Huaping Sun

Substance use disorder among anesthesiology residents, 1975-2009.

IMPORTANCE Substance use disorder (SUD) among anesthesiologists and other physicians poses serious risks to both physicians and patients. Formulation of policy and individual treatment plans is hampered by lack of data regarding the epidemiology and outcomes of physician SUD. OBJECTIVE To describe the incidence and outcomes of SUD among anesthesiology residents. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of physicians who began training in United States anesthesiology residency programs from July 1, 1975, to July 1, 2009, including 44,612 residents contributing 177,848 resident-years to analysis. Follow-up for incidence and relapse was to the end of training and December 31, 2010, respectively. MAIN OUTCOMES AND MEASURES Cases of SUD (including initial SUD episode and any relapse, vital status and cause of death, and professional consequences of SUD) ascertained through training records of the American Board of Anesthesiology, including information from the Disciplinary Action Notification Service of the Federation of State Medical Boards and cause of death information from the National Death Index. RESULTS Of the residents, 384 had evidence of SUD during training, with an overall incidence of 2.16 (95% CI, 1.95-2.39) per 1000 resident-years (2.68 [95% CI, 2.41-2.98] men and 0.65 [95% CI, 0.44-0.93] women per 1000 resident-years). During the study period, an initial rate increase was followed by a period of lower rates in 1996-2002, but the highest incidence has occurred since 2003 (2.87 [95% CI, 2.42-3.39] per 1000 resident-years). The most common substance category was intravenous opioids, followed by alcohol, marijuana or cocaine, anesthetics/hypnotics, and oral opioids. Twenty-eight individuals (7.3%; 95% CI, 4.9%-10.4%) died during the training period; all deaths were related to SUD. The Kaplan-Meier estimate of the cumulative proportion of survivors experiencing at least 1 relapse by 30 years after the initial episode (based on a median follow-up of 8.9 years [interquartile range, 5.0-18.8 years]) was 43% (95% CI, 34%-51%). Rates of relapse and death did not depend on the category of substance used. Relapse rates did not change over the study period. CONCLUSIONS AND RELEVANCE Among anesthesiology residents entering primary training from 1975 to 2009, 0.86% had evidence of SUD during training. Risk of relapse over the follow-up period was high, indicating persistence of risk after training.

Perceived value of Board certification and the Maintenance of Certification in Anesthesiology Program (MOCA

STUDY OBJECTIVE To determine the attitudes and perceptions of diplomates of the American Board of Anesthesiology (ABA) regarding the value of Board certification, Maintenance of Certification (MOC),and the specific components. DESIGN Survey instrument. SETTING American Board of Anesthesiology, Raleigh, NC, USA. SUBJECTS Diplomates of the ABA. MEASUREMENTS A SurveyMonkey link was sent to 3,000 randomly selected 1) non-time-limited diplomates who were not enrolled in MOC, 2) non-time-limited diplomates who were enrolled in MOC, and 3) time-limited diplomates of the ABA (1,000 survey requests per group). The surveys queried demographics, attitudes about the value of Board certification, and attitudes and knowledge about Maintenance of Certification in Anesthesiology (MOCA). MAIN RESULTS 17% to 27% of diplomates from each group completed the survey. The majority of these diplomates perceived Board certification to be of value in demonstrating competence, although fewer believed that Board certification reflected competence. The elements of Professional Standing and Lifelong Learning and Self-Assessment were perceived to be significantly more relevant to the practice of the diplomates than were the Cognitive Examination and Practice Performance Assessment and Improvement activities. Diplomates demonstrated concerns about the cost and complexity of MOC, a lack of evidence that it improves practice, and a belief that the Cognitive Examination covered topics that were not relevant to their current practice. CONCLUSIONS Although diplomates of the ABA highly value Board certification and report that the components of the MOCA program have potential relevance to their practices, they expressed significant concerns about the program as it is currently implemented.

Predictors of performance on the Maintenance of Certification in Anesthesiology Program® (MOCA®) examination

STUDY OBJECTIVE The aim of this study was to determine the independent factors associated with performance on the Maintenance of Certification in Anesthesiology Program (MOCA) examination. DESIGN Cross-sectional study. SETTING The American Board of Anesthesiology, Raleigh, NC. SUBJECTS The American Board of Anesthesiology (ABA) diplomates who were certified between 2000 and 2006 and had taken the MOCA examination at least once by July 2013. MEASUREMENTS MOCA examination score for the first attempt. MAIN RESULTS Independent positive predictors for MOCA examination score in multiple regression analysis included passing the ABA Part 1 and Part 2 certification examinations on the first attempt and male sex, whereas negative predictors included history of action(s) taken against any medical license, taking the examination later in the MOCA cycle and older age at primary certification. CONCLUSIONS Several factors in addition to performance on the written examination for primary certification (Part 1 Examination) are independently associated with performance on the MOCA examination. Because many of these factors are not modifiable, those diplomates who possess unfavorable risk factors should pay special attention to engaging in continuing learning to prepare for the MOCA examination.

Risk and Outcomes of Substance Use Disorder among Anesthesiology Residents: A Matched Cohort Analysis.

Background:The goal of this work is to evaluate selected risk factors and outcomes for substance use disorder (SUD) in physicians enrolled in anesthesiology residencies approved by the Accreditation Council for Graduate Medical Education. Methods:For each of 384 individuals with evidence of SUD while in primary residency training in anesthesiology from 1975 to 2009, two controls (n = 768) who did not develop SUD were identified and matched for sex, age, primary residency program, and program start date. Risk factors evaluated included location of medical school training (United States vs. other) and anesthesia knowledge as assessed by In-Training Examination performance. Outcomes (assessed to December 31, 2013, with a median follow-up time of 12.2 and 15.1 yr for cases and controls, respectively) included mortality and profession-related outcomes. Results:Receiving medical education within the United States, but not performance on the first in-training examination, was associated with an increased risk of developing SUD as a resident. Cases demonstrated a marked increase in the risk of death after training (hazard ratio, 7.9; 95% CI, 3.1 to 20.5), adverse training outcomes including failure to complete residency (odds ratio, 14.9; 95% CI, 9.0 to 24.6) or become board certified (odds ratio, 10.4; 95% CI, 7.0 to 15.5), and adverse medical licensure actions subsequent to residency (hazard ratio, 6.8; 95% CI, 3.8 to 12.2). As of the end of follow-up, 54 cases (14.1%) were deceased compared with 10 controls (1.3%); 28 cases and no controls died during residency. Conclusion:The attributable risk of SUD to several adverse outcomes during and after residency training, including death and adverse medical license actions, is substantial.

Association between Participation in an Intensive Longitudinal Assessment Program and Performance on a Cognitive Examination in the Maintenance of Certification in Anesthesiology Program

Background:As part of the Maintenance of Certification in Anesthesiology Program® (MOCA®), the American Board of Anesthesiology (Raleigh, North Carolina) developed the MOCA Minute program, a web-based intensive longitudinal assessment involving weekly questions with immediate feedback and links to learning resources. This observational study tested the hypothesis that individuals who participate in the MOCA Minute program perform better on the MOCA Cognitive Examination (CE) compared with those who do not participate. Methods:Two separate cohorts of individuals eligible for July 2014 and January 2015 CEs were invited to participate in this pilot. The CE scores for each cohort were compared between those who did and did not participate, controlling for the factors known to affect performance. For the first cohort, examination performances for topics covered and not covered by the MOCA Minute were analyzed separately. Results:Six hundred sixteen diplomates in July 2014 and 684 diplomates in January 2015 took the CE for the first time. In multiple regression analysis, those actively participating scored 9.9 points (95% CI, 0.8 to 18.9) and 9.3 points (95% CI, 2.3 to 16.3) higher when compared with those not enrolled, respectively. Compared to the group that did not enroll in MOCA Minute, those who enrolled but did not actively participate demonstrated no improvement in scores. MOCA Minute participation was associated with improvement in both questions covering topics included the MOCA Minute and questions not covering these topics. Conclusions:This analysis provides evidence that voluntary active participation in a program featuring frequent knowledge assessments accompanied by targeted learning resources is associated with improved performance on a high-stakes CE.

Clinical Performance Scores Are Independently Associated with the American Board of Anesthesiology Certification Examination Scores.

BACKGROUND:It is unknown whether clinical performance during residency is related to the American Board of Anesthesiology (ABA) oral examination scores. We hypothesized that resident clinical performance would be independently associated with oral examination performance because the oral examination is designed to test for clinical judgment. METHOD:We determined clinical performance scores (Zrel) during the final year of residency for all 124 Massachusetts General Hospital (MGH) anesthesia residents who graduated from 2009 to 2013. One hundred eleven graduates subsequently took the ABA written and oral examinations. We standardized each graduate’s written examination score (ZPart 1) and oral examination score (ZPart 2) to the national average. Multiple linear regression analysis was used to determine the partial effects of MGH clinical performance scores and ABA written examination scores on ABA oral examination scores. RESULTS:MGH clinical performance scores (Zrel) correlated with both ABA written examination scores (ZPart 1) (r = 0.27; P = 0.0047) and with ABA oral examination scores (ZPart 2) (r = 0.33; P = 0.0005). ABA written examination scores (ZPart 1) correlated with oral examination scores (ZPart 2) (r = 0.46; P = 0.0001). Clinical performance scores (Zrel) and ABA written examination scores (ZPart 1) independently accounted for 4.5% (95% confidence interval [CI], 0.5%–12.4%; P = 0.012) and 20.8% (95% CI, 8.0%–37.2%; P < 0.0001), respectively, of the variance in ABA oral examination scores (ZPart 2). CONCLUSIONS:Clinical performance scores and ABA written examination scores independently accounted for variance in ABA oral examination scores. Clinical performance scores are independently associated with the ABA oral examination scores.

Effectiveness of Written and Oral Specialty Certification Examinations to Predict Actions against the Medical Licenses of Anesthesiologists

Background: The American Board of Anesthesiology administers written and oral examinations for its primary certification. This retrospective cohort study tested the hypothesis that the risk of a disciplinary action against a physician’s medical license is lower in those who pass both examinations than those who pass only the written examination. Methods: Physicians who entered anesthesiology training from 1971 to 2011 were followed up to 2014. License actions were ascertained via the Disciplinary Action Notification Service of the Federation of State Medical Boards. Results: The incidence rate of license actions was relatively stable over the study period, with approximately 2 to 3 new cases per 1,000 person-years. In multivariable models, the risk of license actions was higher in men (hazard ratio = 1.88 [95% CI, 1.66 to 2.13]) and lower in international medical graduates (hazard ratio = 0.73 [95% CI, 0.66 to 0.81]). Compared with those passing both examinations on the first attempt, those passing neither examination (hazard ratio = 3.60 [95% CI, 3.14 to 4.13]) and those passing only the written examination (hazard ratio = 3.51 [95% CI, 2.87 to 4.29]) had an increased risk of receiving an action from a state medical board. The risk was no different between the latter two groups (P = 0.81), showing that passing the oral but not the written primary certification examination is associated with a decreased risk of subsequent license actions. For those with residency performance information available, having at least one unsatisfactory training record independently increased the risk of license actions. Conclusions: These findings support the concept that an oral examination assesses domains important to physician performance that are not fully captured in a written examination.

Feasibility of patient and peer surveys for Maintenance of Certification among diplomates of the American Board of Anesthesiology.

STUDY OBJECTIVE The initial developmental standards for Maintenance of Certification programs proposed by the American Board of Medical Specialties included the administration of patient and peer surveys by the diplomate every 5 years. The aim of this pilot study was to determine the feasibility of Maintenance of Certification in Anesthesiology Program (MOCA) patient and peer surveys in a selected group of American Board of Anesthesiology (ABA) diplomates. DESIGN The design was a pilot test of survey instruments-MOCA Patient Care Survey and MOCA Peer Survey. SETTING The setting was the ABA, Raleigh, NC. SUBJECTS The subjects were ABA-certified anesthesiologists who were active examiners for the primary certification oral examination as of January 2013. MEASUREMENTS Fifty-one participating physicians in the patient survey group distributed brochures, which included a link to the MOCA Patient Care Survey, to up to 100 consecutive patients at the point of care. Fifty-one participating physicians in the peer survey group distributed invitations to MOCA Peer Survey via e-mail to 20 peers in a variety of roles. Participants developed and evaluated a practice improvement plan based on survey results. Participants were also surveyed on their opinions on the feasibility of implementing the piloted survey instrument in their practices. MAIN RESULTS Response rates for the patient care and the peer surveys were 15% and 75%, respectively. Both surveys indicated a high level of satisfaction with the diplomates; approximately two-thirds of physicians could not identify practice areas in need of improvement. CONCLUSIONS These results suggest that threats to the validity of these surveys include distribution bias for peer surveys and response bias for patient surveys and that surveys often do not provide actionable information useful for practice improvement. Alternative approaches, such as including anesthesiologists within an integrated institutional evaluation system, could be explored to maximize the benefits of physician assessments provided by peers and patients.

Effect of the BASIC Examination on Knowledge Acquisition during Anesthesiology Residency

Background: The American Board of Anesthesiology recently introduced the BASIC Examination, a component of its new staged examinations for primary certification, typically offered to residents at the end of their first year of clinical anesthesiology training. This analysis tested the hypothesis that the introduction of the BASIC Examination was associated with an acceleration of knowledge acquisition during the residency training period, as measured by increments in annual In-Training Examination scores. Methods: In-Training Examination performance was compared longitudinally among four resident cohorts (n = 6,488) before and after the introduction of the staged system using mixed-effects models that accounted for possible covariates. Results: Compared with previous cohorts in the traditional examination system, the first resident cohort in the staged system had a greater improvement in In-Training Examination scores between the first and second years of clinical anesthesiology training (by an estimated 2.0 points in scaled score on a scale of 1 to 50 [95% CI, 1.7 to 2.3]). By their second year, they had achieved a score similar to that of third-year clinical anesthesiology residents in previous cohorts. The second cohort to enter the staged system had a greater improvement of the scores between the clinical base year and the first clinical anesthesiology year, compared with the previous cohorts. Conclusions: These results support the hypothesis that the introduction of the BASIC Examination is associated with accelerated knowledge acquisition in residency training and provides evidence for the value of the new staged system in promoting desired educational outcomes of anesthesiology training.

Association between Performance in a Maintenance of Certification Program and Disciplinary Actions against the Medical Licenses of Anesthesiologists

What We Already Know about This Topic Anesthesiology board certification is now time-limited, requiring participation in a program to maintain certification It is unknown how physician performance is associated with participation and performance in this program What This Article Tells Us That Is New The introduction in 2000 of certificates that require participation in a program to maintain certification was not associated with a significant change in the incidence of disciplinary license actions Completing maintenance of certification program requirements in a timely fashion was associated with a lower incidence of license actions Background: In 2000, the American Board of Anesthesiology (Raleigh, North Carolina) began issuing time-limited certificates requiring renewal every 10 yr through a maintenance of certification program. This study investigated the association between performance in this program and disciplinary actions against medical licenses. Methods: The incidence of postcertification prejudicial license actions was compared (1) between anesthesiologists certified between 1994 and 1999 (non–time-limited certificates not requiring maintenance of certification) and those certified between 2000 and 2005 (time-limited certificates requiring maintenance of certification); (2) within the non–time-limited cohort, between those who did and did not voluntarily participate in maintenance of certification; and (3) within the time-limited cohort, between those who did and did not complete maintenance of certification requirements within 10 yr. Results: The cumulative incidence of license actions was 3.8% (587 of 15,486). The incidence did not significantly differ after time-limited certificates were introduced (hazard ratio = 1.15; 95% CI, 0.95 to 1.39; for non–time-limited cohort compared with time-limited cohort). In the non–time-limited cohort, 10% (n = 953) voluntarily participated in maintenance of certification. Maintenance of certification participation was associated with a lower incidence of license actions (hazard ratio = 0.60; 95% CI, 0.38 to 0.94). In the time-limited cohort, 90% (n = 5,329) completed maintenance of certification requirements within 10 yr of certificate issuance. Not completing maintenance of certification requirements (n = 588) was associated with a higher incidence of license actions (hazard ratio = 4.61; 95% CI, 3.27 to 6.51). Conclusions: These findings suggest that meeting maintenance of certification requirements is associated with a lower likelihood of being disciplined by a state licensing agency. The introduction of time-limited certificates in 2000 was not associated with a significant change in the rate of license actions.