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 …..

8 thoughts on “Seeing through the glass darkly?

  1. this is a really interesting post, thank you. it would appear that we are in a situation where the blind are leading the blind 🙁

    interesting thought that the healthcare profession might not be best placed to combat substance misuse issues. a new role for the Church of England, perhaps?! buildings in even the smallest village, a pre-existing network…although I know the priesthood is its own fertile breeding ground for addiction…

    1. Hey Prim Your suggestion is a good one as communities all have a church – hence why AA use their spaces for meetings. Not sure about the religious connection though as in my head there always felt like judgement was present and I’m not sure that would be helpful for this already shame inducing issue ….

  2. This is fascinating but worrying. I remember with horror visiting a GP and tentatively mentioning my over drinking; his response was that as long as I didn’t exceed one bottle a night, it was fine. (Really??!) Also that I “really didn’t want this on my medical record.” Profoundly unhelpful and actually quite sinister but in retrospect, revealing more about his own situation, I suspect, than mine.

    1. I’m not surprised to hear this Bea and I’m sorry your experience wasn’t more supportive. The fact that you found his second comment sinister is the saddest part, because if I were you, I would not have wanted to go back and talk to them further about my concerns about my drinking after that kind of response.

  3. On one hand, I think it’s a good thing that doctors are reluctant to be hypocrites, even if nobody would know it but them. But if alcohol abuse were as obvious as obesity, it would be a different story. For example, nobody is going to listen to a fat doctor who tells them to lose weight unless the doctor is also candid about his/her own weight loss journey.

    On the other hand, it’s also a sad sign that we expect doctors to be perfect, and apparently that doctors expect themselves to be perfect. If they can dismiss their own problem when it is reflected in someone else, then they don’t really have a problem and can go on being the godlike creatures they’re expected to be.

    (As a side note, I haven’t visited a doctor in almost six years because their air of infallibility annoys me.)

    1. It’s a complex issue SC and I’ve watched overweight doctors lecture patients on weight loss and seem completely unaware of their hypocrisy!! I don’t expect them to be perfect and as a nurse, which the article also talks about, I’m far from flawless. I think their inability to recognise and acknowledge the problem in their patients is more about projection and denial and that’s what makes it tricky.

  4. As a psychiatrist, I am sort of bothered at the lack of compassion I am hearing on some of these comments. I have struggled with binge drinking for 30 years and have had times of sobriety, have done AA, have researched and utilized harm reduction, etc etc. I have learned full compassion and non judgment for all substance abusers, in fact, all humans over my years, and I work diligently to meet the patient where he/ she is. Yet, I cannot get the same care that I give my patients for risk of losing my license (though I have never been hungover at work, nor impaired at work), which is my livelihood. I cannot attend AA meetings in town for fear of being outed. As long as there is an Us vs Them mentality, regardless of which camp of us or them we happen to be in at any given moment, addiction will be seen as a moral problem vs the medical and psychological problem that it is (leading to potential moral problems, right?).

    I have had the shittiest year of my life and am tired of binge drinking on my weekends and am on day two of recognizing that I am never drinking again. I could use some love sent my way. Thanks.

    1. Hey Frog Thank you for reading and commenting on my blog. I’m sorry that you felt the comments were lacking in compassion. I understand how difficult it is as a medical professional to seek help and not compromise your professional standing and registration. I don’t know where you are in the world but here in the UK there are special support services for medics as regards addiction to allow them to safely seek help and continue to practice – is this option not available to you? I’m sorry to hear you’ve had such a shitty year and congratulations on day two. Please let me know how you are doing in the coming days, weeks and months as I’m always happy to support a fellow professional. Sending you kindness and compassion. 🙂

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