Being an anesthesiologist: risks and stress

1. Being an anesthesiologist: risks and stress R1 顏廷珊

2. Do anesthesiologists die at a younger age than other physicians? Anesth analg 2004; 98: 1111-3

3. Methods • Three groups: anesthesiologist (AN), internist (IM), all others (AO) • Records were examined of all American physicians who died in the years 1989, 1990, 2000, and 2001; and those who were alive at the end of 1989, 1995, 2000, and 2001. • Crude death rates: compare ages of living PHs • Age-specific death rate: total NO of decreased PH/ total NO of living PH

4. Crude death rates • 21336 deaths • Mean age of death for all PH: 74.91+/- 13.53 • AN: 68.98+/-15.55 • IM: 74.41+/-14.24 • AO: 75.21+/-13.30 • Women had a younger mean age at death than men(71.90 +/-18.13 vs 75.11+/-13.16) in all PH • AN: F died younger than M ( 66.63 +/- 16.75 vs 69.26+/-15.39)

5. Age-specific death rate • The age-specific mortality rates for each of the specialties were similar in all ages from 31-100 yr of age • There was a slight increase among AN age30 and less

6. Discussion • Historically: controversy • In recent study: AN did die at younger ages • Other countries: Finland, Denmark, Norway no excess mortality; Great Britain and Sweden AN did die younger • In European, AN are younger than AO in average

7. Conclusion • AN had a statistically significant younger mean age than did IM and AO • By factoring in the ages of the living members of the study populations, it was demonstrated that there was no statistical difference in age-specific mortality

8. Cause-specific mortality risks of anesthesiologists Anesthesiology 2000; 93:922-30

9. Background • Anesthesiologists work in an environment characterized by :1. chronic exposure to trace concentrations of anesthetic gases, 2. chronic low-dose radiation exposure,3. exposure to blood and body fluid, 4. psychological stress: irregular working hours, sleep deprivation, sustained vigilance, easy access to drugs

10. Operating room • Compared to that of general internists, a group of physicians who practice outside of op room

11. Materials and methods • Physician master file by American medical association • The underlying and contributing causes of death were obtained by National Death Index • Cohort study began on Jan 1, 1979 and continued through Dec 31, 1995

12. Results

16. AN suicide rate and drug-related death were higher than IM • The rate increased with increasing years since graduation • The difference in rates for drug-related death were greatest in the first 5 yrs after graduation

17. The relative risk for drug-related suicides and drug-related death in AN compared with IM • AN had a greater NO of years of life lost before 65 because of suicides, drug-related suicides, and drug-related deaths and a higher all-cause mortality rate than IM (12956 life-years vs 9936 life years)

18. Discussion • Op room environment: no increase the risk of death from cancer • Suicide, drug-related death, cerebrovascular disease and other external causes • HIV and viral hepatitis

19. Mortality risks compared with general population • AN and IM had lower mortality rates the GP • Increased suicide rate in FAN, and increased accidental poisoning in MAN • Healthy worker effect

20. Mortality risks compared with IM • No any increase in risk of death by cancer • Pancreatic cancer, leukemia • HIV and viral hepatitis life style ? • Suicide  exp. In F • Cerebral vascular disease: op room environment? • Other heart and circulatory disease: lower than IM

21. Anesthesiologists and acute perioperative stress Anesth analg 2002; 95:177-83

22. Anesthesiologist as a stressful specialty… • Chronic stress: competence factors, production pressures, long working hours, night calls, and fatigue; fears of litigation, economic uncertainty, interpersonal relationship • ASA retired members: demand of night calls> difficult cases> liability issue> workload> burnout> economic issue

23. Acute stress • The specific acute stressor encountered is the study of stress in pilots • Sympathomedullary and adrenocortical changes

24. Materials and methods • Cross-section cohort study • Three hospitals: university, veterans, community • Psychologic questionnaires: MBSS and STAI • HR: Holter monitor; BP: every 60 mins and right after induction or IOE; salivary cortisol: 20 min after induction

25. Results

26. physiologic outcome measure: HR • AN’ HR increased during all stages of anesthetic process compared with baseline HR ( finishing/ intubation: 80+/-12 / 84+/- 11)

27. HR >100 in 18% of all inductions, tended to have less yrs of experiences and higher anxiety score

28. HR during clinical days was higher than nonclincal days • In clinical days max. HR: 57% during induction; 18% IOE; 15% various administrative activities; 5% unrelated physical activities • Holter tapes: PAC and VE  no correlation

29. Physiologic outcome measures: BP • Both systolic and diastolic BP after induction were increased, but not clinically significant (125+/-8 / 82+/- 7 vs 107 +/-10 / 70+/- 8, P=0.001) • No correlation with factors • The average BP of AN on clinical days did not differ from that of nonclinical days

30. IOE • The average HR increased by 31% 1 min before IOE • The degree of increased in HR positively correlated to trait anxiety, negatively correlated with years of experience and high monitor coping style

31. Physiologic outcome measure: cortisol • 20min after induction compared with morning baseline • Changes in cortisol level were inversely related to years in practice

32. STAI • Anxiety did not increase significantly after induction • AN In charge of the OR reported increased anxiety level • Anxiety after induction was moderately correlated to the NO of ORs supervised

33. Discussion • AN HR increased during all stages of the anesthetic process but not clinically significant • SBP and DBP were increased but not clinical significant • Significant increased HR and BP were observed during and after IOE • Did not report increased anxiety after induction • May underestimate BP: 17% of all induction were associated with DBP> 90mmHg the significance of intermittent diastolic hypertension is unclear inasmuch as several investigators have reported that mortality secondary to coronary and atherosclerotic heart disease is decreased among AN

34. The average BP and HR among AN during induction is not more than that of other high-intensity specialties such as emergency medicine and surgery • Increased suicide rates among AN: chronic stress?

35. Conclusion • AN associated with minor manifestation of acute physiologic stress • The mortality rate secondary to CAD is less among AN

36. The role of stress in anesthesiologists’ health and well-being Acta anaesthsiol scand 1999; 43: 583-602

37. Background • In both Europe and North America, physicians and their spouses, when compared with the general population, suffer a significantly increased incidence of alcohol and drug abuse, depression, suicide, and psychiatric hospitalization. • Higher rates of suicide among AN and elevated incidence of chemical dependence

38. Unmanaged stress is a worldwide source of suffering and illness for anesthesiologist. • Excessive stress can adversely affect a physicians humanity, ethical fiber, moral integrity, physical condition, psychological stability, and capacity to care for patients in a safe manner.

39. Definition • Stress is the nonspecific adaptive response of the body to any change, demand, pressure, challenge, threat or trauma. • These can originate extrinsically or intrinsically • A situation become stressful when an individual feels unable to cope with demands to which s/he feels compelled to respond.

40. Occupation-related stress • Continuous critical care: an intense and prolonged vigilant focus on the care of our patient • A malpractice suite is among the most stressful : AN involved in litigation have been reported to be more prone to suicide • Tachycardia, PVC, ST segment depression ever noted during anesthesia process

41. Stage in career related stress • Anesthesia training is physically and intellectually taxing • Harsh working conditions, uncertainty of their knowledge and clinical ability, a high degree of responsibility, sleep deprivation and physical fatigue, a general lack of respect for one’s status as a physician

42. Older anesthesiologists: financial stress, aging, production pressure for research, publication, and teaching • Instructing inexperienced trainees is physiological stressful • Teaching and research funding: dilemmas

43. Gender-related stress • “less-than-man”? • Sexual harassment and discrimination, male-dominated environment, “glass ceiling” • Pregnancy, child-rearing, home-keeping • “Sandwich generation”

44. Workplace- related stress • Relationships and interactions with surgeons, obstetricians, consultants and other personnel in the op room and postanesthesia care unit: dynamic spectrum of personalities, competencies, cooperative spirit, motivation, work ethic and personal problems

45. Noise pollution: sympathoadrenal discharge chronic anxiety and hypertension, cognitive and psychological effects • Exhaled vapors and surgical exhaust • Radiation • Latex • Infection • Excessive heat or cold • Uncomfortable chairs and poorly designed work spaces • Visual challenges

46. Production pressures • Long, unpredictable and uncontrollable work hours • Erratic opportunuties for nutrition, hydration, and bathroom breaks • Physical, psychological and intellectual isolation

47. Role-irrelevant stress- sleep deprivation, fatigue and status deprivation • Sleep deprivation is cumulative and can be repaid only through restorative sleep • Circadian rhythms are biological rhythms of sleep and wakefulness that fluctuate on a diurnal time schedule, and disturbances will accentuate sleep debt • Circadian lulls: 1-6 am, 2-4 pm • Naps strictly limited to less than 45mins will enhance alertness, judgment, creativity and productivity; especially effective during circadian lulls

48. Anesthesiologists have both a professional and ethical obligation to ensure that fatigue and inadequate sleep do not jeopardize patient safety • Status deprivation: failure of the long series of physicians’ educational and training achievement

49. Burnout • Burnout is a cumulative process leading to the loss of physical and mental energy, and to emotional exhaustion and withdrawal • High level of emotional exhaustion and depersonalisation, and low levels of personal accomplishment • Physician welfare, patient safety

50. Self-evaluation of stress