3 Fatal Errors Doctors Make When They Suspect Alcohol Abuse
Be sure to check out Part 2 of this post to learn strategies for talking to patients!
A funny thing happened at my last medical check-up: my doctor confided in me. We had just wrapped up the physical, and I was about to head to the lab to have my blood drawn. Then this strange thing happened – something that happens all of the time when you’re a therapist.
"So, you're a substance abuse counselor," my doctor said. She stared with great interest at some invisible speck on the wall, brow furrowed in consternation. My hand was frozen in a reach for my purse. This should be interesting, I thought.
"We've got a lot of alcoholics at this clinic,” she said. “Way more than we expected to have.” The clinic she works for opened last year to much fanfare in a posh Chicago neighborhood. Most of her patients are professionals - people who think they are "high functioning" just because they have salaried jobs. "It's hard to talk to them," she admitted.
"Understandable," I said. "What happens when you do?"
She sighed. "They deny it, of course.”
“Sounds like my next blog entry,” I said.
To my primary care doctor, and to all doctors out there - this 2-part post is for you.
ATTENTION DOCTORS: You're Doing It Wrong (But For the Right Reasons)
I know - that's not what you want to hear. You know your outcomes, though (or lack thereof). You've tried everything. Your patients march out the door, unchanged, and you grumble to your nurse that there is nothing you can do to break through their denial. Doctors aren't supposed to feel frustrated and helpless. Something has to change.
When I'm not in the office doing individual counseling, I go into healthcare systems and coach providers. I've taped conversations, coded sessions, and completed role-play exercises modeling patient interactions. Here's what I know to be true 100% of the time: You're doing it wrong because you just want to help.
Knowledge is Power...In School.
In medical school, you absorb unbelievable amounts of information. These facts, figures, statistics, and scientific processes come from tried-and-true, research-validated stores of knowledge. For four years, you memorize book after book and study after study, hoping to become a heroic healer.
Then you graduate and start the hellscape that is The Internship. Senior residents treat you like garbage. Nurses treat you like garbage. Patients treat you like garbage. (Let's not even get started on how attending physicians treat you). And here you are, just trying to use your knowledge to help others.
By the time you're in your second year of residency, you've learned the dance of compromise that forms the foundation of clinical practice. You have knowledge, sure, but by now you can appreciate how knowledge only goes so far in motivating people to do things. You fully appreciate how nurses, colleagues, and patients must trust you before they heed your advice. And yet, you cling to that small bit of hope - will this all be easier when you're on your own - when YOU are the authority? The years of residency tick by. Is it over yet?
You're on Your Own. Can You Help People, Now?
Finally! You are an independent practitioner. Except that the days of private practice are pretty much over for doctors, and you are likely part of a corporate healthcare system. The good news is that you have better pay, more status, and significantly more authority. There's just this one really, really annoying fact: your patients keep doing dumb things. Like drinking, using drugs, and lying to you.
Take a Guess: How Many Drinks?
There is a nuclear arms race between patients and doctors when it comes to disclosing alcohol abuse.
"I tell my doctor I drink twice a week, no more than 2 drinks at a time," one of my counseling clients shared recently. (This client consumes 20 drinks per day). "I heard that doctors multiply the number of drinks you report by a factor of 4," he said. "So it's close enough."
Another client: "I tell doctors I'm a social drinker." Bear in mind, this client goes on binge drinking sprees 2-3 times per week. "If they really want to know, I just tell them I have a few beers with friends," he said.
The lies. So many lies.
When I worked for a hospital, doctors assumed their patients lied about drinking most of the time, for this very reason. "Multiply it by 5," an attending physician would say. The official record only ever reflected the trivial amount the patient would report. But all of us on the hospital floor knew that the patient was lying. The healthcare records read like one giant wink to staff - the patient report, followed by the punchline of the clinical signs: "Patient reports consuming one glass of wine per day," a note would read. "BAC 2400 upon admission." (For my non-medical readers, that's a Blood Alcohol Concentration 3 times the legal driving limit).
If doctors know for a fact that patients lie about alcohol consumption, then why aren't they better at talking about alcohol abuse?
Doctors, this is not your fault. In all of those years of training and education, no one ever taught you HOW to talk about alcohol. To get us started, I've categorized the most common mistakes doctors make into 3 Fatal Errors. These mistakes are made with the very best of intentions; doctors think they are helping patients the best they know how, or, at the very least "first doing no harm." I'm here to say that the harm is substantial. Once patients think they have a "Clean Bill of Health," they abdicate responsibility for changing.
ERROR 1: Not saying anything.
How can this happen? It's easy. It happens for the same reason no one else in your patient's life is saying anything: fear.
Fear? That's right. Consider everything you have to be afraid of should you confront the patient's drinking: low patient satisfaction scores (a death knell post-healthcare reform), the patient going somewhere else or never coming back (how much paperwork did you do for them, again? You even called their insurance company on their behalf! So unfair!), the patient becoming belligerent, the patient blasting you on internet ratings sites (healthgrades and Yelp, anyone?), or the patient shutting down completely.
If we dig even deeper (and this is hard, I know, but keep reading), the number one most potent fear is that the patient will actually open up to you, and that you will either 1) not have enough time to talk, or 2) not have the skills to talk with confidence. Deny this fear as much as you want, but I have yet to encounter a doctor who does not harbor this secret fear.
The biggest problem with not saying anything? That patient you just saw will come into my office, and say these terrible seven words: "I got a Clean Bill of Health."
ERROR 2: Harsh confrontation.
This is the LEAST common doctor response when alcohol abuse is suspected. I would estimate that less than 5% of doctors consistently engage in Error 2, preferring Errors 1 and 3, when possible. Doctors want to help and heal. They do not want to be probation officers. They do not want to parent adults.
In fact, if you're a primary care doctor, an internist, or a family physician, then you've chosen a lower-paying, lower-status job precisely because you find it rewarding to have ENJOYABLE long-term relationships with patients. You are proud of your good bedside manner and clinical acumen. You don't like being mean. You don't want patients to dislike you. Leave that to the specialists!
Every now and then, however, harsh confrontation DOES happen - usually as a result of the doctor repressing her feelings of frustration and resentment towards the patient for too long. Or perhaps the doctor has avoided saying anything about alcohol abuse to most patients, and something just BREAKS. She can't sit by and watch this one patient self-destruct. Not today. The confrontation explodes:
"You have to stop drinking or you will die."
"You're lying to me."
"You should really cut back."
"You need to go to AA."
As is true for all providers (including me!), a power struggle ensures only one loser: the provider. As soon as we providers engage in power struggles with patients, we have already lost.
ERROR 3: Minimizing.
This is the most common doctor response. It looks something like this: you, the doctor, suspect alcohol abuse. You ask, indirectly, about possible alcohol abuse. Your patient admits to the slight - very slight! - possibility of alcohol abuse. Then there is a long, awkward silence...
... (What now???)
You rush in and minimize:
"It's not that bad."
"It's a pressure in your industry."
"That's pretty normal at your age."
"We can refer you to [someone - ANYONE - who isn't me, your doctor. (e.g. A social worker/therapist/psychiatrist/AA)]."
The patient nods his head and mumbles something. The interaction ends. Did the patient internalize the message? "Well, at least we talked about it," you say to yourself as you prepare for your next appointment. Your patient then comes to my office and repeats the phrase that makes me shudder each time I type it: "I got a Clean Bill of Health."***
There are Strategies, and They are Pretty Straightforward
My job exists because there ARE effective communication techniques to address alcohol abuse. And here's the best news: you don't have to be a trained substance abuse counselor to get a good outcome. Doctors, I need you on board because your authority and knowledge counts for so much. The few doctors who DO effectively talk to their patients and express their concerns are a godsend. Those patients come to my office, ready to change - because of you. Your work is invaluable.
Imagine having 5 simple strategies at your disposal to have these tough conversations. You can emerge from these conversations feeling empowered, refreshed, and hopeful. The locus of control will stay right where it belongs - with the patient. And here's a side effect I know you can live with: the patient will trust you. SS
***At this point you're probably really wondering - why hasn't Sarah called me about my patient? If you haven't received a phone call from me, rest assured that your patient refused (multiple times) to sign a release of information. This blog post is as close as I will ever get.