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Ten year comparisons between occupational groups in the UK suggested that the excessive death rate among doctors from alcoholic cirrhosis was falling in the 1970s. Predictions were falsely optimistic; the 1980s once more showed doctors to have three times the alcoholic cirrhosis of the general population, second only to publicans and bar staff.( 1) Doctors also have higher than average rates for other alcohol related deaths including suicide, alcohol-related cancers, and accidents.( 1)

However, these statistics say nothing of the preceding months or years of distress suffered by an alcoholic doctor and their family which accompany drinking. In some instances, the worry starts in medical school. Why does problem drinking start? In the article in this month's studentBMJ "You are not alone" (see page 471), a medical student describes his experience of drinking more, and coping less, and the despair which resulted. Eventually a way through the thicket was found, with some help and no doubt a lot of courage. When doctors who have recovered from alcohol dependence reflect on the route they took, they often recall a period when drinking was very positive: as a student enjoying newly gained independence (for instance, freshers' week), the good company, and their liking for the buzz or the relaxation that alcohol gave them. They share this experience of alcohol with many of their year. Indeed `heavy' drinking is common in UK medical schools,( 2 3) with over 20% of students who drink consuming more than 21 units - 170g - per week, comparable with their age group in the general population. (Rates tend to be lower in US medical schools.) Even though some students say that their drinking "frequently" interferes with studies, heavy drinking in itself does not predict failure at medical school.

What can you do? A useful warning sign: beware if you regularly use alcohol to solve a problem, whether to get to sleep, to "try to concentrate", or to relax because you are tense - alcohol's neuropharmacology means those problems could well get worse! Avoid heavy sessions: over 10 units (80g) is definitely associated with a risk of accidents (or fights, depending on the company you keep). A safe maximum is 3-4 units. Dependence is less likely to develop if you have at least two or three days per week without taking alcohol. Yes, medical schools are competitive places, but you have a duty to keep yourself fit and well. You won a place there and you deserve it: value your qualities; watch out you are not being unduly self-critical; learn that we need to be "good enough", or occasionally excellent, but that we do not have to be perfect. Seeking help if you need it, is rational; it is a sign of strength, not weakness. Talk to a student counsellor or the dean, rather than drinking problems away, if you are prey to any kind of bullying, or sexual or racial abuse. Be extremely cautious with alcohol if you have a family history of alcohol problems. If you are concerned about a friend's level of drinking - tell them. The author of "You are not alone" had friends who showed their concern about the drinking. At first the drinker seems to pay no attention, or makes you feel a kill joy. Don't be put off. In the long term your friend will appreciate your concern.

There are some, however, for whom self doubts and the pressure of the medical course and the houseman years is a hazardous rite of passage, painfully worsened by drinking.

Follow up studies of medical students have found that some heavy drinking is related to personality vulnerability. Sometimes shyness, perhaps due to overprotective parenting, can be followed by overvigorous celebration of freedom in the first year at university. Another link research has made with earlier family life is that lack of warmth in the parent of the opposite sex predicts stress symptoms in newly qualified doctors. Such people may be acutely sensitive to criticism or sarcasm from certain teachers (who think they are inspiring the student to study harder; or believe that the harsh school they survived should also be endured by trainees without wincing). In the lists of stress factors reported by house officers, unsupportive seniors rate nearly as highly as the distressing difficulty of dealing with death and dying.( 4-6)

But a notable family influence, and arguably the most important overall influence that predicts which students will develop an alcohol problem, is a family history of alcohol dependence. As a rough calculation, it increases the chance from 1 in 20 to 1 in 5 that a medical student will at some time develop a serious alcohol problem.( 7) It is well established that alcohol dependence is familial. However, as well as medicine being a stressful occupation (at times also a very rewarding one) it seems that medicine may be a profession which selectively recruits people at genetic risk: a Colorado medical school found that twice as many medical students compared to a general population sample had an alcohol dependent relative.( 8)

References

1 Drever F, ed. Occupational Health: Decennial Supplement. London: HMSO, 1996:72.

2 Collier DJ, Beales ILP. Drinking among medical students: a questionnaire survey. BMJ 1989;299:19-22.

3 Ashton CH, Kamali F. Personality, lifestyles, alcohol and drug consumption in a sample of British medical students. Med Educ 1995;29:187-92.

4 Firth-Cozens J. Stress in medical undergraduates and house officers. Br J Hosp Med 1989;41:161-4.

5 Firth-Cozens J. The role of early family experiences in the perception of organisational stress: fusing clinical and organisational perspectives. J Occup Organisational Psychol 1992;95: 61-75.

6 Brooke D. Why do some doctors become addicted? Addiction 1996;91: 317-9.

7 Flaherty JA, Richman JA. Substance use and addiction among medical students, residents and physicians. Psychiatr Clin North Am 1993;16(1):189-97.

8 Dilts S, House RM, Arthur WR, Hurley ME. Incidence of alcohol abuse in the parents of medical students. J Am Coll Health 1993;42:82-4.