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In this issue: Leaving the operating theatre

Guest writers: The negation of empathy

The alarming truth: suicide in your profession

A personal story: no one is invulnerable

Volunteering for Interplast

Dr Fitzgerald is a VMO Anaesthetist working in private practice in the south of Sydney. She has worked as a VMO in both the Illawarra Shoalhaven and South Eastern Sydney Local Health Networks.

Dr Fitzgerald was a Supervisor of Registrar Training and has served on multiple appointment committees. She has also served as Chairperson of Anaesthesia in the private sector.

Dr Fitzgerald is a keen nurse educator and recently became an ANZCA Hospital Inspector.

She has been a member of Avant since its inception.

Welcome to the eighth edition of Avant Anaesthetists. In this issue we examine several pertinent topics in Anaesthetics.

This bulletin provides pragmatic advice about leaving the operating theatre. From my experience I am aware of the pressure of risk

management we face in our day to day practice and I think simple safe guards about leaving the OR will benefit us.

Professor Cohen and Dr Quinter’s article on empathy makes me acutely aware that negative empathy is something we are all guilty of at times and it is a problem that should be addressed.

Other topics in this bulletin include:

• Volunteering for Interplast, Dr Liz Bashford’s story.

• The disturbing rate of suicide in the anaesthetic profession.

I hope you find this bulletin informative. Avant welcomes your feedback and ideas on future bulletin topics by emailing [email protected] .

Message from Dr Carolyn Fitzgerald

Dr Carolyn Fitzgerald

Australia’s Leading MDO

Issue 8 May 2012

AvantAnaesthetist

22The Doctors’ Health Fund ProposalWe are pleased to announce the Federal Court has formally approved the scheme of arrangement under which Avant will acquire 100% ownership of The Doctors’ Health Fund.

Avant Mutual Group Chair, Dr Stuart Boland, said:

‘Avant Mutual Group looks forward to providing our members and their employees and families with access to The Doctors’ Health Fund’s market-leading suite of health insurance products.’

We expect the transaction to complete in May.

Rewarding your loyalty in 2012Following the launch of our Loyalty Reward Plan (LRP) in 2010, eligible members are again rewarded for their loyalty in 2012, with premium deductions from 5.5% to 11.0%. Avant’s LRP is a first from an Australian MDO and aims to reward members when Avant’s financial performance is strong.

Not all members are eligible for the Loyalty Reward Plan. Members not eligible include interns, RMO1s and medical students and members who have their professional indemnity policy purchased on their behalf under a corporate group arrangement. For more information please contact member services on 1800 128 268.

DIT research scholarship programWe are delighted to announce the launch of the Avant Doctor in Training Research Scholarships Program. The Avant Doctor in Training Research Scholarships Program has been developed by Avant’s Doctor in Training Advisory Council (DITAC) for Doctors in Training. On offer are two full-time scholarships, to the value of $50,000 each, and four part-time scholarships to the value of $25,000 each. Applications close 5pm on 31 May 2012.

News In brief

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Avant Anaesthetists Issue 08 – May 2012

Avant Anaesthetists Issue 07 – June 2011


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As we all know, sometimes while we have a patient anaesthetised on the operating table, we have to leave the theatre. This may be for a simple toilet break, a cup of coffee or an emergency in the operating complex. Whatever the reason, this involves a handover of care. How can we manage the handover and maintain the safety of our patient?

Most hospitals in Sydney I contacted, both private and public, use the policy documents formulated by our College – ANZCA. The College documents pertaining to this issue are:

PS53 – ‘Statement on the Handover Responsibilities of the Anaesthetist’1 and

PS18 – ‘Recommendations on Monitoring During Anaesthesia’.2

The ‘Statement on Handover’ was revised as a result of the WHO Patient Safety Initiative. The review amalgamated two previous documents; one relating to intraoperative handover and the other to postoperative handover. The new document is in a 12 month pilot phase and the College welcomes any feedback.

As stated, our aim is to ensure our patient is safe during our absence. The protocol for handover

is clearly stated and the principles apply to both temporary and permanent relief.

The College’s guide for planned and anticipated handover1 includes the following advice:

1. The relieving Anaesthetist must be competent, willing and fully available to assume responsibility for the patient.

2. The handover should occur when the patient is stable and at a time when no foreseen adverse events are likely to occur, e.g. not at the time of cross clamping major vessels, removing organs deep in the pelvis or when the syringe pump is about to empty.

3. We must fully communicate the health status, both past and present, of our patient e.g. past history of moderately severe asthma, insulin dependent diabetes.

4. We must describe the anaesthetic technique – whether general anaesthesia, paralysed, spontaneous ventilation with or without syringe pumps, or regional anaesthesia with or without sedation. Point out the intravenous/intravascular lines, how the airway is secured and current fluid management.

5. Our reliever must know the current stage of

Leaving the operating theatreGuest writer: Carolyn Fitzgerald UNSW, FANZCA


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the surgical procedure and the implications for any ensuing complications.

6. Show the record of monitoring and discuss the current figures displayed on the monitor. You should discuss what values you are not happy to accept.

7. Check everything before you leave including delivery systems, monitoring devices and intravenous lines.

8. Finally, notify the surgeon.

On return to the operating theatre, we should go through this again to maintain continuity. This all sounds time consuming, but with practice we can succinctly transfer care.

As an addendum, during the reviews an issue arose about whether the absence should be documented. Time will tell if the College will make a decision about this.

We are all well aware that private hospitals are now undertaking very complex procedures and we do not have extra Anaesthetists or trainees available to relieve us. We rely upon our dedicated anaesthetic nurses and technicians to provide us with cover. These people, I find, are generally invaluable and excellent at assuming responsibility. I think their role should be acknowledged and included in the new College Statement.

If a disaster does occur in your absence, you should be able to demonstrate that you followed the appropriate guidelines.

Sometimes life threatening emergencies do occur. The disclaimer at the end of the College document states:

‘It is recognised that there may be exceptional situations

Your practical take-home advice:

• Follow the College guidelines.

• Tell the team where you are going (preferably not out of the theatre complex).

• Tell the team how long you will be away – 5 minutes is 5 minutes, not 20 minutes.

• Be contactable – don’t forget your mobile phone or leave the extension number where you will be.

• Check everything before you go and after you return.

References

1. The Australian and New Zealand College of Anaesthetists (ANZCA). 2011. Statement of the Handover Responsibilities of the Anaesthetists. ANZCA. Viewed 6 March 2012. <http://www.anzca.edu.au/resources/professional-documents/documents/profes-sional-standards/pdf-files/PS53-2011.pdf>.

2. The Australian and New Zealand College of Anaesthetists (ANZCA). 2008. RECOMMENDATION ON MONITORING DURING ANAESTHESIA. ANZCA. Viewed 6 March 2012. <http://www.anzca.edu.au/resources/professional-documents/documents/professional-standards/pdf-files/PS18-2008.pdf>.

(e.g. some emergencies) in which the interests of patients override the requirements for compliance with some or all of the ANZCA documents.’1

Each case is different but where the patient and operation are stable, in the case of an emergency elsewhere, it may be reasonable to ask the surgeon to stop the procedure, leaving the care with the anaesthetic nurse and surgeon and attend the emergency.


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Health professionals usually regard empathy as a positive attribute to be conveyed to their patients.1 Empathy denotes the capacity of the clinician to sense the emotions and feelings of the patient.2

Derived from the Greek empatheia for ‘in suffering or passion’, empathy implies a shared phenomenology, in which an ‘observer’ is able to accept and understand the expression of another person’s experience because it reflects the observer’s own experience.3

Empathy functions as a foundation for other acts, such as compassion and prosocial behaviour, that allow one person to enter the experience of the ‘other’ in an intuitive manner without having to share that same experience, especially at an emotional level, as is the case for sympathy.4 In medical practice, the patient’s experience of pain is a common substrate for empathy.

Empatheia itself can include the sharing of negative emotions, such as those that may accompany a sense of personal danger or hostility or prejudice,5 which could be directed at another person such as a patient – especially when the legitimacy of that patient’s distress is in doubt and their presentation challenges the clinician’s expectation of a linear relationship between the severity of pain and the extent of tissue damage.6 Often there may be no discernible evidence of the latter.

Empathy may then mutate into a projection of negative emotion and judgement towards the other person and even a conscious avoidance of compassion.7 When empathy is extinguished, and compassion disappears, we have coined the term ‘negative-empathy’.

‘Negative-empathy’ allows community-based stereotypes of chronic pain sufferers to pervade the clinical encounter.8 As stereotypes may contain negative emotional valence, such as ‘putting it on,’ or ‘all in the mind’, ‘negative-empathy’ on the part of health professionals can become a significant component of the complex process of stigmatisation of chronic pain sufferers.

Sociologist Erving Goffman9 defined stigmatisation as a process by which the reactions of a community to specific personal characteristics reduce a person’s identity ‘from a whole and usual person to a tainted, discounted one’, causing that person to be discredited, devalued, rejected and socially excluded from having a voice.

Chronic pain and the negation of empathy

Guest writers: Dr John Quintner and Associate Professor Milton Cohen

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Because clinical relationships are morally charged, chronic pain sufferers are also at risk of being placed in ‘moral jeopardy’ by their clinicians.10 Should they fail to validate the effectiveness claimed by their health professionals, or should they challenge their clinicians’ power to control the relationship, patients may acquire negative labels denoting their motives as suspect and placing the legitimacy or reality of their symptoms in doubt.

Remediation of negative empathy might commence with an examination of binary conceptual frameworks that are readily found in medical teaching and clinical practice: ‘objective’ vs ‘subjective’, ‘normal’ vs ‘abnormal’, ‘body’ (nociception) vs ‘mind’ (somatisation). Recognition of how these dualistic frames can work against patients’ best interests would be

integral to a program seeking not to perpetuate them. The stage would then be set for the emergence of pain theories with greater explanatory power.

By incorporating the insights from neuroscience, a new model of clinical engagement may emerge, one that is scientifically and ethically obliged to discard conceptual frames that perpetuate negative stereotypes. Such a model might include recognition of ‘hidden rules’ of the clinical consultation, such as those governed by power imbalance, that might hinder a rapprochement between clinician and patient.11 In this space, the experiences of both patient and clinician are shared and negotiated, each being an ‘expert’ in their own field of experience, thereby resisting socially or culturally determined stereotypes, and avoiding the trap of ‘negative empathy’.

References

1 Gallagher RM. Empathy: a timeless skill for the pain medicine toolbox. Pain Med 2006; 7: 213-4.

2 Preston SD, de Waal FBM. Empathy: its ultimate and proximate bases. Behavioral and Brain Sciences 2002; 25: 1-72.

3 Wispé L. History of the concept of empathy. In: Eizenberg N, Strayer J, eds. Cambridge: Cambridge University Press, 1987: 17-37.

4 Stein E (1917). On the problem of Empathy. Stein W, transl. Washington: ICS Publications, 1989.

5 Craig KD, Versloot J, Goubert L, Vervoort T, Crombez G. Perceiving pain in others: automatic and controlled mechanisms. J Pain 2010; 11: 101-8.Barnes A, Thagard P. Empathy and analogy. Dialogue: Canadian Philosophical Review 1997; 36: 705-20.

6 Krendl AC, Macrae CN, Kelley W, Fugelsang JA, Heatherton TF. The good, the bad, and the ugly: an fMRI investigation of the functional anatomic correlates of stigma. Social Neuroscience 2006; 1: 5-15.

7 Gallese V, Ferrari PF, Umiltà MA. The mirror matching system: a shared manifold of intersubjectivity. Behavioral and Brain Sciences 2002; 25: 35-6.

8 Shaw LL, Batson CD, Todd RM. Empathy avoidance: forestalling feeling for another in order to escape the motivational consequences. Journal of Personality and Social Psychology 1994; 67: 879-87.

9 Goffman E. Stigma: notes on the management of spoiled identity. New York: Prentice Hall, 1963.

10 Nicolaidis C. Police officer, deal-maker, or health care provider? Moving to a patient-centered framework for chronic opioids management. Pain Medicine; 2011; 12: 890-7.

11 Quintner JL, Buchanan D, Cohen ML. Katz J, Williamson O. Pain medicine and its models: helping or hindering? Pain Medicine 2008; 9: 824-34.

This article is based on a previous article published in Pain Medicine.

Cohen M, Quintner J, Buchanan D, Nielsen A, Guy L. Stigmatization of patients with chronic pain: the “dark side” of empathy. Pain Medicine 2011;12:1637–1643.

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What is the rate of suicide in anaesthetists in Australia?The mental health of doctors in Australia is an important issue for the medical community. Doctors have a high suicide rate – male doctors have a 26% higher risk of suicide and female doctors a 146% higher risk of suicide when compared with the general population1. And suicide is the cause of death of up to 10% of anaesthetists.2–4

What is driving the high rate?In an interview with Dr Di Khursandi, Founder of the Welfare of Anaesthetists Special Interest Group, she said there are two main factors. ‘One is that many human beings get depression, which can be a lethal illness. And the other factor, sadly, is substance abuse … which is associated with accidental or deliberate overdose.’

‘We are no different to the rest of the population’ says Dr Khursandi, ‘…there is a high lifetime incidence of depression in general.’ But many doctors report they would not seek help for depression despite their understanding of mental illness.1 Barriers to help-seeking include concerns about stigma, career development, impact on colleagues, impact on patients, confidentiality, embarrassment and professional integrity.1

‘Sadly, there is an ongoing, small, incidence of substance abuse…’ says Dr Khursandi, ‘… and that is associated with accidental or deliberate overdose. We don’t know why, but we imagine that it is because the drugs are available and one or two anaesthetists choose to sample them’. The chances of a substance-abusing anaesthetist dying from overdose or suicide is 25%.5 It seems that anaesthetists are almost always successful at suicide because they have the tools, knowledge and experience.3

Whilst there is no evidence that rates of alcohol abuse are higher in doctors than in the general population, we know that prescription drugs are abused more often.1 The drugs of choice appear to be opioids, propofol, midazolam or other anaesthetic drugs and benzodiazepines.4

It is thought that high-stress, high performance demands and long hours working alone during high-risk surgical procedures can lead to anaesthetists choosing to self-administer agents to alleviate stress.6 Queensland anaesthetist Dr Brian Lewer adds ‘…self-esteem and a perception of entrapment…’ and ‘…obsessive behaviour and character, high intelligence – all the traits endorsed as required to be a “good” anaesthetist…’7 are factors that may impact on suicide rates.

The alarming truth: Suicide among anaesthetists in Australia


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What can you do?Sadly, the first indication of substance misuse is often when the anaesthetist dies, from either deliberate or accidental overdose. And as pointed out by Dr Khursandi ‘…a lot of addicts are very careful to hide the fact they are addicted.’

What can you do?

• work to recognise the signs of depression and/or substance abuse in colleagues

• work to abolish the stigma of mental illness

• strongly and repeatedly urge and recommend that depressed or addicted doctors seek professional help

• work to support colleagues who are in distress, and continue to approach them, even when help or suggestions have initially been rejected.2,8

And finally, time and time again those working in doctors’ health highlight the need for anaesthetists, and all doctors, to have their own GP. Anaesthetists should choose a GP who is used to dealing with doctors as patients, and ‘…allow yourself to be a patient, and ensure your doctor treats you as one.’8

Where to go for more information?For those who are concerned about doctors’ health issues, The Welfare Of Anaesthetists Special Interest Group has developed resource documents. These are available on the ANZCA website www.anzca.edu.au and the Anaesthesia Continuing Education Coordinating Committee (ACECC) website www.acecc.org.au .

Professor Greg Whelan Medical Adviser at Avant, says ‘Doctors tend to like to talk to doctors… so Avant provides a member and peer support program, and in addition, each state has its own Doctors’ Health Advisory Service.’

• MemberSupportProgram Strictly confidential counselling by qualified, independent professionals is available on request. To access this facility ask for the Member Support Program on 1300 360 364.

• PeerSupportProgram On request, members can be referred to a peer mentor who will support them through the claims or complaints process.

• Accesstootherexternalservices Avant staff have contact details for other services such as the Doctors Health Advisory Service available in each state.

If you wish to access Avant’s support services, telephone our Medico-legal Advisory Service on 1800 128 268.

References

1. Beyondblue. The Mental Health of Doctors. Literature Review.2010.2. Khursandi D. Coping with the tragedy of anaesthetist suicide. ANZCA Bulletin. 2011.3. Khursandi D, editor. Death of the anaesthetist - under anaesthesia. ANZCA ASM; 2011; Hong Kong.4. Welfare of Anaesthetists Special Interest Group. Resource document 20: Suspected or proven substance abuse (misuse) 2011.5. Fry RA. Substance abuse by anaesthetists in Australia and New Zealand. Anaesthesia and Intensive Care. 2005;33(2):248-55.6. Tetzlaff J, Collins GB, Brown DL, Leak BC, Pollock G, Popa D. A strategy to prevent substance abuse in an academic

anesthesiology department. Journal of Clinical Anesthesia. 2010;22:143-50.7. Dr Brian Lewer. Email . 8. Welfare of Anaesthetists Special Interest Group. Resource document 01: Personal health issues and strategies 2011.

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One of our members shares their personal story of their struggle with anxiety and depression.

I think, as a group, anaesthetists are aware we are at greater risk of anxiety and depression than the aver-age, both in the general and the medical population. It has been the subject of increased focus during our training and beyond. It was not until it affected me, personally, that it really hit home.

My experience with this illness started in a fairly mundane way. I was exposed to a gradual build up of stressors that came to overwhelm me, much like the frog placed in the slowly heated water that eventually boils to death. Fortunately I was able to extricate myself in time.

I was a junior consultant anaesthetist working as a VMO in both public and private practice. I was busy try-ing to establish myself professionally while trying to raise a young family with a partner who also worked full time. As I picked up work, I was required to participate in more on-call rosters. We took on a large mortgage so there was more pressure on me to increase my income. I started to feel my life was out of control and I had no idea how to fix the situation. Add a family tragedy and some extremely stressful clinical incidents at work into the mix and I clearly wasn’t coping. I found it increasingly difficult to sleep, I was unpleasant to be around and I cut myself off from those who were most concerned about me.

It was very difficult for me to ask for help. I felt I should be coping and was ashamed I wasn’t and I turned to self medication to try to deal with my problems. I reached a crisis point and I had to get help. Through my GP I found a supportive psychiatrist who got me on the right antidepressant after some trial and error. I also saw a psychologist who helped me work through some of my perfectionist tendencies and negative thinking and I took time off to re-evaluate my life.

A few years down the track I am much happier. I may not be quite as well off financially as I would have been if I had kept going down the old path, but I am far richer in friendship, health and enjoyment of life. And I believe I am a much better doctor and person as a result. I know I am still vulnerable to another epi-sode of anxiety or depression but I have developed strategies to recognise the warning signs and seek help earlier. I learnt that no one is indispensable and there will always be great demands on your time. You need to be wise about what you take on. Many of my colleagues commented to me afterwards that they were surprised this could have happened to me. I guess the lesson is that no one is invulnerable.

No one is invulnerable: anxiety and depression

A life-changing partnership

‘You simply can’t explain the look on the parents’ faces when they see their child for the first time after they have their lip repaired,’ said Marion Wright, General Manager, Interplast Australia and New Zealand.

‘Most of them thought they were never ever going to receive treatment, mainly because they couldn’t afford it, and also because there was no-one who could operate.’

Dr Liz Bashford, an Australian anaesthetist who has been volunteering with Interplast for more than 15 years, cites this as one of the main reasons for her commitment to Interplast’s programs.

‘A lot of what we do over there really makes a huge difference to people’s lives in quite a dramatic way. Most of our work in Australia isn’t on the same scale, so it’s very rewarding in that aspect,’ said Dr Liz Bashford.

The greatest challenge for Interplast is funding its programs, which include transport, accommodation and food, medical supplies and equipment, and sponsoring the training of international medical staff in Australia. The charity receives support from AusAid and Rotary, but ongoing funding from corporate sponsors, like Avant, is especially crucial to Interplast’s forward planning.

10Every year Interplast volunteers perform hundreds of operations in the Asia Pacific region, dramatically changing the lives of patients with cleft lips and cleft palates, burn scar contractures and hand injuries.



A life-changing partnership

Funding from Avant enabled Dr Liz Bashford, surgeon Dr James Masson, theatre nurse Jeremy Moles and hand therapist Josephine Gibbs to spend two weeks in Papua New Guinea in February and March of 2011, performing 10 procedures in Madang and 13 in Port Moresby, two of which consisted of seven and eight hour surgeries for patients with near amputations due to bush knife injuries.

Assisting 23 patients during this time, in less than ideal conditions, is impressive, but one of the most difficult experiences for Interplast’s volunteers is knowing they can’t help everyone.

‘It’s awful having to say no to people, but it’s only a few weeks. You could be there for six months and still have work to do at the end of it,’ said Dr Liz Bashford.

This is one of the main reasons Interplast volunteers also take the time to teach local medical practitioners the techniques and skills they will need to eventually undertake specialist surgical procedures by themselves.

‘It’s extremely important to make sure we use every case as a teaching experience. There are only about 16 specialist anaesthetists in Papua New Guinea out of a population of 6 million. In comparison, we have over 4500 anaesthetists for 22 million Australians.’ said Dr Liz Bashford.

Dr Bashford cites her team’s biggest achievement during the time she’s been volunteering with Interplast as seeing one of the local surgeons she worked with on three trips undertaking cleft lip and palate repairs.

‘When I first met him he wasn’t able to do any of that, but now he’s doing wonderful repairs by himself,’ she said.

For information about volunteering, please contact Interplast on (03) 9249 1231 or visit www.interplast.com.au .

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1800 128 268 www.avant.org.au

Risk Management Toolkit Avant’s online Risk Management Toolkit is designed to educate and support members on contemporary practice issues. Visit www.avant.org.au and login to the Members Only section using your User ID and password. Then click on ‘Risk Management Resources’ and ‘Tools and resources.’

Other online resourcesAustralian and New Zealand College of Anaesthetists – www.anzca.edu.au

Anaesthesia Continuing Education Coordinating Committee - www.acecc.org.au

Doctor’s Health Advisory Service – www.dhs.org.au

Interplast – www.interplast.com.au

Online toolbox

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IMPORTANT: Professional indemnity insurance products available from Avant Mutual Group Limited ABN 58 123 154 898 (Avant) are issued by Avant Insurance Limited, ABN 82 003 707 471, AFSL 238 765 (Avant Insurance). Life risk insurance products available from Avant are issued by Hannover Life Re of Australasia Ltd ABN 37 062 395 484 and are distributed by Avant Insurance. The information provided here is general advice only. You should consider the appropriateness of the advice having regard to your own objectives, financial situation and needs before deciding to purchase or continuing to hold a policy with us. For full details including the terms and conditions (and exclusions) that apply, please read and consider the policy wording and/or PDS for the relevant product, which are available at www.avant.org.au or by contacting us on 1800 128 268. This publication contains general information relating to legal and/or clinical issues within Australia (unless otherwise stated). It is not intended to be and should not be considered a substitute for obtaining personal legal or other professional advice or proper clinical decision-making with regard to the particular circumstances of the situation. Avant Mutual Group Limited and its subsidiaries will not be liable for any loss or damage, however caused (including through negligence), that may be directly or indirectly suffered by you or anyone else in connection with the use of information provided in this publication.

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