelihood.
“Fortunately, for me, someone at work noticed what I was doing. It was actually a fellow addict and she brought it to the attention of some seniors.
“Unfortunately, this woman who I owe a huge debt of gratitude to died from her own addictive disease by herself, by her own hand, which I think is a tragedy.”
For Phillip, it was through the intervention of his hospital, participation in a treatment program and counselling, and regular monitoring by the medical council that he has remained drug-free for the past 13 years.
“If you do have a colleague who you think has a problem, then you shouldn’t sweep that under the carpet, you need to initiate something that’s going to intervene in that person’s life, otherwise you’re going to be going to a funeral,” Phillip says.

Incidence of Substance Abuse

Auckland City Hospital specialist anaesthetist, Dr Robert Fry, in 2005 published research on substance abuse among anaesthetists.
He has long advocated for unnamed unidentified reporting of cases to the Australian and New Zealand College of Anaesthetists (ANZCA) as the incidence of anaesthetists abusing substances is unclear.
However, he says it is likely that anaesthetists have a similar incidence of substance abuse as physicians, with overseas research showing about 10 to 15 per cent of physicians abuse substances – which is no different to the general population.
But where anaesthetists differ, is they are six times more likely to use intravenous drugs which means overdosing, rapid dose escalation and mistakes are more likely as is the need for admission to a treatment facility to get over the addiction.
“So we tend to do it with stronger, quicker drugs and that’s probably why we tend to end up on the treatment programs so frequently,” he says.
“Because anaesthetists use very strong drugs all the time with absolute control, it is possible that we have an invalid over-confidence that we can do the same for ourselves. And anaesthetists choose these stronger drugs as we have relatively easy access to them.”
His research finds the chances of a substance-abusing anaesthetist dying from overdose or suicide is 25 per cent – higher for registrars at 31 per cent.
And for those who successfully seek treatment, the likelihood of them remaining in anaesthesia long-term is only 20 per cent.
Former chair of the welfare special interest group, Dr Diana Khursandi, says as well as substance abuse, other factors such as depression, burnout and other stresses can also trigger a suicide.
“Each one is a tragedy for everybody – the people who work with them, the families,” she says.
“Doctors in general kill themselves more frequently than the general population and anaesthetists are particularly good at it, which is very sad.
“One of the things we would hope to do is to try to help these people before they reach that tragic decision. But sadly they’re not always preventable. But depression certainly is treatable, and people who abuse substances can, with the correct intervention and treatment, be successfully rehabilitated.”
Resource documents, which are available on the ANZCA and Anaesthesia Continuing Education Coordinating Committee (ACECC) websites, deal with two dozen welfare issues ranging from personal health strategies, substance abuse, financial pressures, recognising depression, and sexual misconduct, to mentoring, retirement, latex allergy and medico-legal issues.
They were updated in 2011 and include new documents on critical incident support, organ donation, communication, consent, mandatory reporting, the disruptive anaesthetist, and bullying. The documents are pointers to accessing help and are not meant to be prescriptive.
Doctors are notoriously bad at looking after themselves and have a tendency to self-medication and self-prescription, which is dangerous. One of the main refrains from everyone working in the area of doctors’ health is the need for anaesthetists and pain medicine specialists to have their own GP.
It’s one of the first pieces of advice Dr Khursandi gives when addressing anaesthetists on how to look after themselves.
“It’s things like having your own GP, making sure you’ve got support systems if you have a critical incident, making sure you have mentors, making sure that your life-balance includes things other than work, not prescribing for yourself, not having corridor consultations,” she says.
In addition, the support and, in some cases intervention, of colleagues is vital.
“Everyone needs the support of colleagues; if you are getting to a stage where you are extremely distressed, then certainly you should be doing something about it, or other people should be trying to help you,” Dr Khursandi says. “It doesn’t always work though. People don’t always receive the message.”

Mandatory Reporting

This is where mandatory reporting can come in. Introduced nationally in Australia in 2010, and in operation in New Zealand since at least 2003, mandatory reporting requires registered health professionals to report to their registration authorities colleagues whose conduct might put patients at risk of substantial harm. In Western Australia, an amendment means doctors are exempt from reporting when treating other health professionals.
While the new laws in Australia don’t change the onus that was already on medical professionals to report colleagues, the legislation is stricter, and the fear has been that the new legal requirements would stop doctors in need from seeking help.
Speaking after the first 12 months of operation, views on the impact of the laws on the numbers of doctors seeking help from the Doctors’ Health Advisory Services around the country were mixed.
Victorian Doctors’ Health Program medical director, Dr Kym Jenkins, said feedback from services via the Australasian Doctors’ Health Network showed only in Queensland had callers to the state-based service dropped off. In Victoria they remained the same, in South Australia the picture was unclear but calls hadn’t increased, in New South Wales they initially dropped off but then picked up, while in ACT the number of callers was too small for analysis. The Northern Territory and Tasmania don’t have a service, and reporting is not required in WA.
Dr Jenkins said the main effect of the laws in Victoria had been an increasing amount of confusion about what needs to be reported, particularly among employers.
“The impact on our service is the level of uncertainty people have about whether they should or shouldn’t report, and various organisations thinking they’re obliged to report when they’re not,” she said.
If in doubt, she checks a hypothetical case with the health committee of the Victorian branch of the Medical Board of Australia.
Queensland’s Doctors’ Health Advisory Service president, Dr Joan Lawrence, said the Queensland experience had shown mandatory reporting had inhibited doctors from seeking help, despite the service making it clear it does not report patients to the medical board.
“In some cases, where perhaps patients were really at risk if the doctor didn’t stop practising, then what we might do is encourage the person who was bringing that doctor to our notice to make contact with the medical board if they saw fit, but we certainly don’t report people,” she said.
Her advice to anaesthetists is to not hesitate to seek help if they are experiencing problems, including depression, undue anxiety or extreme stress.
“They can be reassured that if they do seek help, they won’t be reported,” she said. “That’s been our concern all along with mandatory reporting – that it will drive people underground, and they’ll be so afraid of being mandatorily reported, whether they need it or not, and that it will impact on their practice, that they think they’ve got to keep it hidden and deal with it themselves, which usually means no treatment, or self-treatment, which is usually even worse.”

Investigating Substance Abuse

Being the subject of suspicion and intervention by colleagues can be a traumatic experience, regardless of whether those suspicions are right or wrong.
One anaesthetist wrongly accused of abusing fentanyl at work, who was the subject of an intervention and urine test, says it nearly ruined his career and destroyed his relationships with some colleagues.
“I found it an incredibly distressing experience which I’ve never got over,” he says.
In his case, he felt the proper procedures were not followed: that the person conducting the intervention was not experienced or trained in doing it and was not from the anaesthetic department; and that neither he nor his wife were provided an adequate level of support or counselling in the aftermath.
“That experience ruined the end of my career for me in terms of the pleasure that I had had from it,” he says. “The irony was that I was at a particularly good phase in my professional and personal life at the time."
Cases such as this emphasise the need for hospitals to have in place and follow guidelines, which can be developed with reference to the welfare special interest group’s resource document and best-practice protocols.
Christchurch Hospital anaesthetist, Dr Vaughan Laurenson, has been involved with welfare issues in his department for about 20 years, during which time he has dealt with about a dozen actual and suspected cases of substance abuse.
He says the incidence of abuse, while uncommon, is common enough that it is likely most anaesthetists will encounter a case during their career.
Protocols emphasise that anyone suspecting someone of diverting drugs should talk to an appropriate senior colleague and not challenge the person themselves.
The process is then to gather evidence and only act once sure there is proof; to set up an intervention, including involving the suspect’s family; to notify the health committee of the medical council to suspend the person’s registration if they refuse a urine test; to organise a lab to do an urgent urine test; and to organise psychiatric support and follow up care, including an appropriate treatment program.
However, Dr Laurenson says the process is never straight forward and the stakes are high. “There are risks of error, failure, litigation and death,” he says.
The problems are compounded by addicts skillful at concealing their addiction, the need to act quickly if a fentanyl addict is spiraling out of control, difficulties in keeping track of drug dispensing within departments, and the possibility of raising suspicions of others by checking records.
“Once the rumour mill starts up and you start to hear about it from four to five other people  … it’s probably time you acted, whether or not you think you’re sure, to clear the air, and you can feed back into the system the person’s not diverting drugs,” he says. “It’s a horrible situation.”
But the key message, he says, is that it can’t be ignored with the hope it will go away.
“It is like any other medical emergency – it must be dealt with in a timely, appropriate manner to the best of your ability.”
For Dr Ray Hader, the intervention of his friend proved unsuccessful and he died aged 34 from an accidental overdose, while at home having a meal.
“He always thought he had it under control, he could get the dose right,” Dr Brandon Carp says. “I think he just slumped down and he blocked off his airways. And that was it. He was too anaesthetised to wake himself up.”
In honour of his friend, and to mark the 10^th anniversary of his death in 2008, Dr Carp set up the Ray Hader Trainee Award for Compassion. ANZCA trainees or Fellows within three years of fellowship by examination are eligible to apply for the award, which promotes a compassionate approach to the welfare of anaesthetists, their colleagues, patients and the community.
Dr Carp says the nature of the award reflects Dr Hader, who was compassionate and passionate about anaesthesia and helping people. “It also helps me deal with my sense of helplessness and loss,” he says.
He concedes the award serves a dual purpose.
“At the very least it helps the individual who gets the award to do something that recognises them, and that’s good enough. But if it alerts people to this problem, and makes it more relevant and discussed, then that’s probably a good thing as well.”
*Not his real name
The Australian and New Zealand College of Anaesthetists is the professional organisation for more than 5400 specialist anaesthetists (Fellows) and more than 1700 anaesthetists in training (trainees). ANZCA, which includes the Faculty of Pain Medicine, is one of Australasia’s largest medical specialist colleges. ANZCA is directly responsible for the training, examination and specialist accreditation of anaesthetists and pain medicine specialists and for the standards of clinical practice in Australia and New Zealand. The Welfare of Anaesthetists Special Interest Group is jointly managed by ANZCA, the Australian Society of Anaesthetists and the New Zealand Society of Anaesthetists and was formed to raise awareness of the many personal and professional issues which can adversely affect the physical and emotional well-being of anaesthetists at all stages of their careers.
Meaghan Shaw is the Media Manager for the Australian and New Zealand College of Anaesthetists. This is an updated version of an article that first appeared in the ANZCA Bulletin in September 2011.