Attention-Deficit/Hyperactivity Disorder and Successful Completion of Anesthesia Residency: A Case Report

Abstract

Cognitive and physical disabilities among anesthesia residents are not well studied. Cognitive disabilities may often go undiagnosed among trainees, and these trainees may struggle during their graduate medical education. Attention-deficit/hyperactivity disorder (ADHD) is an executive function disorder that may manifest as lack of vigilance, an inability to adapt to the rapid changes associated with anesthesia cases, distractibility, an inability to prioritize activities, and even periods of hyperfocusing, among other signs. Programs are encouraged to work closely with residents with such disabilities to develop an educational plan that includes accommodations for their unique learning practices while maintaining the critical aspects of the program. The authors present the management of a case of an anesthesia resident with a diagnosis of ADHD, the perspectives of the trainee, program director, clinical competency director, and the office of general counsel. This article also provides follow-up in the five years since completion of residency.

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Academic Medicine, Vol. 91, No. 2 / February 2016
210
Article
Motor, sensory, and cognitive
disabilities are not well studied
among residents in anesthesia. To our
knowledge, just a single case report exists
documenting the successful completion
of residency by a trainee with an acquired
motor disability.1 Programs may not admit
trainees with disabilities because of a lack
of knowledge about protections afforded
to such individuals, a lack of faith in
their ability to function in the anesthesia
environment, and the misperception that
accommodation to assist the trainee may
interfere with the core requirements of the
program. To help fill these gaps, we present
a case of a resident in anesthesia with
attention-deficit/hyperactivity disorder
(ADHD) who completed an anesthesia
residency program and subsequently
embarked on a successful career in
anesthesiology. We secured permission
from the trainee prior to publication of
this article to share its contents.
Case Report
The resident doctor we observed was
first diagnosed with ADHD at age 10
per his direct report. During childhood
he was noted to be inattentive, with a
tendency to be “spacey” and to daydream.
On psychometric testing as an adult,
the resident always exhibited superior
intellectual functioning, but had relatively
weaker verbal IQ than performance IQ,
and weaknesses on measures of processing
speed, trouble with self-motivation, time
management, and organization. During
subsequent testing as an adult, a diagnosis
of mild developmental learning disability
was noted in addition to the executive
function problems associated with
ADHD.
The resident received psychopharmacologic
treatment and academic accommodations
throughout his schooling years. While
in elementary school, tests were orally
administered. To address difficulties in
high school, college, and medical school,
for example, exams were administered
in a separate room with additional time
accommodations, and earplugs were
allowed. He took the Medical College
Admission Test with the accommodation
of additional time and testing in a
separate room. However, because of a
concern for being stigmatized, he never
requested accommodations for any
national board examinations.
Although the resident was always a
relatively slow reader, even while in
medical school, he described to us that he
worked harder than most other students,
putting more time into studying, and
as a result excelled academically. This
was especially true during clinical
rotations in medical school. Following
medical school, the resident did a one-
year internship, followed by a two-year
research fellowship, and subsequently
matched into an anesthesiology residency
at a top-tier, internationally recognized
program.
The resident had his medication regimen
adjusted to minimize difficulties
specifically related to prioritization,
organization, and executive function-
ing prior to starting residency in
anesthesiology. However, difficulties
were noted by supervising physicians
early on in his training, with excessive
perfectionistic tendencies that were
thought by his supervisors to be a
negative characteristic for being a good
anesthesiologist. These difficulties were
reported via written evaluations and
verbal report to the program director.
Despite the resident’s efforts to minimize
these issues, they were increasingly
noticed by superiors because of recurrent
lateness, time management issues, task
prioritization difficulties, and fixation
on issues that were of little value in
the provision of safe, quality patient
care. The resident was initially placed
on “structured remediation” by the
clinical competency committee (CCC).
Remediation included explanation
of written expectations, including
counseling, defined break times,
weekly meetings with the resident’s
preceptor, and an expectation that cases
would be discussed with the attending
Abstract
Cognitive and physical disabilities
among anesthesia residents are not well
studied. Cognitive disabilities may often
go undiagnosed among trainees, and
these trainees may struggle during their
graduate medical education. Attention-
deficit/hyperactivity disorder (ADHD) is
an executive function disorder that may
manifest as lack of vigilance, an inability
to adapt to the rapid changes associated
with anesthesia cases, distractibility,
an inability to prioritize activities, and
even periods of hyperfocusing, among
other signs. Programs are encouraged
to work closely with residents with such
disabilities to develop an educational
plan that includes accommodations for
their unique learning practices while
maintaining the critical aspects of the
program. The authors present the
management of a case of an anesthesia
resident with a diagnosis of ADHD, the
perspectives of the trainee, program
director, clinical competency director, and
the office of general counsel. This article
also provides follow-up in the five years
since completion of residency.
Acad Med. 2016;91:210–214.
First published online August 3, 2015
doi: 10.1097/ACM.0000000000000854
Please see the end of this article for information
about the authors.
Correspondence should be addressed to Michael G.
Fitzsimons, Department of Anesthesia, Critical Care,
and Pain Medicine, Massachusetts General Hospital,
55 Fruit St., Boston, MA 02114; telephone: (617)
726-8980; e-mail: mfitzsimons@partners.org.
Attention-Deficit/Hyperactivity Disorder
and Successful Completion of Anesthesia
Residency: A Case Report
Michael G. Fitzsimons, MD, Jason C. Brookman, MD, Sarah H. Arnholz, JD,
and Keith Baker, MD, PhD

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Article
Academic Medicine, Vol. 91, No. 2 / February 2016 211
physician the night before. Difficulties
continued, and because the CCC felt that
anesthesiology might not be the right
specialty for him, the resident took a
voluntary leave of absence to assess his
choice of specialty.
During the leave of absence, the resident
began a structured program of cognitive
behavioral therapy to further assist with
ADHD symptom management. He also
chose to inform the program director
about his diagnosis of ADHD and
requested educational accommodations
within the structure of the residency
program to help achieve the academic
potential that he believed was possible
(see List 1). These accommodations
helped the resident develop different
strategies to manage his condition, and
had a significant positive impact on his
clinical work performance. He underwent
a “fitness for duty” evaluation through
the occupational health clinic before
returning from his leave of absence. On
return to clinical duties, the resident was
more closely supervised and continued
to excel academically. He successfully
completed the initial residency program
and went on to a highly competitive
subspecialty fellowship. After successful
completion of this fellowship, this
individual joined the faculty of a top-tier
academic program, where he has excelled
clinically and remains one of the top
faculty educators in the department.
Discussion
The Americans with Disabilities Act
of 1990 (ADA) defines disability as a
physical or mental impairment that
substantially limits one or more of a
person’s major life activities.2 Under the
ADA, employers may not discriminate
against a qualified individual with a
disability and must provide a reasonable
accommodation to enable the individual
to perform the essential functions
of his or her position, so long as the
accommodation does not create an
undue hardship for the employer.
Courts have treated medical residents
as employees under federal and state
antidiscrimination laws.3–5 Disability
among residents in the nation’s training
programs at academic medical centers is
poorly studied and thus may be poorly
managed. Physical and sensory disability
(PSD) is defined as any impairment of
special sense organs, including vision
or hearing, that limits one or more life
activities. PSD occurs in approximately
1 in 178 matriculating medical students
and 1 in 238 medical students who
graduate. Of students who matriculate
with PSD, 76.8% go on to graduate.6
Although this is an impressive success
rate, it is still well below the 96.6%
eight-year graduation rate for students
without PSD.7 The most common PSDs
are associated with hearing, ambulation,
and vision.6
Impairment due to learning disabilities
is also poorly studied. Amendments to
the ADA passed by Congress in 2008
provide strong support for the view that
ADHD may be considered a disability
under the statute, and the condition has
been recognized as such by at least one
federal district court.8 Certain learning
disabilities have been recognized as a
disability under the ADA for which a
reasonable accommodation must be
offered. It is estimated that 3% to 6%
of college students have some form of
learning disability.9 The incidence among
medical students is unknown, but Faigel10
noted that services offered to medical
students with learning disabilities
increased significantly after the passage
of the ADA. A national study of residents
in emergency medicine programs noted
that 1.3% of trainees have a documented
disability, and over 50% of program
directors suspected that at least one of
their residents may have a disability.11 Of
the various disabilities that exist, learning
disabilities were the most common,
followed by depression/bipolar disorder
and musculoskeletal impairment.11 The
majority of the disabilities (61%) were
diagnosed before residency.11 Increased
time allotment for examinations was
required for 15% of the individuals,
although four residents without disability
were also granted additional time.
Individuals diagnosed with a disability
before residency were more likely to
graduate on time when compared with
those diagnosed during residency.11
Childhood ADHD is characterized by
impulsivity, hyperactivity, and inattention
and specifically has been recognized as
a disability under the ADA. Behaviors
and patterns indicating inattention
and hyperactivity–impulsivity are
defined by the Diagnostic and Statistical
Manual (see Appendix 1). Studies
generally demonstrate that nearly half
of the individuals diagnosed as children
will have symptoms that persist into
List 1
Requested Educational Accommodations and Expectations of Supervising Staff
for a Resident With Attention-Deficit/Hyperactivity Disorder Completing an
Anesthesia Residency
1. A period of intense supervision of the resident by a single staff physician upon return from
leave of absence
2. Direct daily feedback by staff to the resident specifically addressing:
a. Time management
b. Task prioritization / focus / fixation
c. Areas for improvement
3. Daily case debriefing
4. Specification and discussion by the attending physician with the resident of high-level issues
that are relevant to the case at hand
5. Review of daily task list by the resident
6. Guidance to staff members by the resident as to when and how to provide instruction and
nonurgent teaching
7. Allowance for a written task list to be generated by the resident in the operating room
8. Assistance by faculty for the resident to develop a comprehensive reading plan
9. Assistance by faculty for the resident to develop a checklist for managing logistics of the daily
case load
10. Allowance by faculty for the resident to type up preoperative evaluations to assist with
presentation
11. Time allowance by faculty for the resident’s personal health care appointments
12. Deployment of the resident to more difficult rotations and responsibilities as soon as
appropriate
13. Providing the resident with a copy of all written communications and counseling
14. Allowing the resident to attend clinical competency committee meetings when performance is
discussed

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Article
Academic Medicine, Vol. 91, No. 2 / February 2016
212
adulthood.12 Symptoms of hyperactivity
may diminish while inattention persists
with age. Inattention in adulthood
manifests as difficulty keeping
appointments, meeting deadlines, or
focusing on a single task.13 Adults with
ADHD often manifest sleep disorders,
although this depends on the type
of ADHD diagnosed.14 Additionally,
children with ADHD may develop
substance use disorders later in life.15
The incidence of ADHD in anesthesia
residents and trained anesthesiologists
has not been reported, to our
knowledge. Critical executive skills of
anesthesiologists include the ability to
focus on detail, multitasking, efficiency,
crisis management, personal interactions,
and two-way communications, all of
which may be compromised by poorly
treated ADHD. Anesthesiologists are in
a highest-risk specialty for developing
substance use disorders.16 A history
of ADHD may compound that risk.
Individuals whose sleep patterns may
already be compromised may only worsen
with the rigorous and unpredictable
schedule of residency, fellowship, and
posttraining clinical practice.
The management of ADHD involves both
pharmacologic and nonpharmacologic
therapies. Stimulants such as
amphetamine and methylphenidate are
used effectively to reduce distractibility
and increase attention.13 Side effects
include decreased appetite, weight loss,
insomnia, depression, and anxiety. The
long-term effects of such medications
are unknown. Atomoxetine is the only
nonstimulant medication approved for
the treatment of ADHD. Atomoxetine is
a blocker of norepinephrine transmitters.
Cognitive behavioral therapy is the
primary nonpharmacologic treatment for
ADHD and has been shown to be highly
effective in adults with ADHD when
used in combination with pharmacologic
treatment.17,18
The training of a physician with ADHD
during residency involves a fine balance
between the obligations to the individual
and the protection of the patient.19
Because ADHD may constitute a
disability and courts have recognized an
employer’s obligation to participate in
an “interactive process” to assess possible
reasonable accomodations for a disability,
residency programs are well advised to
engage in the reasonable accommodation
process with qualified residents with
this condition.4,20,21 Accommodations
may include an adjustment to the work
schedule, time off, reassignment of
certain responsibilities, or modifying the
work environment. Accommodations
must, however, meet two major
requirements. First, the accommodation
may not create undue financial or
administrative burden on the program
and, second, must not significantly alter
the nature of the program.19 In the health
care setting, patient safety considerations
also must be factored into the assessment
of reasonable accommodations.
The CCC chair and the program
director work closely to assist trainees
experiencing performance problems
during residency. Program collaboration
with the hospital’s in-house counsel on
these matters is helpful to allow for an
understanding of the legal obligations
of the program, as well as the limits on
those obligations. At our institution,
several educational interventions were
made to assist the resident with ADHD
prior to implementation of remediation.
Appropriate assessment of the impact of a
medical condition on clinical performance
can prove difficult, especially while
attempting to maintain medical privacy.
Use of a “fitness for duty” assessment
through the hospital’s occupational health
department is critical to obtain guidance
on possible workplace accommodations
while ensuring privacy with regard to
the resident’s health condition. When
the resident disclosed a disability due
to ADHD, two-way communication
was facilitated and more options were
available to develop a plan to manage the
condition and to incorporate appropriate
accommodations. The resident’s health
care providers documented that the
resident’s condition and treatment plan
were compatible with the safe performance
of residency-related duties. Thus he
was formally deemed fit for duty. The
accommodations requested by the resident
were viewed as reasonable, and many were
simply good educational practice, such
as direct daily feedback and debriefing
after cases (List 1). We also considered
issues related to “forward feeding”
of clinical performance information.
Forward feeding is the practice of
providing a trainee’s performance data
to future faculty members to allow
them to structure their rotation and
interactions to maximize a trainee’s
performance. Trainees with marginal
performance may escape detection when
information is not conveyed to faculty
members.22 Information not shared
may thus potentially place a patient at
risk. We decided to share the requested
accommodations with subsequent
rotations and faculty members but not
disclose the resident’s disability. On
completion of training, the condition was
viewed as fully controlled, without risk
to patients. The personal leave of absence
to optimize his approach to learning was
mentioned in letters of recommendation
for both fellowship and faculty positions,
but the clinical diagnosis was not
disclosed. When he applied to another
state for a medical license, the board of
medicine was informed of his diagnosis
and the fact that he successfully completed
the requirements of the residency as well
as optimized his approach to learning.
The resident in this case made significant
personal contributions to the positive
outcome achieved during his residency
training. He acknowledged his disability
and the impact it was having on clinical
performance, personal interactions,
and professional responsibilities. The
resident accepted personal responsibility
for investigating the requested
accommodations and balanced this
with taking personal responsibility
for attending appointments and other
therapeutic interventions, all while
maintaining a positive relationship with
his supervisors throughout his residency.
Our program has a written performance
improvement policy that guides our
approach to performance issues. Our
CCC consists of respected educators
within the department who are willing
to consider factors such as disability
and impairment as causes of failure to
achieve our expectations. We encourage
CCC members in anesthesiology and
other specialties to consider such factors,
engage in open discussions with trainees
about their learning style, develop
relationships with individuals trained in
the diagnosis of cognitive disability, and
establish a culture where trainees can seek
and use the tools they need to succeed.
Conclusions
Educational and other accommodations
are tools to enable a resident to meet
the essential performance demands of a
residency in the face of a disability. We
describe the successful management of
a resident with ADHD. Through the use

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Article
Academic Medicine, Vol. 91, No. 2 / February 2016 213
of workplace accommodations and other
supports put in place by the resident,
including pharmacotherapy and cognitive
behavioral therapy, the resident was
able to successfully graduate from our
program and carry out the independent
practice of anesthesiology. The resident
subsequently successfully completed a
fellowship, became board certified in
anesthesiology, and has won teaching
awards as a faculty member at a noted
academic institution.
Funding/Support: None reported.
Other disclosures: None reported.
Ethical approval: The permission of the trainee
has been obtained prior to creation and
publication of this article. Identifying details,
including the location and time frame of the
events described, have been omitted to maintain
confidentiality.
M.G. Fitzsimons is assistant professor, Harvard
Medical School, and Department of Anesthesia,
Critical Care, and Pain Medicine, Massachusetts
General Hospital, Boston, Massachusetts.
J.C. Brookman is assistant professor of
anesthesiology, Department of Anesthesiology and
Critical Care Medicine, Johns Hopkins Medicine,
Baltimore, Maryland.
S.H. Arnholz is legal counsel, Office of the General
Counsel, Partners Healthcare System, Boston,
Massachusetts.
K. Baker is associate professor, Harvard Medical
School, and Department of Anesthesia, Critical Care,
and Pain Medicine, Massachusetts General Hospital,
Boston, Massachusetts.
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Appendix 1
Attention-Deficit/Hyperactivity Disorder: Diagnostic Criteria
A. A persistent pattern of inattention and/or hyperactivity–impulsivity that interferes with functioning or development, as characterized by (1) and/or (2):
1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental
level and that negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For
older adolescents and adults (age 17 and older), at least five symptoms are required.
a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or
misses details, work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or
lengthy reading).
c. Often does not listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
d. Often does not follow through on instructions and fails to finish schoolwork, chores, or other duties in the workplace (e.g., starts tasks but
quickly loses focus and is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in
order; messy, disorganized work; has poor time management; fails to meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older
adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallet, keys, paperwork, eyeglasses, mobile
telephones).
h. Is often easily distracted by extraneous stimuli (for older adolescents or adults, may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents or adults, returning calls, paying bills, keeping
appointments).
2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least six months to a degree that is inconsistent
with developmental level and that negatively impacts directly on social and academic/developmental activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For
older adolescents and adults (age 17 and older), at least five symptoms are required.
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other
workplace, or in other situations that require remaining in place).
c. Often runs about or climbs in situations where it is inappropriate. (Note: in adolescents or adults, may be limited to feeling restless.)
d. Often unable to play or engage in leisure activities quietly.
e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants,
meetings; may be experienced by others as being restless or difficult to keep up with.
f. Often talks excessively.
g. Often blurts out an answer before a question has completed (e.g., completes people’s sentences; cannot wait for turn in conversation).
h. Often has difficulty waiting his or her turn (e.g., while waiting in line).
i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without
asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).
B. Several inattentive or hyperactive–impulsive symptoms were present prior to age 12 years.
C. Several inattentive or hyperactive–impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives;
in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another
mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).
Source: Reprinted with permission from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, Va: American Psychiatric
Association; 2013. All rights reserved.