Random Drug Testing to Reduce the Incidence of Addiction in Anesthesia Residents: Preliminary Results from One Program

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DOI: 10.1213/ane.0b013e318176fefa · Source: PubMed
Substance abuse occurs in approximately 1%-2% of anesthesia residents and nearly 80% of programs have had one or more resident (s) with such a problem. Education and control efforts have failed to reduce the frequency of substance abuse. Anesthesia providers have a professional obligation to be drug-free for the well being of their patients. We have instituted a program of preplacement and random urine testing of residents in anesthesiology in an attempt to decrease the incidence of substance abuse. We demonstrate that such a program is feasible, despite logistic and cultural obstacles. Larger multi-institutional studies will be required to determine whether instituting a program of random urine testing decreases the incidence of substance abuse in anesthesiology residents.
Economics, Education, and Policy
Section Editor: Franklin Dexter
Special Article
Random Drug Testing to Reduce the Incidence of
Addiction in Anesthesia Residents: Preliminary Results
from One Program
Michael G. Fitzsimons, MD
Keith H. Baker, MD, PhD
Edward Lowenstein, MD
Warren M. Zapol, MD
Substance abuse occurs in approximately 1%–2% of anesthesia residents and nearly
80% of programs have had one or more resident (s) with such a problem. Education
and control efforts have failed to reduce the frequency of substance abuse.
Anesthesia providers have a professional obligation to be drug-free for the well
being of their patients. We have instituted a program of preplacement and random
urine testing of residents in anesthesiology in an attempt to decrease the incidence
of substance abuse. We demonstrate that such a program is feasible, despite logistic
and cultural obstacles. Larger multi-institutional studies will be required to
determine whether instituting a program of random urine testing decreases the
incidence of substance abuse in anesthesiology residents.
(Anesth Analg 2008;107:630 –5)
The incidence of substance abuse, including alcohol,
among physicians is unknown.
The incidence of
substance abuse by anesthesiologists in training or in
practice is also uncertain. Although the incidence of
alcohol abuse among physicians appears to be no
more prevalent than among other professionals, phy-
sicians may display a higher misuse of prescription
opioids. Anesthesiology residents appear to have one
of the highest known incidences of addiction to phar-
maceutical substances of all groups of health care
providers. The incidence of substance abuse is esti-
mated as 1.6% of anesthesiology residents in the
United States.
This high incidence of substance abuse
is believed due to a combination of workplace stress
inherent in commencing this demanding profession
(i.e., assuming responsibility for the safe induction,
maintenance, and emergence of the anesthetized, para-
lyzed, often critically ill surgical patient), theorized second-
hand occupational exposure and sensitization to the
effect of opioids,
and the ready availability of potent
drugs used to anesthetize patients (particularly nar-
cotics). Collins et al.’s
survey of 111 training pro-
grams in 2005 reported that 80% of programs had
experience with trainee impairment, primarily opioid
abuse. Nineteen percent of programs reported at least
one death due to overdose or suicide between 1991
and 2001. The highest risk of drug-related death for
anesthesiologists is within the first 5 years after
completion of medical school.
Residents in anesthesia
are over-represented in the Medical Association of Geor-
gia’s Impaired Physicians Program.
Additionally, an-
esthesiology residents and attending anesthesiologists
have more years of life lost due to suicide and
drug-related deaths than internists.
For the past decade, anesthesiology residency pro-
grams have relied on education (lectures by recovered
physicians, movies depicting the impact of physician
drug addiction including loss of career or life, etc.) and
strict control of substances (daily accounting, establish-
ing operating room [OR] pharmacies, etc.), to detect and
discourage substance abuse by anesthesiologists. These
measures have not reduced the incidence of substance
Recent technologic advances, including surveil-
lance of drug transactions via anesthesia drug dispensing
systems (Pyxis) along with analysis of anesthesia informa-
tion managements systems and pharmacy information
management systems may allow earlier detection of diver-
sion by analysis of abnormal patterns of usage. These
practices are not yet widely adopted.
Other professions responsible for the lives of others
(aviation, transportation, etc.) that have experienced
problems with substance abuse are now required by
the United States Congress to conduct random urine
testing to attempt to reduce risk to the public. Illicit
drug use decreased significantly after random testing
was initiated in the US military in the early 1980s.
Among impaired physicians, recovery is improved
when random urine monitoring occurs because of the
consequences of a positive substance screen.
sumably, physicians who understand the conse-
quences of a positive urine screen would avoid use of
illicit substances. Pre-employment drug testing of
From the Department of Anesthesia and Critical Care, Har-
vard Medical School, Massachusetts General Hospital, Boston,
Accepted for publication March 17, 2008.
Address correspondence and reprint requests to Michael G.
Fitzsimons, MD, Department of Anesthesia and Critical Care,
Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114.
Address e-mail to mfitzsimons@partners.org.
Copyright © 2008 International Anesthesia Research Society
DOI: 10.1213/ane.0b013e318176fefa
Vol. 107, No. 2, August 2008630
housestaff physicians at a teaching hospital has been
We are not aware of any civilian anesthe
siology residency programs that require random drug
testing. Mandatory random substance testing is com-
mon among physicians in recovery programs.
Over the past two decades, substance abuse within
the residency of the Department of Anesthesia and
Critical Care (DACC) at the Massachusetts General
Hospital (MGH) has reflected the national incidence,
despite education and strict accounting of drugs. We
therefore decided to initiate preplacement and pos-
temployment random urine testing of all anesthesia
residents to attempt to deter and detect substance
A DACC Committee on Chemical Dependency was
established in 2003 to investigate the feasibility, cost,
and ramifications of random urine testing for occupa-
tionally available controlled substances. The commit-
tee was chaired by the department chairperson
(W.M.Z.) and included the residency program director
(K.H.B.), director of critical care, volunteer faculty
members, chief residents, Office of General Counsel,
and the medical director of the MGH Occupational
Health Clinic (OHC). The senior hospital administra-
tion was informed and reviewed and approved our
proposed program. The MGH OHC was invited to
participate in the development of our program, be-
cause they had established protocols and instituted
preplacement and “for-cause” urine testing for em-
ployees under the regulations of the Department of
Transportation guidelines.
At the time our policy was approved (2003), man-
datory testing had not been a requirement for becom-
ing a resident in our program. Thus, current residents
and those already committed to our program through
the National Resident Matching Program were en-
tered into the testing process on a voluntary and
anonymous basis. The election of participation or
nonparticipation of any resident was not known to our
committee or the department leadership. However,
beginning in 2004, we informed all resident applicants
that random testing would be required if they
matched to the MGH residency in anesthesiology. All
new residents who began training from July 2005
onward have signed formal written contracts that
acknowledge that they agree to our mandatory ran-
dom urine testing policy.
We planned our urine testing frequency based on
reported risk levels and our experience with substance
abuse among our own residents. Residents in the first
clinical anesthesia year (CA-1) are subject to at least
two random tests per year with an additional 20% of
the class subjected to a third test. Residents in their
second and third clinical anesthesia year (CA-2, CA-3)
are subject to at least one test a year with 30% of the
trainees subjected to a second test. The additional
testing is intended to eliminate any belief that once
any individual completes a test, he/she would be
exempt from screening for an entire year. We believe
that more frequent testing would be disruptive to
patient care.
The random urine testing protocol is in accordance
with the previously established MGH OHC protocol
for preplacement and for-cause testing. We decided
not to observe collection of urine specimens to main-
tain privacy and dignity. Each urine sample is split to
allow later confirmatory analysis if required.
The DACC committee determined the occupation-
ally available substances that we would screen for. We
focus on substances commonly available from the OR
pharmacy. However, we omitted two substances,
sufentanil and propofol, which are available. At the
time we designed our panel, propofol was not consid-
ered a significant drug of abuse; however, propofol is
an increasingly common substance of abuse
metabolites do appear in urine.
Sufentanil was not
added to our panel because it is rarely used in our
department and would add substantial costs to test-
ing. Distribution patterns for sufentanil are monitored
by our pharmacy. The for-cause test includes a
broader spectrum of substances of abuse. Our protocol
allows screening for other substances as warranted by
the circumstances (Table 1).
Urine drug testing is performed at an outside
facility. The sample is initially screened for substances
by enzyme immunoassay. Confirmatory analysis of a
positive immunoassay is via gas chromotograpy
mass spectroscopy.
An independent certified medical review officer
(MRO) receives, interprets, and reports all results of
the workplace urine drug-testing program.
necessary, the MRO directly contacts the tested resi-
dent and determines whether the results were truly
positive or due to confounding factors, such as taking
a prescription medication. Results confirmed as posi-
tive by the MRO are reported directly to the Chairper-
son of the MGH DACC. Any positive immunoassay,
Table 1. Urine Testing Panel (2007)
Preplacement Random For-cause
Amphetamines Fentanyl Amphetamines
Barbiturates Amphetamines Barbiturates
Benzodiazepines Methadone Benzodiazepines
Cocaine Opiates
Methadone Oxycodones Marijuana
Methaqualone Phencyclidine Methadone
Benzodiazepines Methaqualone
Fentanyl Ketamine Opiates
Phencyclidine Cocaine Phencyclidine
Propoxyphene Meperidine Propoxyphene
When for-cause testing is initiated, a serum alcohol level is obtained if clinically indicated.
For-cause testing is designed to search for any drugs of abuse and testing is not limited to
listed substances.
Opiate testing includes codeine, morphine, hydromorphone, hydrocodone, oxycodone,
monoacetyl morphine.
Vol. 107, No. 2, August 2008 © 2008 International Anesthesia Research Society 631
which is ultimately deemed excusable by the MRO, is
considered a negative result and is not reported to the
department in any fashion.
Any resident suspected of illicit drug use because of
their behavior is immediately removed from clinical
duty and placed on a Medical Leave of Absence. The
Hospital’s Professional Staff Health Status Committee
is informed as required by Joint Commission on the
Accreditation of Healthcare Organizations. The resi-
dent is confronted by at least two individuals, includ-
ing the department chairperson and/or a designee. A
psychiatrist experienced in dealing with drug abuse is
in attendance whenever possible. The individual then
undergoes mandatory urine drug testing. A positive
urine test results in immediate referral for clinical
evaluation or inpatient treatment. Outpatient treat-
ment may occur through the Massachusetts Medical
Society’s Physician’s Health Service.
Each state has its own requirements for reporting
substance abuse among practitioners. Physicians are
generally required to self-report their own depen-
dence or abuse. Certain circumstances may dictate
that a hospital directly report abuse to the state medical
board. The American Board of Anesthesiology currently
requires that a resident with documented abuse of
alcohol or drugs receive an unsatisfactory evaluation
for “Essential Character Attributes.” Other agencies
such as the Department of Public Health or Federal
Drug Enforcement Agency, and local police may need
to be notified.
We have data on MGH DACC residents for the 6 yr
before implementation of our policy (1998 –2003) and
for the 4 yr after testing began (January 2004 to
December 2007) at MGH. The 6-yr period before
testing was the time for which we could obtain reliable
employment records. Resident drug abuse “events”
were reported and analyzed for the year of occurrence
and training level at the time of the event. Drug abuse
events were defined as a positive urine test for illicit
drugs, admitted diversion of a substance for personal
use, direct observation of illicit use of a substance, or
request for treatment for substance abuse or depen-
dence. We calculated our incidence in events/resident
year. The incidence before and after testing was com-
pared using Fisher’s exact test.
Program Initiation
Forty-three percent (43%) of residents voluntarily
elected to participate in random urine testing during
the initial phase-in. The CA-1 class, which knowingly
would be subjected to the most frequent testing,
consented at the highest rate (65% of the class) (Table
2). Approximately one-third of the CA-2 and CA-3
classes consented. We found no evidence that intro-
duction of our policy interfered with resident recruit-
ment. The program matched every position offered
between 2003 and 2006 and did so with our usual
“ranked to match” ratio.
Since the inception of the urine testing program for
residents, 236 urine tests (preplacement, random, and
for-cause) have been performed (Table 3). Eighty-four
preplacement, 150 random, and two for-cause tests
have been performed.
Substance Abuse Events
Overall, the incidence of substance abuse was 1% in
the 403 resident-years during the 6 yr before testing
began. During this same time, in the most highly
vulnerable CA-1 residents, the incidence of drug
abuse in the 138 resident-years was 2.2% (three
events). During this time period, one event occurred in
a resident during the second year (CA-2). In contrast,
no events have occurred during 330 resident-years
since testing began in 2004. The data are associated
with a P value of 0.13 by Fisher’s exact test. Thus, we
cannot conclude from our data whether there has been
a decrease in the incidence of abuse.
Cost Analysis
The total costs of the testing program are composed
of two elements, test collection and analysis and
administrative fees. We estimate collection and anal-
ysis expenses at less than $20,000/yr. The program
requires approximately 20% of a full time equivalent
nurse practitioner, which amounts to $20,000 per year.
We estimate that at full implementation, a total cost of
$50,000 per year would be associated with testing all
residents in our program at the desired rate.
Substance abuse appears to be more frequent in
anesthesiologists than in other medical specialties.
Table 2. Participation Rate for Voluntary and Anonymous Resident Urine Testing During Phase In
Class Number Participating (%) Not participating (%) No response (%)
CA-1 23 15 (65) 7 (30) 1 (5)
CA-2 24 8 (33) 12 (50) 4 (17)
CA-3 27 9 (33) 16 (59) 2 (7)
Total 74 32 (43) 35 (47) 7 (10)
All current residents either within the program or committed via the National Residency Matching Program were given the option to participate (or not ) in random urine testing.
Table 3. Total (Random and Preplacement) Urine Drug Tests
(January 2004 to December 2007)
Status 2004 2005 2006 2007 Total
CA-1 37 30 29 37 133
CA-2 7 15 17 24 63
CA-3 2 9 20 9 40
Total 46 54 66 70 236
Random Drug Testing in Anesthesia Residents ANESTHESIA & ANALGESIA
Education and substance control measures have not
significantly reduced this incidence. This report de-
scribes the development and initial experience of
mandatory random drug testing in a civilian academic
department of anesthesiology. Only 8% of anesthesia
residencies use random urine testing, and all of them
are military programs.
More than 60% of all program
directors would approve of random urine screening.
This is the first report of random urine drug testing of
civilian anesthesia residents.
Our preliminary experience does not have the
statistical power to determine the effect of urine drug
testing on the incidence of resident drug abuse. As-
suming an incidence of 1%, an estimated decrease of
20% and a power of 80%, it would require a compari-
son of 800 resident-years, with and without drug
testing within our own program, to establish a statis-
tically significant effect at the P 0.05 level. Large
multicenter studies will be required to demonstrate
Anesthesiologists are responsible for the care of the
public and this carries an ethical obligation to ensure
that medical care is delivered by unimpaired indi-
viduals. Though empirical data indicate that the great-
est risk of substance abuse is early in the anesthesia
residency and diminishes with time, the hazard re-
mains thereafter.
Any drug testing program is expensive. However,
the costs must be weighed against the benefits. The
United States Postal Service estimated a cost savings
of more than $100 million dollars over a 10-yr period
when they studied the effect of preplacement urine
testing between September 1987 and May 1988. The
savings were primarily due to lower rates of absen-
teeism, reduced involuntary turnover, fewer Em-
ployee Assistance Program referrals, fewer medical
claims, and less frequent disciplinary action than
would have been realized had those testing positive
been employed.
Zwerling et al.
evaluated the cost-
benefit relationship of pre-employment drug screen-
ing among United States Postal Service workers in
Boston, MA. They were unable to find a definite
benefit, because the costs and benefits of drug testing
are based on many assumptions, such as the incidence
of substance abuse within the population tested.
We estimate our annual cost at less than $50,000.
The financial benefits of a drug testing program are
more difficult to determine. Detoxification may in-
volve 3–7 days of intensive medical and psychiatric
care at a fee of up to $9000. Inpatient treatment for 30
days is approximately $25,000. Residential treatment
of up to 90 days is common. Outpatient treatment for
4 8 wk approaches $8000. Our previous experience
suggests that residents generally take 6 mo to return to
duty after substance abuse events. We estimate the
cost of diagnosis, initial management, and lost clinical
revenue at more than $60,000–$70,000 for a single
event. When the costs of psychiatric care, follow-up
through physicians’ health services for 3–5 yr, and
mandatory drug testing for a physician in recovery is
considered, the total cost of returning a physician to
unrestricted medical practice is likely in excess of
$100,000. Thus, if we deter a single physician from
illicit drug use we can save a significant amount of
Establishing a program of substance testing was not
easy and we encountered several limitations and
challenges. First, the OHC moved off-site shortly after
our testing program was established. This required
our residents to change clothes, leave the hospital, and
walk two blocks. We have addressed this by config-
uring a newly constructed toilet adjacent to the OR
suites for urine sampling. Second, most substances are
only detectable in urine for about 2– 4 days after use.
Detection times are dependent on dose, sensitivity of
the method of detection, route of administration,
duration of substance use, and variability between
Our initial protocol permitted a 36-h
window to appear for testing. This time frame in-
creases the admittedly small likelihood of a false
negative result. Because anesthesiologists work in an
environment where their presence is critical at nearly
all times, residents cannot be called away at a mo-
ment’s notice to undergo a test. Thus, we believe that
we should allow some time for residents to make
appropriate arrangements for urine sampling after
clinical obligations are complete. However, the es-
tablishment of our new sampling site will enable
reduction of the time between notification and
mandatory urine sampling. We are planning to
reduce the interval.
Administration of a urine-testing program in a
large academic anesthesia department where resi-
dents cover multiple services (intensive care unit,
pain, obstetrics) in several hospitals, and spend time in
distant locations (laboratories, simulator, etc.) pre-
sented additional problems. All randomization, noti-
fication, and record keeping in our program occurs
through the OHC. The clinic contacts individuals
directly via the hospital paging system. If a resident
does not respond and notify the clinic of his/her time
of availability after three pages, a member of the
Committee on Chemical Dependency or the residency
Program Director is notified. If the paged physician is
not able to free himself from clinical responsibilities
for urine sampling he/she is rerandomized to another
day. This provides a potential breach in the random
nature of the program.
The greatest problem to date is that the number of
tests obtained (236) has fallen short of the number
called for (Table 3). The rate of testing increased
progressively each year on the CA-1 and CA-2 resi-
dents. In 2007 we achieved an average of about 1.5
tests per CA-1 resident and approximately one test per
CA-2. This increase was not observed in the CA-3
residents, and only approximately 1/3 of CA-3 resi-
dents were tested in calendar year 2007. We speculate
that this is due to the many rotations outside of the
Vol. 107, No. 2, August 2008 © 2008 International Anesthesia Research Society 633
MGH ORs and this hospital. This unsatisfactory rate
needs to be addressed. Establishment of a comparable
testing program at other hospitals through which
residents rotate would solve much of this problem.
Better coordination of the Occupational Health Service
with our scheduling system so residents on vacation
are not selected for sampling and so residents at other
hospitals can be paged through the paging system of
the outside rotations will likely increase adherence.
We expect that our proximate and new testing location
and a more intensive follow-up via our paging system
will increase the number of tests we successfully
perform each year.
The risk of a false positive result is also a major
concern. Indeed, false positive results have been re-
ported with urine screening. Rifampin and fludro-
quinolones have been reported to cause false positive
testing for opiates
and oxaprozin for benzodiaz
Nonsteroidal antiinflammatory drugs have
been reported to cause false positive results for barbi-
turates and cannabinoids.
We experienced one false
positive urine screen for morphine, which was attrib-
uted by independent MRO review to the consumption
of poppy seeds in a bagel, and was considered a
negative result. This event prompted us, in conjunc-
tion with the Occupational Health Service to raise our
confirmatory level from 300 to 2000 ng/mL, the level
accepted by the federal government. Poppy seeds
have traces of morphine and codeine and positive
urine screens have been reported after consuming
Education of physicians and their families, and
stringent substance control have not reduced the
incidence of substance abuse in anesthesiology resi-
dents. We envision substance testing as one compo-
nent of a policy intended to prevent individuals from
embarking on a course of behavior with potentially
deadly results. In fact, nearly 20% of addicted indi-
viduals will die or nearly die (require resuscitation)
before substance abuse is detected.
A large and
sufficiently powered study to determine the impact of
preplacement and random urine testing on the inci-
dence of resident substance abuse is very difficult
within a single anesthesia department. We do not
know if those residents who were not tested in this
preliminary experience were those at highest risk and
avoided testing. It is possible that our announcing a
mandatory policy served to drive at-risk resident
applicants to other training programs that do not test
and shifted the burden to another academic depart-
ment within the field of anesthesia. A multidepart-
ment study would need to address all causes of false
negative results, including delay in testing after
notification, failure to appear for testing, and sub-
stances that are not included or difficult to detect by
We have demonstrated that it is feasible to establish
and operate a random urine testing program for
civilian residents in anesthesiology and define some of
the impediments to complete adherence and suggest
measures to improve (and approach complete) adher-
ence. Although our data may suggest a decrease in the
incidence of substance abuse, we cannot make this
definite conclusion. Only larger, presumably multi-
institutional, studies will have the power to determine
whether random testing will decrease substance abuse
in anesthesiology residents. If it were proven to reduce
the incidence of abuse in anesthesia residents, a pro-
gram could be expanded to other specialties and
groups at risk for substance misuse.
Physicians are placed in a position of direct respon-
sibility for their patient’s safety. A system-level effort
to address the effectiveness of substance screening
among all physicians has been suggested.
abuse by physicians endangers patients and jeopardizes
the public’s trust in our profession. The profession of
anesthesiology should be encouraged to conduct a
large trial powered to determine if randomized urine
testing will reduce the incidence of drug abuse in
anesthesia residents.
The authors thank Hui Zheng, PhD, for statistical assis-
tance, Dr. Debra Weinstein, Vice President for Education,
Partner’s Healthcare, Dr. Jo Shapiro, Senior Associate Direc-
tor of Partners GME, and Ann Prestipino, Senior Vice
President for Surgery and Anesthesia Services and Clinical
Business Development, Massachusetts General Hospital for
their administrative support instituting the Random Urine
Testing Program.
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© 2008 International Anesthesia Research Society 635
    • "Despite the widespread adoption of drug-free workplace programs by employers, testing employees for drugs is controversial [6]. In addition to legal, ethical, and economic concerns, the effectiveness of mandatory drug testing in improving occupational safety has not been well established [2,78910. Empirical evidence suggests that the effectiveness of drug-free workplace programs may vary among industries. "
    [Show abstract] [Hide abstract] ABSTRACT: To assess the role of drug violations in aviation accidents. Case-control analysis. Commercial aviation in the United States. Aviation employees who were tested for drugs during 1995-2005 under the post-accident testing program (cases, n = 4977) or under the random testing program (controls, n = 1 129 922). Point prevalence of drug violations, odds ratio of accident involvement and attributable risk in the population. A drug violation was defined as a confirmed positive test for marijuana (≥50 ng/ml), cocaine (≥300 ng/ml), amphetamines (≥1000 ng/ml), opiates (≥2000 ng/ml) or phencyclidine (≥25 ng/ml). The prevalence of drug violations was 0.64% [95% confidence interval (CI): 0.62-0.65%] in random drug tests and 1.82% (95% CI: 1.47-2.24%) in post-accident tests. The odds of accident involvement for employees who tested positive for drugs was almost three times the odds for those who tested negative (odds ratio 2.90, 95% CI: 2.35-3.57), with an estimated attributable risk of 1.2%. Marijuana accounted for 67.3% of the illicit drugs detected. The proportion of illicit drugs represented by amphetamines increased progressively during the study period, from 3.4% in 1995 to 10.3% in 2005 (P < 0.0001). Use of illicit drugs by aviation employees is associated with a significantly increased risk of accident involvement. Due to the very low prevalence, drug violations contribute to only a small fraction of aviation accidents.
    Full-text · Article · Feb 2011
  • [Show abstract] [Hide abstract] ABSTRACT: An abstract is unavailable. This article is available as HTML full text and PDF.
    Article · Jan 2010
  • [Show abstract] [Hide abstract] ABSTRACT: Pole-zero modeling of low-pass signals, such as an electromagnetic-scatterer response, is considered in this paper. It is shown by use of pencil-of-functions theorem that (a) the true parameters can be recovered in the ideal case (where the signal is the impulse response of a rational function H(z)), and (b) the parameters are optimal in the generalized least-squares sense when the observed data are corrupted by additive noise or by systematic error. Although the computations are more involved than in all-pole modeling, they are considerably less than those required in iterative schemes of pole-zero modeling. The advantages of the method are demonstrated by simulation example and through application to the electromagnetic response ofa scatterer. The paper also includes very recent and tantalizing results on a new approach to noise correction. In contradistinction with spectral subtraction techniques, where only amplitude information is emphasized (and phase is ignored), we propose a method that (a) estimates the sample variance for the particular data frame, and then performs the subtraction from the Gram matrix.
    Conference Paper · May 1981
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