Alcoholism among Surgeons—Is It a Hidden Hazard?

Dear Sir,

An alcoholic has been rightly defined as a man who drinks more than his own doctor —Alvan L. Barach

Even though the General Medical Council in the UK states “a surgeon must not work when their health state is adversely influenced by fatigue, disease, drugs or alcohol,” many surgeons are under the influence of one or more when operating. ¹ Alcoholism is becoming a major health hazard for surgeons. ²

The median consumption of alcohol among male and female Finnish doctors was 6.2 and 2.8 liters respectively of absolute alcohol per person per year. The consumption was higher in those aged over 40, with beer being the most consumed by men and wine, by women. ³ About 14% of male and 25% of female surgeons in a study in America suffered from alcoholism. ⁴ In a specialty-wise study from Tamil Nadu, India, among 235 respondents, 82% of doctors used alcohol and they were mostly from the surgical fields. The prevalence rate was higher among doctors (82%) than the general population (7%–75%). ⁵

Surgeons reporting a major medical error in the previous three months are more likely to have alcohol dependence. ⁴ A study from Brighton and Sussex, UK, showed that there are no deleterious effects on surgical performance following the consumption of one glass of wine 45 minutes prior to micro-laryngoscopy among ENT surgeons of varying experience, but there was a 7.25% reduction in the ability after three glasses of wine, hurting performance, with decreased surgical dexterity, cognitive functions, and professionalism. ¹ The ability of surgeons to communicate with the scrub nurse was affected negatively after ≥3 glasses of wine. In a study done among orthopedic surgery residents in the USA, 56% reported burnout/depression and 61% had hazardous alcohol dependence. The identified risk factors were exceedingly prolonged duty hours, lack of program support with unmanageable work volume, and lack of physical exercise. ⁶

During the COVID-19 pandemic, alcohol consumption has threateningly increased in physicians in quarantine in Poland, with over 40% using alcohol more than 4 times/week due to anxiety and hopelessness. ⁷ A study from Norway showed that female surgeons are less likely to abstain from alcohol, more likely to drink weekly, and more likely to engage in hazardous drinking than other female doctors. With separate gender analyses, being a surgeon was a significant predictor of drinking for both females (OR = 2.8, 95% CI = 1.2–6.6) and males (OR = 1.5, 95% CI = 1.0–2.3). ⁸ A study from Belgium on gender distribution in the medical specialties found that in anesthesia, internal medicine and gynecology-obstetrics, women reported equal or even higher levels of hazardous drinking than men. ⁹ About 10% of doctors allow alcohol to affect their overall well-being, health and medical practice. ¹⁰ Last but not least, the bottom line in the final statistics remains that 1 in 6 surgeons abuse alcohol. ¹¹

By personal observation, the factors that drive a surgeon to look for an easy outlet in alcohol include the long working hours in the operation theatre under stressful conditions, lack of major increment or periodic hike in salary, no appreciation or any type of recognition from the mentor/organization, the stress of either causing or managing a postoperative surgical complication, the medicolegal hassles in the career and reputation of a surgeon if there is any unexpected or inadvertent surgical error, and job dissatisfaction. Increased alcohol consumption in surgeons has been associated with older age, disappointment or dissatisfaction with career and job, heavy smoking, use of benzodiazepines, stress and burnout symptoms, suicidal ideation, psychiatric morbidity, emotional exhaustion, and diseases related to alcohol. ¹² Protective factors against the surgeons having alcohol dependence were marriage or spousal support, career satisfaction, job autonomy, and academic practice. ¹³

Excessive consumption of alcohol appeared to degrade laparoscopic surgical performance the following day, even at 4 pm, suggesting the need to define recommendations regarding alcohol consumption the night before performing laparoscopic surgeries. ¹⁴ The smell of alcohol in the surgeon’s breath during duty hours should raise the alarm in the medical and paramedical colleagues. The surgeon should be removed from the call-duty roaster immediately.

A safe surgeon should be neither an occasional nor a regular drinker while in the line of duty. It is high time for the statutory medical governing bodies to enforce clear, transparent guidelines directed at alcohol use for on-call doctors. ¹⁵ For example, the Indian Medical Association had issued an advisory that doctors should refrain from drinking with “nondoctors” in public areas and that the safe limit should be 18 ml for male doctors and 9 ml for female doctors. ¹⁶ As Rule 24 of the Aircraft Rules states that the pilot and the crew members are not allowed to consume alcohol 12 hours before the commencement of a flight, the same rule should be applicable for surgeons where no alcohol consumption should be the dictum for 12 hours preop. ¹⁷

In general, 30% of Indian doctors and physicians go through depression, while 17% have experienced thoughts about ending their life. ¹⁸ It is time for the surgical community to relax, prevent burnout, avoid professional stress, take vacations, have robust medical indemnity insurance for tackling any medicolegal hassle, and get involved in a hobby like dancing/photography or sports regularly. All surgery-related conferences should have strict restrictions on serving alcoholic drinks. Any surgeon requiring detox or rehabilitation due to alcoholism should be taken care of by the hospital. It should be mandatory for the surgical community to undergo a periodic mental health checkup. As there are very few publications in the journals and medical textbooks about the problem of alcoholism in the medical community, it is time to highlight this issue. This is the only way to conserve good surgical hands and acumen from becoming extinct! The journey from “social drinking” to “problem drinking” is short for surgeons.