How seriously should physicians take alcohol consumption in patients? How aggressively should they screen for abuse? In a recent all-physician discussion on Medscape Connect, doctors shared their experiences and opinions on these issues.
A primary care physician kicked off the discussion: “Do you ask your patients about their drinking habits? Have you found strategies that work to have them cut down if they exceed the recommended weekly limits?”
One of the most common kinds of response came from those who felt the pressures of time. One primary care physician replied:
Counseling for no more than 15 minutes is an entire level 3 visit in itself. If we’re devoting a whole visit to alcohol, chances are that even if we haven’t specifically asked, it’s come to our attention either through multiple visits, or because of a problem directly related to the alcohol use. I try to ask about alcohol if it will interact with a med I want to give, on pre-ops and admission history and physical examination, and when I first meet a patient. Otherwise, if there’s no liver issues or concerns on the part or the family and friends, I generally give a blurb about recommended safe amounts and not driving with alcohol.
A gastroenterologist concurred about time constraints: “Do I screen for it in patients who come to see me for unrelated things? Oh, I was busy addressing their primary complaint that took more than the allotted 15-minute time slot.”
One physician reported asking patients about their vices for reasons of compliance: “The questions about alcohol and tobacco are prompted by the EMR, and I want to be sure I pass the test when Uncle Sam comes in with the white gloves.”
Complaints about time and compliance prompted one neurologist to ask for more hard data to prove that there is actually value in policies about alcohol abuse screening. “This is a tough issue, since it is important to ask, but I would like to see some validity numbers that demonstrate it is worth our time to do so.”
A primary care physician addressed this anecdotally:
I have been asking my patients about their drinking habits when I do their wellness physicals every year, and one thing I’ve noticed is that my problem drinkers almost never fess up. They grossly underestimate their alcohol intake. However, when I send them to specialists for various complaints and alcohol consumption comes up, they invariably tell them the truth. I don’t know if they’re trying not to look bad to their family doc, or whether they figure seeing a specialist is more serious, so they had better come clean. In any event, I try to encourage them to drink less, but without evidence of liver injury, I can’t say I’ve been all that successful.
Another primary care physician was similarly pessimistic in patients’ ability to be forthright about difficult personal issues:
I used to do ambulatory outpatient procedures at a local hospital, and the hospital policy was to inquire about domestic abuse with all female patients. After 2 years, they did an internal review of admissions that were either suspicious for or confirmed for domestic abuse…What it showed was that asking questions about abuse had abysmal sensitivity and specificity for predicting a hospitalization as a consequence of domestic violence.
Another physician farms out the task in deference to local industry: “My staff always asks about alcohol and tobacco at every visit, but I tend not to focus on alcohol because the history of our county is virtually buried in beer. The county seat, with about 30,000 residents, had 2 breweries.”
A neurologist suggested a limited and pragmatic approach to dealing with screening: “I think the best we can do is address and define what is considered safe alcohol use vs alcohol abuse, and leave the door open for further discussion if the patient wishes to engage.”
A gastroenterologist noted that his practice’s attempts to screen for vices had not gotten to alcohol yet:
My back office staff is also trained to ask about tobacco history and to bug (advise) patients to stop smoking to fulfill the “best practice alert” form in the EMR. I am in what is called a very large group, and these numbers are useful to show how well we are doing with encouraging patients to stop smoking. I have not seen this done for alcohol yet.
A dermatologist cynically questioned the value of screening, by providing an analogous situation in dermatology:
One issue with detection is that we can get punished for doing a good job. When I first started in dermatology, I used to prescribe an antifungal to all who had athlete’s foot on my routine exam. Within a few months, I received a warning about being “out of norm,” and that my prescribing habit for antifungals was higher than the average…Crazy, no? Being punished for doing a good job!”
The consensus seemed to be that for reasons of practicality and efficacy, this kind of screening was assigned a low priority by most practitioners.
And, of course, several doctors could not resist a one-liner. In response to the original question of “Do you ask your patients about their drinking?” a surgeon wrote, “Yeah, I ask them, ‘Hey, do you have that flask on you? I really need a drink right now.'”
The full discussion of this topic is available here. Please note that this is open to physicians only. Source
