The prevalence of substance use disorders in American physicians.

BACKGROUND: There have been few studies on the prevalence of substance use disorders (SUDS) in the physician population at large nor have any studies compared the prevalence of SUDS in American physicians by specialty. METHODS: We conducted a national study of SUDS in a large sample of U.S. physicians from all specialty disciplines using the AMA Physician Masterfile. Substance Use Disorders (SUDS) were measured using validated instruments. RESULTS: Of the 27,276 physicians who received an invitation to participate, 7,288 (26.7%) completed surveys. 12.9% of male physicians and 21.4% of female physicians met diagnostic criteria for alcohol abuse or dependence. Abuse of prescription drugs and use of illicit drugs was rare. Factors independently associated with alcohol abuse or dependence were age (OR = .985; p < .0001), hours worked (OR = .994; p = .0094), male gender (OR = .597; p < .0001), being married (OR 1.296; p = .0424) or partnered (OR 1.989; p = .0003), having children (OR .745; p = .0049), and being in any specialty other than internal medicine (OR 1.757; p = .0060). Specialty choice was strongly associated with alcohol abuse or dependence (p = .0011). Alcohol abuse or dependence was associated with burnout (p < .0001), depression (p < .0001), suicidal ideation (p = .0004), lower quality of life (p < .0001), lower career satisfaction (p = .0036), and recent medical errors (p = .0011). CONCLUSION: Alcohol abuse or dependence is a significant problem among American physicians. Since prognosis for recovery of physicians from chemical dependency is exceptionally high, organizational approaches for the early identification of problematic alcohol consumption in physicians followed by intervention and treatment where indicated should be strongly supported.

An interactive individualized intervention to promote behavioral change to increase personal well-being in US surgeons.

OBJECTIVE: Evaluate the utility of a computer-based, interactive, and individualized intervention for promoting well-being in US surgeons. BACKGROUND: Distress and burnout are common among US surgeons. Surgeons experiencing distress are unlikely to seek help on their own initiative. A belief that distress and burnout are a normal part of being a physician and lack of awareness of distress level relative to colleagues may contribute to this problem. METHODS: Surgeons who were members of the American College of Surgeons were invited to participate in an intervention study. Participating surgeons completed a 3-step, interactive, electronic intervention. First, surgeons subjectively assessed their well-being relative to colleagues. Second, surgeons completed the 7-item Mayo Clinic Physician Well-Being Index and received objective, individualized feedback about their well-being relative to national physician norms. Third, surgeons evaluated the usefulness of the feedback and whether they intended to make specific changes as a result. RESULTS: A total of 1150 US surgeons volunteered to participate in the study. Surgeons' subjective assessment of their well-being relative to colleagues was poor. A majority of surgeons (89.2%) believed that their well-being was at or above average, including 70.5% with scores in the bottom 30% relative to national norms. After receiving objective, individualized feedback based on the Mayo Clinic Physician Well-Being Index score, 46.6% of surgeons indicated that they intended to make specific changes as a result. Surgeons with lower well-being scores were more likely to make changes in each dimension assessed (all Ps<0.001). CONCLUSIONS: US surgeons do not reliably calibrate their level of distress. After self-assessment and individualized feedback using the Mayo Clinic Physician Well-Being Index, half of participating surgeons reported that they were contemplating behavioral changes to improve personal well-being.

Avoiding burnout: the personal health habits and wellness practices of US surgeons.

OBJECTIVE: To evaluate the health habits, routine medical care practices, and personal wellness strategies of American surgeons and explore associations with burnout and quality of life (QOL). BACKGROUND: Burnout and low mental QOL are common among US surgeons and seem to adversely affect quality of care, job satisfaction, career longevity, and risk of suicide. The self-care strategies and personal wellness promotion practices used by surgeons to deal with the stress of practice are not well explored. METHODS: Members of the American College of Surgeons were sent an anonymous, cross-sectional survey in October 2010. The survey included self-assessment of health habits, routine medical care practices, and personal wellness strategies and standardized assessments of burnout and QOL. RESULTS: Of 7197 participating surgeons, 3911 (55.0%) participated in aerobic exercise and 2611 (36.3%) in muscle strengthening activities, in a pattern consistent with the Centers for Disease Control and Prevention recommendations. The overall and physical QOL scores were superior for surgeons' following the Centers for Disease Control and Prevention recommendations (all P < 0.0001). A total of 3311 (46.2%) participating surgeons had seen their primary care provider in the last 12 months. Surgeons who had seen their primary care provider in the last 12 months were more likely to be up to date with all age-appropriate health care screening and had superior overall and physical QOL scores (all P < 0.0001). Ratings of the importance of 16 personal wellness promotion strategies differed for surgeons without burnout (all P < 0.0001). On multivariate analysis, surgeons placing greater emphasis on finding meaning in work, focusing on what is important in life, maintaining a positive outlook, and embracing a philosophy that stresses work/life balance were less likely to be burned out (all P < 0.0001). Although many factors associated with lower risk of burnout were also associated with achieving a high overall QOL, notable differences were observed, indicating surgeons' need to employ a broader repertoire of wellness promotion practices if they desire to move beyond neutral and achieve high well-being. CONCLUSIONS: This study identifies specific measures surgeons can take to decrease burnout and improve their personal and professional QOL.

Single dose of 24 milligrams of buprenorphine for heroin detoxification: an open-label study of five inpatients.

Previous studies indicate that buprenorphine has efficacy in medically supervised opioid withdrawal, but the optimal dosing for maximum tolerability and ease of administration remains undetermined. Five heroin-dependent individuals entered this open-label study of inpatient detoxification with a single 24 mg dose of buprenorphine. The mean Clinical Opiate Withdrawal Scale (COWS) score prior to buprenorphine administration was 17.6 (SD = 3.36). COWS scores declined significantly thereafter. There was one episode of precipitated withdrawal that resolved within four hours. Use of ancillary medications was minimal. This study suggests that a single high dose of buprenorphine can be used safely and effectively for inpatient detoxification.

A double-blind, double-dummy, randomized, prospective pilot study of the partial mu opiate agonist, buprenorphine, for acute detoxification from heroin.

The optimum dose of buprenorphine for acute inpatient heroin detoxification has not been determined. This randomized, double-blind, double-dummy, pilot study compares two buprenorphine sublingual tablet dosing schedules to oral clonidine. Heroin users (N = 30) who met DSM-IV criteria for opioid dependence and achieved a Clinical Opiate Withdrawal Scale (COWS) score of 13 (moderate withdrawal), were randomized to receive higher dose buprenorphine (HD, 8-8-8-4-2 mg/day on days 1-5), lower dose buprenorphine (LD, 2-4-8-4-2 mg/day on days 1-5), or clonidine (C, 0.2-0.3-0.3-0.2-0.1 mg QID on days 1-5). COWS scores were obtained QID. Twenty-four hours after randomization, the percentages of subjects who achieved suppression of withdrawal, as defined by four consecutive COWS scores <12, were: C = 11%, LD = 40%, and HD = 60%. Generalized estimating equation regression models, controlling for baseline COWS and time, indicated that COWS scores over the course of 5 days were lower in both LD and HD compared to C (chi(2)(2) = 13.28, P = 0.001). Similar analyses examining scores over time on the Adjective Rating Scale for Withdrawal (ARSW) and on a Visual Analog Scale of Opiate Craving (VAS) indicated an overall treatment effect on the VAS accounted for by a significant difference between HD and C, but no overall treatment effect on the ARSW. There were no discontinuations due to treatment-related adverse events. Both HD and LD regimens are safe and efficacious treatment for opioid detoxification, but HD demonstrated superiority to C on a greater number of measures.

Genetic determinants of addiction to opioids and cocaine.

OBJECTIVE: The completion of the human genome sequence has spurred investigation of the genetic contribution to substance dependence. In this article some of the recent scientific evidence for genetic determinants of opioid and cocaine dependence is reviewed. METHOD: An electronic search of the medical literature was conducted to locate published studies relevant to the genetics of opioid and cocaine dependence. The collected information judged to be most pertinent is described and discussed. RESULTS: Genetic epidemiologic studies support a high degree of heritable vulnerability for both opioid and cocaine dependence. Polymorphisms in the genes coding for dopamine receptors and transporter, opioid receptors, endogenous opioid peptides, cannabinoid receptors, and serotonin receptors and transporter all appear to be associated with the phenotypic expression of this vulnerability once opioids or cocaine are consumed. CONCLUSIONS: Despite this initial progress, identification of specific genes and quantification of associated risk for the expression of each gene remain to be elucidated. While alteration of an individual's genome to change the phenotype seems remote, future interventions for treatment of opioid and cocaine dependence may include precise medications targeted to block the effects of proteins that have been identified through genetic research.

The medical marriage: a national survey of the spouses/partners of US physicians.

OBJECTIVE: To evaluate physician relationships from the perspective of their spouses/partners. METHODS: Nearly all data on satisfaction with physician relationships come from the perspective of the physician rather than their spouse/partner. We conducted a national study of the spouses/partners of US physicians from August 17, 2011, through September 12, 2011. Responding spouses/partners provided information on demographic characteristics, their own work life, and the work life of their physician partners. Spouses/partners also rated relationship satisfaction and the effect of the work life of their physician partner on the relationship. RESULTS: Of the 1644 spouses/partners of physicians surveyed, 891 (54.2%) responded. Most spouses/partners (86.8%) reported that they were satisfied with their relationship with their physician partner. Satisfaction strongly related to the amount of time spent awake with their physician partners each day. Despite their overall satisfaction, spouses/partners reported their physician partners frequently came home irritable, too tired to engage in home activities, or preoccupied with work. On multivariate analysis, minutes spent awake with their physician partners each day was the strongest predictor of relationship satisfaction, exhibiting a dose-response effect. No professional characteristic of the physician partners (eg, hours worked per week, specialty area, and practice setting) other than the number of nights on call per week correlated with relationship satisfaction on adjusted analysis. CONCLUSION: The spouses/partners of US physicians report generally high satisfaction with their relationships. The mean time spent with their physician partners each day appears to be a dominant factor associated with relationship satisfaction and overshadows any specific professional characteristic of the physicians' practice, including specialty area, practice setting, and work hours.

Burnout and satisfaction with work-life balance among US physicians relative to the general US population.

BACKGROUND: Despite extensive data about physician burnout, to our knowledge, no national study has evaluated rates of burnout among US physicians, explored differences by specialty, or compared physicians with US workers in other fields. METHODS: We conducted a national study of burnout in a large sample of US physicians from all specialty disciplines using the American Medical Association Physician Masterfile and surveyed a probability-based sample of the general US population for comparison. Burnout was measured using validated instruments. Satisfaction with work-life balance was explored. RESULTS: Of 27 276 physicians who received an invitation to participate, 7288 (26.7%) completed surveys. When assessed using the Maslach Burnout Inventory, 45.8% of physicians reported at least 1 symptom of burnout. Substantial differences in burnout were observed by specialty, with the highest rates among physicians at the front line of care access (family medicine, general internal medicine, and emergency medicine). Compared with a probability-based sample of 3442 working US adults, physicians were more likely to have symptoms of burnout (37.9% vs 27.8%) and to be dissatisfied with work-life balance (40.2% vs 23.2%) (P < .001 for both). Highest level of education completed also related to burnout in a pooled multivariate analysis adjusted for age, sex, relationship status, and hours worked per week. Compared with high school graduates, individuals with an MD or DO degree were at increased risk for burnout (odds ratio [OR], 1.36; P < .001), whereas individuals with a bachelor's degree (OR, 0.80; P = .048), master's degree (OR, 0.71; P = .01), or professional or doctoral degree other than an MD or DO degree (OR, 0.64; P = .04) were at lower risk for burnout. CONCLUSIONS: Burnout is more common among physicians than among other US workers. Physicians in specialties at the front line of care access seem to be at greatest risk.

Work-home conflicts have a substantial impact on career decisions that affect the adequacy of the surgical workforce.

OBJECTIVE: To evaluate factors associated with work-home conflicts (W-HCs) of US surgeons and their potential personal and professional consequences. DESIGN: Cross-sectional study. PARTICIPANTS: Members of the American College of Surgeons. MAIN OUTCOME MEASURES: Burnout, depression, quality of life, alcohol use, career satisfaction, and career decisions (ie, reduce work hours or leave current practice). RESULTS: Of 7197 participating surgeons, 3754 (52.5%) had experienced a W-HC in the previous 3 weeks. On multivariate analysis, hours worked per week, having children, sex, and work location (Veterans Administration or academic center) were independently associated with an increased risk for W-HC (all P < .01), while some factors (increased age and subspecialty field) reduced the risk. Surgeons with a recent W-HC were more likely to have symptoms of burnout (36.9% vs 17.1%; P < .001), depression (50.9% vs 28.1%; P < .001), alcohol abuse/dependency (17.2% vs 14.4%; P = .003), and were less likely to recommend surgery as a career option to their children (46.0% vs 54.4%; P < .001). Work-home conflicts were also independently associated with surgeons reporting a moderate or higher likelihood of planning to reduce clinical work hours (odds ratio, 1.769) and leave their current practice in the next 24 months for a reason other than retirement (odds ratio, 1.706) after controlling for other personal and professional factors. CONCLUSIONS: Integrating personal and professional lives is a substantial challenge for US surgeons. Conflict in this balance appears to be a major factor in their decision to reduce work hours and/or move to a new practice, with potential substantive manpower implications for the surgical workforce.

Prevalence of alcohol use disorders among American surgeons.

OBJECTIVES: To determine the point prevalence of alcohol abuse and dependence among practicing surgeons. DESIGN: Cross-sectional study with data gathered through a 2010 survey. SETTING: The United States of America. PARTICIPANTS: Members of the American College of Surgeons. MAIN OUTCOME MEASURES: Alcohol abuse and dependence. RESULTS: Of 25,073 surgeons sampled, 7197 (28.7%) completed the survey. Of these, 1112 (15.4%) had a score on the Alcohol Use Disorders Identification Test, version C, consistent with alcohol abuse or dependence. The point prevalence for alcohol abuse or dependence for male surgeons was 13.9% and for female surgeons was 25.6%. Surgeons reporting a major medical error in the previous 3 months were more likely to have alcohol abuse or dependence (odds ratio, 1.45; P < .001). Surgeons who were burned out (odds ratio, 1.25; P = .01) and depressed (odds ratio, 1.48; P < .001) were more likely to have alcohol abuse or dependence. The emotional exhaustion and depersonalization domains of burnout were strongly associated with alcohol abuse or dependence. Male sex, having children, and working for the Department of Veterans Affairs were associated with a lower likelihood of alcohol abuse or dependence. CONCLUSIONS: Alcohol abuse and dependence is a significant problem in US surgeons. Organizational approaches for the early identification of problematic alcohol consumption followed by intervention and treatment where indicated should be strongly supported.

Personal consequences of malpractice lawsuits on American surgeons.

BACKGROUND: Our objective was to identify the prevalence of recent malpractice litigation against American surgeons and evaluate associations with personal well-being. Although malpractice lawsuits are often filed against American surgeons, the personal consequences with respect to burnout, depression, and career satisfaction are poorly understood. STUDY DESIGN: Members of the American College of Surgeons were sent an anonymous, cross-sectional survey in October 2010. Surgeons were asked if they had been involved in a malpractice suit during 2 previous years. The survey also evaluated demographic variables, practice characteristics, career satisfaction, burnout, and quality of life. RESULTS: Of the approximately 25,073 surgeons sampled, 7,164 (29%) returned surveys. Involvement in a recent malpractice suit was reported by 1,764 of 7,164 (24.6%) responding surgeons. Surgeons involved in a recent malpractice suit were younger, worked longer hours, had more night call, and were more likely to be in private practice (all p <0.0001). Recent malpractice suits were strongly related to burnout (p < 0.0001), depression (p < 0.0001), and recent thoughts of suicide (p < 0.0001) among surgeons. In multivariable modeling, both depression (odds ratio = 1.273; p = 0.0003) and burnout (odds ratio = 1.168; p = 0.0306) were independently associated with a recent malpractice suit after controlling for all other personal and professional characteristics. Hours worked, nights on call, subspecialty, and practice setting were also independently associated with recent malpractice suits. Surgeons who had experienced a recent malpractice suit reported less career satisfaction and were less likely to recommend a surgical or medical career to their children (p < 0.0001). CONCLUSIONS: Malpractice lawsuits are common and have potentially profound personal consequences for US surgeons. Additional research is needed to identify individual, organizational, and societal interventions to support surgeons subjected to malpractice litigation.

Prognosis for the recovery of surgeons from chemical dependency: a 5-year outcome study.

HYPOTHESIS: Rates of relapse, monitoring contract completion, and return to medical practice may differ between surgeons and nonsurgeons being monitored for diagnosed substance use disorders. DESIGN: Retrospective 5-year longitudinal cohort study. SETTING: A sample of 16 state physician health programs in the United States. PARTICIPANTS: Nine hundred four physicians who underwent treatment for a substance use disorder and were consecutively admitted to 1 of 16 state physician health programs between September 1, 1995, and September 1, 2001. The study analyzed a subset of data comparing 144 surgeons with 636 nonsurgeons. MAIN OUTCOME MEASURES: Rates of continued drug and alcohol misuse (relapse), monitoring contract completion, and return to medical practice at 5 years. RESULTS: Surgeons were significantly more likely than nonsurgeons to enroll in a physician health program because of alcohol-related problems (odds ratio, 1.9; 95% CI, 1.3-2.7; P = .001) and were less likely to enroll because of opioid use (odds ratio, 0.5; 95% CI, 0.3-0.8, P = .002). Surgeons were neither more nor less likely than nonsurgeons to have a positive drug test result, complete or fail to complete the monitoring contract, or extend the monitoring period beyond the original 5 years specified in their agreements. Fewer surgeons than nonsurgeons were licensed and practicing medicine at the conclusion of the monitoring period, although this difference was not statistically significant. CONCLUSIONS: Surgeons in this study had positive outcomes similar to those of nonsurgeons. However, further research is necessary to conclude whether surgeons are less likely than their nonsurgeon peers to successfully return to medical practice following chemical dependency treatment.

Special report: suicidal ideation among American surgeons.

BACKGROUND: Suicide is a disproportionate cause of death for US physicians. The prevalence of suicidal ideation (SI) among surgeons and their use of mental health resources are unknown. STUDY DESIGN: Members of the American College of Surgeons were sent an anonymous cross-sectional survey in June 2008. The survey included questions regarding SI and use of mental health resources, a validated depression screening tool, and standardized assessments of burnout and quality of life. RESULTS: Of 7905 participating surgeons (response rate, 31.7%), 501 (6.3%) reported SI during the previous 12 months. Among individuals 45 years and older, SI was 1.5 to 3.0 times more common among surgeons than the general population (P < .02). Only 130 surgeons (26.0%) with recent SI had sought psychiatric or psychologic help, while 301 (60.1%) were reluctant to seek help due to concern that it could affect their medical license. Recent SI had a large, statistically significant adverse relationship with all 3 domains of burnout (emotional exhaustion, depersonalization, and low personal accomplishment) and symptoms of depression. Burnout (odds ratio, 1.910; P < .001) and depression (odds ratio, 7.012; P < .001) were independently associated with SI after controlling for personal and professional characteristics. Other personal and professional characteristics also related to the prevalence of SI. CONCLUSIONS: Although 1 of 16 surgeons reported SI in the previous year, few sought psychiatric or psychologic help. Recent SI among surgeons was strongly related to symptoms of depression and a surgeon's degree of burnout. Studies are needed to determine how to reduce SI among surgeons and how to eliminate barriers to their use of mental health resources.

A comparison of two versions of the clinical institute withdrawal assessment for alcohol: the CIWA-Ar and CIWA-AD.

Scores from two versions of the Clinical Institute Withdrawal Assessment for Alcohol, the CIWA-Ar and CIWA-AD, were compared in 135 alcohol detoxification episodes. The paired mean score for withdrawal severity was statistically higher with the CIWA-AD (p < 0.001), but the mean difference of 0.45 (95% CI: 0.38-0.53, t = 11.74) is not likely to be clinically significant. The difference in the total score between the two scales was 1 point or less 82.6% of the time, and nearly all (97.7%) of the CIWA-AD scores were within 3 points of the paired CIWA-Ar score (range - 6 to + 6).