What Kills Anaesthetists?

Alan Merry

Wright and Roberts reviewed 572 obituaries in the BMJ from April 1995 to December 1995 and in the issue of 6 April 1996, and concluded that anaesthetists died younger than practitioners in other specialities.[1] Khaw, however, questioned the interpretation of their data, on the basis that there was no information on denominators, or on the age distribution of the different specialties.[2] Over the years the possibility has been raised of an association between anaesthesia and various diseases, including multiple sclerosis, [3] cirrhosis and melanoma, [4] and harmful effects such as abortion, [5] but again the data need careful interpretation and, particularly after the widespread introduction of scavenging, there seems to be little evidence to suggest a greater overall risk of ill health from environmental pollution in being an anaesthetist than in being any other sort of doctor. [6,7]

A number of anaesthetists have committed suicide in Australia and New Zealand in recent years. These events make an understandably profound impact on the anaesthesia community. Assistants to the anaesthetist have also committed suicide. All cause mortality is lower in medical practitioners than in the general population, but the rate of suicide is higher; furthermore, although the numbers are small and many factors need to be considered in the interpretation of data related to this question, it does seem that the rate of suicide among anaesthetists may be higher than that among other doctors. [7,8] The risk seems to be more marked for females, for suicides involving the use of drugs, and in those over the age of 65. Depression carries a major risk for suicide in general, as does substance abuse. Censure by medical boards might increase the risk.

One can only speculate over the possible reasons for this increase in the risk of suicide, assuming it is real. Ready access to effective means of committing suicide is probably paramount. Many anaesthetists work long hours in the environment of the operating room, undertake substantial amounts of on call work over most of their working life, and interact regularly with a wide range of people over issues about which their authority often seems to be less than their responsibility. The relationship between anaesthetists and many of their patients is transient, and it often seems that the sign of having provided an excellent service is that this service is (in effect) invisible, and unnoticed by the patient. Achieving this is unlikely to result in the same sort of direct positive feedback to the practitioner as achieving an obvious and beneficial surgical result. Anecdotally, many anaesthetists seem to have internal loci of control, and the conflict between the obvious risks of anaesthesia and the ability of anaesthetists to manage the factors contributing to that risk may difficult to manage. The absence of natural light in the operating room and the disruption of circadian rhythms in the life of anaesthetists may also predispose to depression. [9] Family life may be very protective of health generally, or it may be a great source of stress, depending on the circumstances of each case. Anaesthesia may attract risk takers, and one could imagine therefore that recreational activities chosen by some anaesthetists also contribute to a few early deaths. On the other hand, if preserving life is to matter, then life needs to be worth preserving, and these same activities may be the very important in giving anaesthetists a good reason to live.

There is strong evidence to support the following strategies for the prevention of suicide: training medical practitioners to recognise and treat depression (therefore, having a medical practitioner is important for anaesthetists, and training anaesthetists to recognise depression in themselves or their colleagues would seem sensible); restriction of access to methods for committing suicide (which is impractical for anaesthetists); and integrated programmes founded in institutions to address risk and resilience factors (an opportunity for ANZCA). There is some evidence to support the following strategies: providing support after failed suicide attempts (which may not be very common in anaesthetists); treating mental illness; promoting public awareness; screening for depression and suicide risk; crisis counselling; and support for families of those who have committed suicide. Focussing directly on awareness of suicide may be counter-productive.[10]

1. Wright, D J and Roberts, A P, Which doctors die first? Analysis of BMJ obituary columns. BMJ, 1996. 313: 1581-2.
2. Khaw, K T, Which doctors die first? Lower mean age at death in doctors of Indian origin may reflect different age structures. BMJ, 1997. 314: 1132.
3. Flodin, U, Landtblom, A M, Axelson, O, Multiple sclerosis in nurse anaesthetists. Occupational & Environmental Medicine, 2003. 60: 66-8.
4. Carpenter, L M, Swerdlow, A J, Fear, N T, Mortality of doctors in different specialties: findings from a cohort of 20000 NHS hospital consultants. Occupational & Environmental Medicine, 1997. 54: 388-95.
5. Boivin, J F, Risk of spontaneous abortion in women occupationally exposed to anaesthetic gases: a meta-analysis. Occupational & Environmental Medicine, 1997. 54: 541-8.
6. Accorsi, A, Barbieri, A, Raffi, G B, Violante, F S, Biomonitoring of exposure to nitrous oxide, sevoflurane, isoflurane and halothane by automated GC/MS headspace urinalysis. International Archives of Occupational & Environmental Health, 2001. 74: 541-8.
7. Alexander, B H, Checkoway, H, Nagahama, S I, Domino, K B, Cause-specific mortality risks of anesthesiologists. Anesthesiology, 2000. 93: 922-30.
8. Swanson, S P, Roberts, L J, Chapman, M D, Are anaesthetists prone to suicide? A review of rates and risk factors.Anaesthesia & Intensive Care, 2003. 31: 434-45.
9. Wirz-Justice, A, Terman, M, et al., Brightening depression. Science, 2004. 303: 467-9.
10. Beautrais, A, Fergusson, D, et al., Effective strategies for suicide prevention in New Zealand: a review of the evidence. New Zealand Medical Journal, 2007. 120: 1-13. http://www.nzma.org.nz/journal/120-1251/2459/ (accessed 8/4/2007).