February 26, 2012 by Robert Wascher
Filed under A Cancer Prevention Guide for the Human Race, Alcoholism, Depression, Drug Abuse, Job Stress, Mental Health, Mental Illness, Physicians, Surgeon Burn-Out, Surgeon Burnout, Weekly Health Update, alcohol, alcohol abuse, medical errors, physician error, surgeon performance, surgeons, surgery
A new study indicates that chronic alcohol abuse among surgeons is far more common than among the general population.
EPIDEMIC OF ALCOHOL ABUSE AMONG SURGEONS
In a previous column (Surgeon Performance and Alcohol), I reviewed a clinical research study that revealed just how significantly alcohol intake degrades surgical skills among surgeons, even well into the day following alcohol intake. In another recent column, I examined a study that revealed a disturbingly high rate of burnout and depression among American surgeons (Surgeon Burnout and Depression). This week, I will present a newly published clinical study that, once again, raises serious concerns about the health and wellbeing of many surgeons in the United States.
In a study that appears in the current issue of the Archives of Surgery, more than 7,000 surgeons in the United States agreed to participate in a confidential assessment of alcohol abuse and alcohol dependence among members of the American College of Surgeons. Validated surveys and tests were administered to these surgeon-volunteers, and the resulting data was analyzed.
Based upon the results of the Alcohol Use Disorders Identification Test, 15 percent of the responding surgeons, overall, were identified as meeting the criteria for either chronic alcohol abuse or alcohol dependence. Further evaluation of the data collected in this study revealed that 14 percent of the participating male surgeons met the criteria for chronic abuse of alcohol or alcohol dependency, while 26 percent of the corresponding female surgeons met these same worrisome criteria. Moreover, surgeons who reported having committed a major medical or surgical error within the previous 3 months were 45 percent more likely to abuse alcohol, or to be dependent upon alcohol, when compared to surgeons who did not report any recent errors. Similarly, surgeons who reported feeling burned out in their professional lives were 25 percent more likely to be problem drinkers when compared to surgeons who did not report professional burnout. Finally, surgeons who reported symptoms consistent with depression were nearly 50 percent more likely to abuse alcohol than surgeons who did not report feeling depressed.
Interestingly, surgeons were less likely to have alcohol abuse and dependency problems if they were older, male, or had children. (Approximately 11 percent of adult males in the general population are thought to have chronic alcohol abuse problems, while only about 5 percent of adult females in the general population appear to abuse alcohol on a regular basis.)
The findings of this study, once again, indicate a disturbingly high rate of substance abuse among American surgeons; and this is the first study to show that female surgeons, unlike women in the general population, are twice as likely as their male counterparts to regularly abuse alcohol. Taken together with previous studies showing very high rates of depression and career burnout among surgeons in the United States, the findings of this latest study are rather worrisome. (Previous studies have also linked an increased likelihood of medical and surgical errors to surgeons who are depressed, and who abuse alcohol and other drugs.)
I should also note that only 29 percent of the surgeons who were contacted agreed to participate in this confidential study. Because this participation rate is much lower than what is typically seen in most survey-based research studies, it raises the important question as to whether or not the rate of alcohol abuse and alcohol dependency might actually be considerably higher among surgeons, in general, than what is reflected in this study. Indeed, most statistics experts believe that a very common reason for nonparticipation in survey-based studies is a reluctance to divulge negative information about oneself. Moreover, even people who elect to participate in survey-based studies often “fudge” their responses in ways that tend to underestimate their bad habits and other self-perceived shortcomings. Therefore, it is entirely possible that the incidence of chronic alcohol abuse and alcohol dependency among surgeons may be even higher than what was reported in this study….
As I have observed in previous columns, surgeons who abuse alcohol, or other drugs, are more likely to be associated with medical errors and worse patient outcomes. However, the stigma of reporting oneself as having an alcohol, or other drug, problem is so great in the medical profession that impaired surgeons (as with other physicians) are generally extremely reluctant to admit that they have an alcohol or drug problem. Most medical boards still require physicians to indicate whether or not they have a history of drug or alcohol abuse on licensure applications, and the medical profession, in general, still seems to be in a state of denial regarding the unusually high incidence of drug and alcohol abuse among physicians when compared to the general public. It also goes without saying that the potential consequences of being operated upon by an impaired surgeon can be catastrophic to both patients and their loved ones, and, therefore, the still prevailing “head in the sand” approach to identifying, and rehabilitating, impaired physicians would not appear to serve the public interest very well, in my view.
While the vast majority of surgeons are passionately devoted to providing the best possible care to their patients, and would therefore not engage in personal behaviors that might potentially endanger their patients, it is becoming increasingly clear that a sizable percentage of surgeons in the United States are seriously impaired by burnout, depression and other mental health illnesses, and by alcohol and drug abuse. Therefore, a better system of screening out surgical trainees who are predisposed to these serious health problems should be considered, while, at the same time, medical authorities at the state and federal levels should make it easier, and less threatening, for currently impaired physicians and surgeons to reach out for help without fearing that they will be punished or professionally sanctioned as a result. I, therefore, applaud the American College of Surgeons for sponsoring and publishing this important study as a preliminary step forward in this direction.
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Dr. Wascher is an oncologic surgeon, professor of surgery, cancer researcher, oncology consultant, and a widely published author
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THE SILENT EPIDEMIC OF SURGEON
BURNOUT AND DEPRESSION
Here in the United States, we face momentous, and as yet unclear, changes in the delivery of health care. Approximately 46 million Americans lack any health insurance at this time, and tens of millions of others have grossly inadequate health insurance. Therefore, many millions of Americans are just one major illness away from a financial catastrophe.
In addition to the huge dilemma of how we go about making health care more efficient and more affordable for everyone, the United States, like most countries around the world, is in the midst of a dramatic shift in the average age of its population. As the graying of America continues (not to mention the ongoing epidemic of obesity across all age ranges, as well), the growing need for high quality, comprehensive health care will continue to present major challenges to our health care system here, and in many other countries around the world.
When I graduated from medical school in 1988, health care experts were predicting a huge surplus of physicians in this country, and in response to this concern, medical schools around the United States began cutting back their class sizes, and a de facto moratorium on opening new medical schools was initiated. Fast forward to 2010, and it has since become apparent that these dire predictions of an impending physician glut were absolutely incorrect. As our population grows older, and more diverse, the demand for physicians is increasingly in danger of outstripping the projected supply of doctors, including surgeons.
Aging patients have a higher incidence of illnesses and injuries that require the expertise of surgeons, and general surgeons in particular. Broadly trained and experienced general surgeons are the primary care doctors, and the workhorses, of the surgical world, and they manage an astonishing array of diseases and injuries. Unfortunately, and for a variety of reasons, comprehensive general surgeons are slowly withering in numbers, while the demand for their skills only continues to increase. Generational attitude shifts among recently graduating physicians have seen young new doctors gravitate towards less demanding “boutique” specialties, and away from the more challenging surgical specialties (like general surgery). Even among those young doctors who still elect to pursue residency training in general surgery, more than two-thirds will go on to train and practice in more restricted subspecialty surgery areas. (Disclaimer: As a surgical oncologist, I am one of those subspecialty surgeons. However, I still include a great deal of general surgery care in my practice, and I continue to take general surgery call in our medical center.) Another factor that discourages potential general surgeons is the enormous debt load that most newly minted doctors graduate from medical school with, and the resultant pressure that they feel to train in specialties that do not require the additional 5 to 10 years of training that general surgeons must complete. (Increasingly, new medical school graduates are, instead, seeking out specialties that are more financially lucrative, and require shorter durations of residency training, than general surgery.)
Yet another adverse factor that has harmed the recruitment of new general surgeons is the ongoing and progressive fragmentation of traditional general surgery practice into other subspecialty domains. For young doctors who are attracted to the diverse and clinically challenging sort of surgical practice that has historically made general surgery a highly desirable profession, the increasing practice restrictions imposed upon general surgeons have removed a major incentive to undergo the many years of training necessary to become a comprehensive general surgeon
Against the backdrop of these and other pressures that continue to dwindle the ranks of broadly trained and practicing general surgeons (as well as other critical core surgical specialists), the issue of surgeon burnout has only recently started to receive its due attention. The comprehensive practice of general surgery, and other demanding surgical specialties, can be grueling and exhausting, particularly in the private practice setting where declining reimbursements compel surgeons to work ever longer hours to maintain their income and lifestyle. (Future threatened cuts in reimbursements to surgeons will likely only further exacerbate surgeon workload problems, and eventual surgeon shortages, as new health care reform initiatives begin to roll out in the coming years.)
A newly published research study, which appears in the current issue of the Journal of the American College of Surgeons, reveals a very disturbing picture of burnout, exhaustion, and depression among surgeons, and the potentially adverse consequences of distressed surgeons on patient outcomes.
In this study, nearly 8,000 surgeon members of the American College of Surgeons responded to a detailed survey, which included self-assessments of their practice details, a validated depression screening tool, and validated assessments of both burnout and overall quality of life. The results of these surgeon surveys were, in a word, depressing.
Among the surgeons who reported working less than 60 hours per week, 30 percent described themselves as burned-out with their profession. Among surgeons who worked 60 to 80 hours per week, 44 percent felt burned-out, and among those surgeons who put more than 80 hours per week, 50 percent experienced significant feelings of burnout. In addition to the number of hours spent in clinical practice per week, the number of nights spent performing overnight surgery call was a highly significant predictor of surgeon burnout. These two surgeon workload factors were also highly statistically significantly linked to clinical depression, difficulties in finding a reasonable home-work balance, and increased conflicts at both home and at work. Additionally, the rates of both personal emotional exhaustion and feelings of depersonalization towards patients were directly associated with working more than 80 hours per week, and with performing 2 or more night calls per week.
Excessive hours spent in clinical practice, as well as performing 2 or more overnight calls per week, also correlated with a significant increase in the number of self-reported medical and surgical errors committed by exhausted and burned-out surgeons. Nearly 11 percent of surgeons who worked more than 80 hours per week admitted to committing medical or surgical errors, compared to about 7 percent of surgeons who worked less than 60 hours per week.
Surgeons who either worked more than 80 hours per week, or who took more than 2 night calls per week, were also significantly more likely to express regret regarding their choice of specialty, and more likely to indicate that they would not choose to become surgeons if they had an opportunity to choose their specialty all over again.
The results of this survey of surgeons across the United States have been generally confirmed by other similar studies, recently. These disturbing findings, as reported by surgeons themselves, paints a picture of a large population of highly essential physician specialists who are, increasingly, feeling burned-out, depressed, emotionally exhausted, regretful of their career choices, and progressively more prone to both depersonalizing their relationships with their patients and to committing more medical and surgical errors. In short, my chosen profession appears to be a profession that is, frankly, approaching a state of crisis.
Because of these enormous (and growing) pressures and stresses that are being experienced by many surgeons, including general surgeons, many public health experts are viewing the current and future surgical workforce with considerable consternation. As more and more surgeons hang up their white coats and put away their scalpels early in their careers, and as more and more newly graduated doctors shy away from the more demanding surgical specialties, our country appears to be headed for a potentially catastrophic mismatch between the demands of an aging population for surgical care and the diminishing pool of physicians who are willing to shoulder the heavy responsibilities, and significant stresses, of surgical practice.
It is my hope that the governmental agencies responsible for implementing current and future health reforms will pay close attention to this study, and others like it. If hard-working surgeons cannot sustain reasonable income levels (against the decades of grueling training required, and the hundreds of thousands of dollars in educational loans that most young doctors acquire) without working themselves into a state of exhaustion, burnout, and divorce, the ranks of general surgeons, and other core surgical specialists, will continue to become thinner and thinner. Ultimately, if things do not change, and soon, you and I might find it difficult to obtain access to high quality surgical care, particularly for emergency illnesses and injuries….
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For a groundbreaking overview of cancer risks, and evidence-based strategies to reduce your risk of developing cancer, order your copy of my new book, “A Cancer Prevention Guide for the Human Race,” from Amazon, Barnes & Noble, Books-A-Million, Vroman’s Bookstore, and other fine bookstores!
Disclaimer: As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity
Dr. Wascher is an oncologic surgeon, a professor of surgery, a cancer researcher, an oncology consultant, and a widely published author
For a different perspective on Dr. Wascher, please click on the following YouTube link:
I and the staff of Weekly Health Update would again like to take this opportunity to thank the more than 100,000 health-conscious people, from around the world, who visit this premier global health information website every month. (As of 9/16/2010, more than 1,000,000 health-conscious people have logged onto Weekly Health Update so far this year!) As always, I enjoy receiving your stimulating feedback and questions, and I will continue to try and personally answer as many of your inquiries as I possibly can.