Daily Archives: 15/06/2015

Seeing through the glass darkly?

Whilst studying the Kings College Understanding Addiction MOOC recently a commentator in the discussion thread linked to this research which was a qualitative exploration of GPs’ drinking and their alcohol intervention practices called ‘seeing through the glass darkly’.  Granted the research is almost 10 years old but I felt it gave a great window into the dilemma for healthcare professionals who are advising patients about drinking when they themselves may be drinking harmfully.

Booze IV's

This would have been me prior to my stopping and one of my many motivators to quit was the hypocrisy of my own actions and advice giving – and with smoking it was no different either!  How do you expect people to take your health advice seriously if you don’t even follow it?  Less ‘do as I say not as I do’ and more social role-modelling.

The whole published article is worth a read as its qualitative nature means there is some really rich data to observe.  I’m only going to share the discussions which is exceptional on its own.

Alcohol has long been regarded as a ‘difficult business’ for primary care23 and indeed alcoholism the dirty work of medicine.31 Part of this difficulty derives from the fact that problem drinking is ill-defined, multifaceted and surrounded by arbitrary notions such as ‘social drinking’ and ‘safe limits’.25 Thus it may be difficult to establish clear boundaries between what is safe or unsafe and what constitutes alcohol use or abuse. Moreover, uncertainty surrounding sensible drinking limits plus differences in patients’ physical and social circumstances requires clinical judgement in determining when drinking moves from being a social pursuit to risky behaviour.

However, alcohol intervention work may be further complicated by clinicians’ own alcohol use. Most GPs in this study drank and many reported minor adverse effects. Several respondents also referred to more serious drinking problems in colleagues. A serious concern raised was the perceived lack of care facilities for clinicians with substance-use problems. Nevertheless, some GPs in this study reported drawing on their own drinking experience to initiate discussions with patients about alcohol. However, other GP-colleagues were more reticent. A number of GPs described problem drinking as something that exceeded or was different to their own pattern of alcohol use. Such bench-marking by GPs drinking at higher-risk levels would mean that some risk-drinking patients might not receive the care they required.

Primary care nurses have reported overlooking patients whose drinking behaviour was similar to their own.22 It is interesting that primary care nurses, most of whom are women, were less likely to deliver brief alcohol interventions to women rather than men.12 For GPs, brief alcohol interventions tend to be under-delivered to better-educated, higher social-status patients; individuals much like themselves.8,13 Thus the mechanism underpinning inconsistent delivery of alcohol-related care may be perceived social-distance from patients.

Clinicians’ personal and social characteristics are likely to influence their own health behaviour and risk-taking activity. However, our data suggest that clinicians’ personal and social characteristics may also influence their perception, or indeed recognition, of health risks in others and their tendency to deliver preventive care to different ‘types’ of patients. The latter is little explored in the healthcare literature and requires further careful research including whether inconsistent delivery of preventive care extends beyond alcohol to other lifestyle issues such as obesity or smoking.

It would seem that if we are to tackle alcohol as an issue within wider society we need to address it’s usage and abuse within the healthcare profession.  If we within healthcare can’t acknowledge and resolve our own issues leading to poor advice giving to those who come to us for our professional support what hope do we have?

At the same time as this research this news story was covered by The Telegraph and the BBC stating:

The British Medical Association has called for action over alcohol and drug abuse among medics after a BBC survey showed the problem was widespread.

BBC One’s Real Story found over the last 10 years 750 hospital staff in England had been disciplined over alcohol and drug-related incidents.  The BMA estimates one in 15 medics have a problem with drugs or alcohol at some point in their life-time.  But the figures, obtained via the Freedom of Information Act, may seriously under-represent the scale of the problem Real Story reported.  Ethics Committee chairman Michael Wilks said the profession was in denial.

Doctors are known to be at least three times as likely to have cirrhosis of the liver – a sign of alcohol damage – than the rest of the population.

 

In the research I found this opening sentence very telling Alcohol has long been regarded as a ‘difficult business’ for primary care and indeed alcoholism the dirty work of medicine.  If this is how it is still perceived then this is where we need to start first and if we don’t then I’m not sure that healthcare is the right place for substance misuse issues.  One of the reasons for the success of AA is because of the non-judgement and support of others who understand.  If we can’t develop that same level of non-judgement and understanding in medicine then I am saddened and disappointed in my own clinical profession, particularly as one of those who needed that help, and is now trying to offer it but from outside the healthcare system …..