One Strike, You're Out: One Size Fits None more

1428 CORRESPONDENCE Keith H. Berge, M.D.,§ Marvin D. Seppala, M.D., William L. Lanier, M.D. §Mayo Clinic, Rochester, Minnesota. berge.keith@mayo.edu References 1. Berge KH, Seppala MD, Lanier WL: The anesthesiology community’s approach to opioid- and anesthetic-abusing personnel: Time to change course. ANESTHESIOLOGY 2008; 109:762–4 2. McLellan AT, Skipper GS, Campbell M, DuPont RL: Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ 2008; 337:2038 3. Menk EJ, Baumgarten RK, Kingsley CP, Culling RD, Middaugh R: Success of reentry into anesthesiology training programs by residents with a history of substance abuse. JAMA 1990; 263:3060–2 4. Wischmeyer PE, Johnson BR, Wilson JE, Dingmann C, Bachman HM, Roller E, Tran ZV, Henthorn TK: A survey of propofol abuse in academic anesthesia programs. Anesth Analg 2007; 105:1066–71 5. Wilson JE, Kiselanova N, Stevens Q, Lutz R, Mandler T, Tran ZV, Wischmeyer PE: A survey of inhalational anaesthetic abuse in anaesthesia training programmes. Anaesthesia 2008; 63:616–20 6. Alexander BH, Checkoway H, Nagahama SI, Domino KB: Cause-specific mortality risks of anesthesiologists. ANESTHESIOLOGY 2000; 93:922–30 7. Berry AJ, Fleisher LA: Cause-specific mortality risks of anesthesiologists. New evidence for the existence of old problems. ANESTHESIOLOGY 2000; 93:919–21 8. Paris RT, Canavan DI: Physician substance abuse impairment: Anesthesiologists vs. other specialties. J Addict Dis 1999; 18:1–7 9. Pelton C, Ikeda RM: The California Physicians Diversion Program’s experience with recovering anesthesiologists. J Psychoactive Drugs 1991; 23:427–31 10. Domino KB, Hornbein TF, Polissar NL, Renner G, Johnson J, Alberti S, Hankes L: Risk factors for relapse in health care professionals with substance use disorders. JAMA 2005; 293:1453–60 (Accepted for publication January 27, 2009.) Anesthesiology 2009; 110:1428 Copyright © 2009, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. In Reply:—We read the letters to the editor written in response to our review article1 and the accompanying editorial2 with great interest, and we are encouraged by the enthusiasm generated for this very important discussion. Drs. Skipper and DuPont contest our assertion that “outcomes have not appreciably changed” during the period of time covered by our review (1992–2007), and cite three papers to support their position.3–5 Each of these papers report similar positive outcomes for physicians treated and monitored by physician health programs, but they specifically do not indicate any improvement in outcomes in the periods covered (1991– 2005). These reports support our assertion that “outcomes have not appreciably changed.” In interpreting these studies, it is important to appreciate that the selection process, which is generally described as individuals who complete a multiyear program, tends to systematically eliminate early relapsers from the data set. Nonetheless, these are peerreviewed reports that could and perhaps should have been cited in our review. We agree that treatment and monitoring by a physician health program is essential if an anesthesiologist wishes to return to clinical practice. Skipper and DuPont also cite the lack of evidence for patient harm reported in the 2005 study by Domino et al.; however, lack of evidence is not the same as lack of harm. We believe is it both self serving for the addicted practitioner as well as somewhat irrational from a neurophysiologic perspective to argue that an individual who is managing a addiction that requires diverting medication from their patients is a competent anesthesia provider. One might argue that given a stable dose of methadone, one could be an attentive and focused anesthesiologist. As pointed out by Dr. Torri, when someone is diverting drugs and charting it on a patient’s record, one need not look further for harm. To suggest that harm is only measurable in morbidity and mortality is indeed to minimize the role and value of modern anesthesia practice. Although we had a serious discussion as to whether to suggest a “one strike, you’re out” policy for anesthesia practitioners, we chose to suggest an individualized approach. It should be noted that asking a trained nurse or physician to find another specialty of medicine in which to practice is hardly draconian, and we find it difficult to assert that individuals have some form of right to return to the scene of the crime. We note that “out” could easily mean out of clinical medicine entirely, but even this scenario allows for alternative careers. However, we are also acutely aware of individuals who were treated for substance abuse who have been successfully practicing anesthesiology for 20 or more years without a relapse. Unfortunately, these cases are rare. The suggestion made by Berge et al. is a simple solution without ambiguity, but each case of addiction and recovery has its own narrative that we believe merits consideration. We applaud the assertion made by Dr. Katz that if, as a society, we are going to adopt a “one strike, you’re out” policy, it should be based on evidence. However, we add with some resignation that the lack of appropriate evidence does not diminish the imperative to make decisions when confronted with an addicted colleague. Ethan O. Bryson, M.D.,* Jeffrey H. Silverstein, M.D. *Mount Sinai School of Medicine, New York, New York. ethan.bryson@mountsinai.org References 1. Bryson EO, Silverstein JH: Addiction and substance abuse in anesthesiology. ANESTHESIOLOGY 2008; 109:905–17 2. Berge KH, Seppala MD, Lanier WL: The anesthesiology community’s approach to opioid- and anesthetic-abusing personnel: Time to change course. ANESTHESIOLOGY 2008; 109:762–4 3. Pelton C, Ikeda RM: The California Physicians Diversion Program’s experience with recovering anesthesiologists. J Psychoactive Drugs 1991; 23:427–31 4. Paris RT, Canavan DI: Physician substance abuse impairment: Anesthesiologists vs. other specialties. J Addict Dis 1999; 18:1–7 5. Domino KB, Hornbein TF, Polissar NL, Renner G, Johnson J, Alberti S, Hankes L: Risk factors for relapse in health care professionals with substance use disorders. JAMA 2005; 293:1453–60 (Accepted for publication January 27, 2009.) Anesthesiology 2009; 110:1428–9 Copyright © 2009, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Looking Beyond Model Fidelity To the Editor:—We read with interest the article by Chandra et al. in which the authors address the cost-effectiveness of simulation-based teaching of procedural skills.1 The authors compared an inexpensive low-fidelity simulator to a relatively expensive high-fidelity simulator for learning a complex psychomotor skill: Fiberoptic orotracheal intubation. They found that the high-fidelity simulator had no additional educational benefit. These findings are consistent with the results of other research that has found low-fidelity models to be as effective as high-fidelity models The above letter was sent to the authors of the referenced article. The authors did not feel that a response was required. —James C. Eisenach, M.D., Editor-inChief. Anesthesiology, V 110, No 6, Jun 2009