Doctors and alcohol misuse

There is no conclusive evidence to show that doctors drink more alcohol than anyone else, but alcohol misuse in this profession is a risk to patients. Ian Harwood and Stephen Stansfeld discuss the public myth and the medical reality

The media continue to draw attention to the perceived high level of alcoholism among doctors and its effect on their work. In 1998 the BMA reported that the misuse of alcohol and other drugs by doctors impaired professional competence and constituted a potential threat to patients.¹ It has been suggested that misuse of alcohol and drugs by doctors is the major component of concern about the conduct, performance, and health of the medical profession.²

Since the 1980s, alcohol has become relatively cheap and widely available. It was calculated in 1990 that even if doctors had the same alcohol consumption as the general population, almost 4000 doctors were drinking at levels sufficient to impair their professional functioning.³ The effects of alcohol use on function and its propensity to impair professional skills and judgment are reflected in the increasing risk of mistakes occurring as alcohol consumption rises. At blood concentrations of 80 mg/100 ml, the legal limit for driving, it is estimated that the risk of an adverse incident occurring is doubled. At 100 mg/100 ml, the accident risk is increased tenfold.⁴ Doctors' mistakes can lead to needless suffering and death.

Drinking doctors: a review of the evidence

The perception that doctors, as a profession, drink heavily has been emphasised by high profile cases and media attention. A 1974 study claimed that alcoholism occurred more often in male doctors than in other men in the same social class.⁵ Studies in the 1970s alleged that doctors were 2.7 times more likely than controls in the same social class to be admitted to alcohol treatment units.⁶ In 1997, more problems with addiction were found among doctors in the United Kingdom than in the general population,⁷ and doctors and lawyers were among the occupational groups with higher than average mortality from alcohol related diseases.⁸

However, this view is not universally held. The Medical Council on Alcohol has stated: “Doctors and nurses are less likely than the general population to drink above the 21/14 units per week level… nevertheless, some doctors become alcohol dependent. In treatment they do remarkably well.”⁹

A problem in comparing the studies and research reports on alcohol consumption in doctors is the lack of consistency and comparability of data, and this is compounded by variability in the surveyed population's demographics, social class, and size. It is difficult to find data that can be easily compared on an occupational basis.

Medical student drinking: youthful high spirits or public health time bomb?

Sinclair described ritualised drinking games and excessive alcohol consumption in his study of medical students passing through a major London medical school in the 1990s.¹⁰

The table shows risk factors at different drinking levels in men and women. A 1997 study of 90 house officers from Newcastle indicated that over 60% were exceeding recommended safe drinking limits, while 10% were drinking at hazardous levels. A 1998 study of first year medical students showed that 49% of men and 44% of women drank over the medium to high risk levels. ¹¹ Binge drinking, drinking more than half of the low risk limit on one single occasion, was reported by 27% of men and 14% of women.

A longitudinal study surveyed a cohort of undergraduate medical students at Newcastle in 1995 and 1998 and then one year after graduation.¹² Mean alcohol consumption in both sexes increased over the survey period. The proportion of those drinking above the recommended safe limits of alcohol consumption increased considerably from 1995 to 1999, with a higher proportion of men drinking above their safe limits compared with women. The growing consumption and harmful drinking behaviour continued beyond the house officer year. The largest increase in the percentage of women drinking at medium to high risk levels took place during the first year of work as a house officer. Pleasure was given as the main reason for drinking, but other reasons such as anxiety and exam or work pressures increased over the period. Binge drinking also increased.

Behaviour

Whether doctors in the United Kingdom drink more than their professional and social class equals remains unclear. The evidence points to a culture of drinking heavily at increasingly unsafe levels while a medical student. Alcohol use develops as a means of alleviating the stress of working as a doctor. A study of civil servants showed that a stressful psychosocial work environment in terms of effort-reward imbalance is a risk factor for alcohol dependence in men.¹³ In 1996, between 22% and 30% of British doctors said that they were dissatisfied with their work.¹⁴In 2003, a BMJ editorial referred to 28% of doctors and other health professionals showing above threshold levels of stress, compared with around 18% in the general working population.¹⁵

That individuals turn to socially sanctioned methods of self soothing and comforting as the pressures of work and private life increase is understandable. It is reasonable to conclude that alcohol abuse, both overt and covert, is a considerable problem for doctors today.

Traditionally, doctors cover up and compensate for the problems of a drinking colleague, partly because of humanitarian concerns but also because of the threat of being tainted by the professional shame and stigma. Many doctors do not know whether it is best to confront their colleague or to report them to someone else, which may be perceived as whistleblowing.

Doctors with alcohol problems generally present late for treatment. The culture of denial among doctors mitigates against seeking help for a problem with alcohol abuse. A study at the Maudsley Hospital found that physical, psychological, and psychiatric problems were rarely a reason for seeking treatment among healthcare professionals.¹⁶ The most common reason for referral was poor work performance or absenteeism (41%). Self referrals were infrequent (9%).

Treatment outcomes for alcoholic doctors are comparatively good. Doctors are part of a profession that traditionally has placed great store on self reliance and competence, and it is often difficult for individuals to acknowledge problems, particularly those associated with stigma and social disapproval which threatens their, and often their partners', livelihoods.¹⁷

Investigations are frequently protracted and inhumane for a doctor with a health problem. Addiction itself fosters denial and isolation. The identification of addiction problems is often characterised by a crisis. The problem may be chronic, but public exposure gives the condition an acute on chronic character.

Many medical students today are being taught to become aware of personal stress handling behaviours, to develop positive coping strategies, and to take more responsibility for their own physical and mental health.

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Conclusion

While the evidence that doctors are more at risk of alcohol abuse than those in other professions and from equal social classes is not conclusive, it is clear that a sick doctor can have a disproportionate adverse influence on the health of considerable numbers of people in their community. As a group, they feel under pressure to conceal and deny their personal problems until a crisis forces them into treatment. Professional carers with alcohol related problems deserve interventions and treatment modalities that will deal with their needs holistically. The NHS must recognise that it does not make economic sense to allow a valuable human resource to be used at anything less than maximum efficiency and production.

Doctors who are concerned about their drinking behaviour should have easy access to relevant treatment, which must be confidential to build trust in the medical population and to break down the barriers of denial. At present, the United Kingdom does not have any standard care pathways or recognised methods of intervention for doctors whose conduct is impaired by alcohol, such as those offered throughout the United States. In many of these programmes, over 90% of doctors achieve long term abstinence from alcohol or drugs and return to work, often with monitoring.¹⁸

The NHS, the monopoly employer, provides no central funding for care of doctors in difficulty. The NHS has recognised that it must look to the widely adopted private sector initiatives of the 1980s to develop the physical and mental health of its valuable human resources to maxi­mise loyalty, productivity, and output.¹⁹

The BMA set up a new initiative “Doctors for Doctors” in 2002 to deal with the barriers that doctors have in getting help. It is targeted at those needing help as well as those anxious to help a colleague. Calls have been made for the setting up of supportive occupational health schemes for general practitioners. The pioneering Staffordshire GP's Support Scheme, which was set up in 1994 with time limited funding to help local general practitioners who felt that they were “under stress or in distress,” has been shown to enhance general practitioners' wellbeing. Such short term, local initiatives are merely stop gaps until the NHS starts to look after its medical workforce in a coordinated, proactive way that values their skills and contributions.²⁰

The lack of dedicated treatment and intervention programmes leaves addicted doctors unchallenged, untreated, and abandoned. With good outcomes from treatment of this group, whose professional training has cost a considerable amount, there are compelling reasons to develop specialist care pathways. The addicted doctor, the profession, and the general public would all benefit.

Ian Harwood, final year medical student, Barts and The London Queen Mary School of Medicine
Email: ian.harwood@tiscali.co.uk
Stephen Stansfeld, professor of psychiatry, Centre for Psychiatry, Wolfson Institute for Preventative Medicine



studentBMJ 2006;14:265-308 July ISSN 0966-6494

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	EDUCATION Doctors and alcohol misuse       Ian Harwood,Stephen Stansfeld (July 2006)
	Dr Rajasree Pai R (August 21st, 2006)       Lecturer, Dr SMCSI Medical College Hospital, Trivandrum drrajashreepai@yahoo.com
	The article gives insight into the issue of alcohol abuse among doctors. An interesting fact is that the lawyers are also found to have similar abuse rates,this might point to the fact that it may be related to stress at work. Doctors everywhere have more stressful duties to carry out when compared to many other professions. Drug abuse is also found to be common among them because of the easier access. An attempt at finding the true cause of drug abuse among doctors might benefit the entire medical fraternity.

	EDUCATION Doctors and alcohol misuse       Ian Harwood, Stephen Stansfeld (July 2006)
	Dr Avinash Aujayeb (August 28th, 2006)       F2, North Tyneside General Hospital avinash.aujayeb@ncl.ac.uk
	Me and my colleagues were recently placed in a very difficult situation in that we had a doctor friend who was coming to work extremely hungover or still drunk every morning.A few times,we let him go home as we deemed he was not safe to see patients but the problem escalated until we had not choice but to confront him about his behaviour.We promised not to go to our seniors if he stopped drinking to such excess and a simple chat was more than enough for him to turn over a new leaf. I think that any programme to help doctors,however laudable it is,will only be touching the tip of the iceberg.Some specific measures should be in place for people to admit they need help,perhaps an analogy should be made here to some signs at the tops of some cliffs giving the phone number of the samaritans. Also,how do we recognise someone who needs help?Our case was flagrant but sometimes the signs are subtle and we are too engrossed in our work to notice.Perhaps educational supervisors can help.But what wwould we have done if he had not changed?I do not know-we do not know what services are in place,nor what help is available nor what could happen to us if found unsafe to practise?These should be advertised more-simple phamplets or posters would do.