Special Perioperative Considerations in Anesthesiology

Anesthesia providers are faced with increasing work stressors and challenges that affect both patient care and the health of providers. Most physicians cope with stressors by relying on situational and personal characteristics. Addiction remains a relatively common maladaptive response. Anesthesiologists tend to abuse more potent medications than the general population and have a higher mortality rate than other practitioners with substance use disorder. Distractions from personal stressors, combined with a myriad of distractions in the operating room, can jeopardize vigilant practice. How can we better provide for the safety of our patients and satisfaction within our own lives? 1) Mindful practice can lead to an internal state of personal wellness. 2) Intentional design of clinical processes can simplify our workflows and increase resilience to errors. 3) Adoption of performance improvement techniques and error reduction strategies can focus on identifying deviations from practice. 4) Checklists and standardized workflows, along with structured communication and team training can improve shared understanding and the reliability of our work. Adoption of such interventions can reduce the burden of our work and improve outcomes for both the practitioner and the patient. This review contains 2 figures, 6 tables, and 55 references. Keywords: burnout, disclosure of mistakes, distractions, malpractice, mindfulness, performance improvement, physician impairment, safety, substance use disorder

Psychiatric ethics

As psychiatric practice becomes more embedded in social, cultural, and financial networks, it is hardly surprising that the scrutiny of psychiatrists by organizations and institutions grows almost daily. This chapter focuses on the scrutiny of psychiatric ethics. Seven papers are reviewed, ranging from the mid-1950s up to 2009. Topics considered include: professional relationships between psychiatrists, physician impairment, confidentiality in the context of dangerousness, standard-of-care disputes, assessments of competency and decision-making capacity, the history and ethics of psychosurgery and neuromodulation, treatment refusal in chronically mentally ill patients, and conflicts of interest in clinical practice guideline authorship. Each paper is summarized with background information, methods, results, and a critical discussion of its significance.

The Aging Physician and Other Professionals

Capacity to practice ones’ profession safely and effectively may become an issue as physicians or other professionals age. While this chapter will focus primarily on the psychiatric assessment of the aging physician, impairment due to illness in persons employed in other healthcare positions, the military, aviation, the judicial system, and law enforcement present similar public safety concerns. The assessment of a physician is used as a model for the evaluation of these other professionals. The role of the state physician’s health committees and physician competency committees in arranging for assessment, support, and monitoring of the impaired aging physician is discussed. Also discussed are mandatory screening and reporting regarding fitness for duty.

Personal Drug Diversion of Narcotics by Physicians:

Diversion of opioids and other controlled substances for personal use by physicians poses a risk to patient health, safety and welfare, as well as the health and well-being of the physicians themselves. This type of diversion places patients at risk for infectious disease transmission, substandard patient care, and/or denial of medication. State medical boards (SMBs) have an obligation to ensure that the highest quality of care is provided to all patients, which includes a multifaceted role in investigating, monitoring and disciplining physicians and a responsibility to make concerted efforts to prevent harm to patients. Thus, SMBs are an integral part of the process when a physician is suspected of being impaired. Implementation of both preventive and responsive measures is crucial in attempting to not only avoid physician drug diversion, but to effectively address drug diversion when it occurs. In April 2011, the House of Delegates of the Federation of State Medical Boards (FSMB) adopted its Policy on Physician Impairment. The policy provides guidance for state medical and osteopathic boards on the inclusion of physician health programs (PHPs) to facilitate evaluation, recovery and rehabilitation and monitoring of physicians, as well as to protect the public from impaired physicians. This article reviews the problem of controlled-substances diversion by physicians and its adverse effect on public and personal safety, and it demonstrates how SMBs or other parties can use the FSMB Policy on Physician Impairment as a guide to develop their own professional assistance programs to ensure public safety.