One of the most prevalent occupational hazards for an anesthesia provider is addiction to anesthesia drugs. Numerous reports estimate the incidence at about 1% per year of training. The American Board of Anesthesiology (ABA) database reports an incidence of 0.86% for residents between 1975 and 2009 [1]. The risk has been known since the beginning of anesthesiology. Males are victims more often than females, American medical school graduates more than international graduates, and younger more frequently than older residents. The incidence has not decreased over time, despite knowledge, resources, and educational efforts dedicated to prevention. The consequences are serious with death, near death, and coma as the initial presentation in 5–10% of cases; less than half of addicted residents finish residency, and of those who do, 43% relapse over a 30-year career [2].

The cause is multi-factorial and includes the stress level in the operating room, psychiatric co-morbidity, prior experimentation with illicit drugs, “start to finish” drug handling, and the natural attraction that draws physicians to anesthesiology from learning that there is a chemical solution to most clinical problems. One provocative hypothesis is the observation that during anesthesia administration the provider is exposed to drugs during handling ampules (aerosol), from expired gas of extubated patients, or contact with work surfaces that are contaminated with the drugs. Chronic exposure may lead to changes in brain chemistry with down-regulation of dopamine receptors in brain reward centers with the addictive drug becoming the preferred agonist. Depression is also associated with chemical dependence in anesthesiology with a genetic linkage to addiction and self-medication known to be a symptom of depression.

The syndrome most commonly involves members of the fentanyl family with lesser contribution from propofol, inhaled agents, nitrous oxide, ketamine, midazolam, with rare reports of many other drugs including lidocaine, ephedrine, and even curare.

Detection is difficult, as self-reporting is rare, access to drugs and diversion are unpleasantly possible, and advanced parenteral skills make it possible to conceal self-administration and chemical dependence for extended intervals. Unfortunately, suicide and accidental death are both more common than self-reporting. The commonest means of detection when death or coma is not the presentation is investigation based on suspicious behavior or direct observation (needle in arm).

Treatment is difficult and requires prolonged in-patient care—best provided at a site with experience in addiction for physicians. Intervention must be planned, organized, and include direct admission to a treatment unit with the leverage of termination, report to the state medical board and the police (felony-diversion of controlled substance).

Re-entry to the specialty is controversial, with some reports of success in staff physicians with supervision of Physician Health Programs (PHP), although the relapse rate is high and dangerous (5–10% mortality). The controversy is even more intense over re-entry for residents because of the high failure rate to finish the residency, the frequent relapse rate, and 9% mortality [3].

Increasing attention is being paid to prevention of diversion, related to the risk of transmission of diseases to patients or co-workers, especially hepatitis C, from handling of contaminated syringes for diversion in the clinical arena. Automated dispensing, electronic user profiles and alerts for mal-transactions are being developed, along with random testing of waste-solutions. Random drug testing has been tried for detection of diversion, also adding an element of prevention. There are costs involved, logistical interferences with clinical work flow, false positives, and a vast array of strategies to “beat-the-test.” Randomization anomalies and false-positives are less of an issue when the testing is conducted with the use of a medical review officer (MRO), an expert in random testing who conducts the randomization as directed by the employer and verifies the validity of each test by excluding positives with a legitimate medical excuse (a prescription).

Stress and fatigue has been a part of medical education from the start. When medical residency began, the resident lived in the hospital with 1 day off (after rounds) per month. Even with duty hour restrictions and work hour monitoring, residency is a life-disruptive pattern, requiring adjustment to fatigue, sleep deprivation, and stress. Fatigue has a dose-dependent impact on both cognitive as well as motor performance. More than 24 h of consecutive sleep deprivation impairs function as much as being legally intoxicated by alcohol. Fatigue is generally associated with medical error with errors of omission being most common. The impact of fatigue on clinical tasks negatively influences both speed and accuracy. Experience with fatigue improves performance, more in accuracy than speed. Fatigue in anesthesia training has been associated with decreased efficiency with laryngoscopy, incomplete pre-anesthesia assessment, needle sticks, body fluid exposure, and an increased wet tap rate at night compared to the daytime. Risk for fatigue-caused medical error is highest during the low point in the human circadian rhythm (1–7 AM) and greater at the same level of fatigue with less clinical experience. Limiting consecutive work to 16 h has been shown to possibly improve patient safety in postgraduate year (PGY)-1 residents (interns). More experienced residents have learned to adapt and can extend patient care to 24 h and beyond for continuity; although it is clear that beyond 24 h, new patients should not be assigned. Even personal safety is an issue, as the resident awake for 24 consecutive hours has a greatly increased risk of having an auto accident while driving home. Sustained fatigue has been associated with reduced immune function, irritable bowel syndrome, depression, and a variety of other diseases. Strategies to reduce the impact of fatigue include napping, caffeine, and breaks from clinical work. Combinations of these choices work best. The highest risk is experienced by the most junior residents, high acuity care, and during low points of the circadian rhythm.

In a much more gradual manner, aging causes decrease in brain function in a manner similar to fatigue. Although the evidence is scarce, it is clear that at some point in human aging, there is decreased fine motor control and decreased tolerance of fatigue, especially during the low point in the circadian rhythm. Some of the decrements in performances have been compensated by reduced call duration, frequency, or assignment of alternate responsibilities. With the aging of the anesthetic work force, the issue will undergo increasing scrutiny over the upcoming decade.

The Americans with Disabilities Act requires that an employer not discriminate based on illness. This means that an illness—physical or mental—cannot be the sole reason to not hire or to fire an individual. In the context of anesthesiology residency, it means that an individual presenting with a physical or mental illness must be allowed to train or continue training with reasonable accommodations. For physical disabilities, mechanical devices and orthotics have allowed individuals with spine or limb issues to function clinically in the anesthesiology world. Issues with the special senses can sometimes be accommodated with mechanical or electronic devices. Ultimately, the individual must be able to perform the basic duties of clinical anesthesiology with reasonable accommodations. Eligibility for board certification is determined by the Credentials Committee of the American Board of Anesthesiology (ABA) using letters and medical records. The unfortunate truth is that some disabilities cannot be accommodated, while others, particularity mental illness, can be difficult to accommodate.

The practice of medicine requires the highest standards of professionalism for personal behavior during clinical care education and research. Since the practice of anesthesiology is the practice of a medical specialty, this fully applies to anesthesiology. The anesthesiologist has the responsibility to place the needs of the patient above his/her own, and to practice with altruism, beneficence, and to fully respect the patient’s autonomy and diversity. This commitment includes personal well-being, respect for colleagues, and participation in the smooth functioning of the development, the hospital, and the health care system as a whole. Respect for rules is an expectation—especially requirements for medical licensure and board certification. Deadlines are absolute and missing deadlines is a serious breach of professionalism that can have adverse consequences. Hot button professionalism issues are found in cases of conflict-of-interest and fraudulent scientific conduct. The anesthesiologist is the leader of the anesthesia team and must show respect for the talents and training of all team members. Most of the clinical care provided by the anesthesia team is provided as consultative services, and the respect for the needs of the primary care physicians (surgeon or proceduralist) is an important element of professionalism. The need to respect resources and economical use of supplies, disposables, equipment, and drugs is an increasing reality of anesthesia practice. Determining risk and recommending interventions to improve surgical outcome are consultant tasks that are an expected part of professional anesthesiology duties. Some elements of hospital functioning, such as acute pain management, transfusion practice, and operating room scheduling can be tasks best performed by an anesthesiologist, and hence are responsibilities accepted as part of a consultative anesthesiology practice.

Bioethics is becoming a common component of medical education. Despite numerous ethical issues, ethics is not a common component of anesthesiology residency. Changes in the American Board of Anesthesiology Oral Examination format and the RRC guidelines for Anesthesiology residency curriculum have changed this rapidly. Accordingly, it is reasonable to focus on the applications of ethics to anesthesia practice.