5 Simple Strategies Doctors Can Use to Discuss Problem Drinking
So you've read about the 3 fatal errors doctors make when they suspect alcohol abuse. Now you would like some solutions. As the most influential health expert in your patient's life, you don't want to miss an opportunity to help your patient change.
Missed opportunities are heart-wrenching. As a doctor, you are constantly Monday-Morning Quarterbacking: Could you have helped someone make an important life change? Intervened? When it comes to alcohol abuse, the answer is an emphatic "YES."
The Situation: Elevated Liver Enzymes
Reviewing lab work offers a great opportunity to discuss problem drinking. It's also a common missed opportunity. When I first assess a counseling client who reports a pattern of heavy drinking, I probe for health concerns. He will often admit to having “slightly elevated” liver enzymes, but excellent health, otherwise.
“It’s just slight,” he says.
“Elevated liver enzymes could be serious,” I say. “The word ‘slight’ is a misnomer. You liver is being damaged.”
He deflects: “My doctor said not to worry about it.”
Had I been sitting in the consultation room with you and your patient, I doubt I would have heard you say, "Don't worry about it." Regardless, your patient has internalized a false message, most likely due to one of the fatal errors doctors commit when discussing alcohol abuse.
Let's review 5 simple strategies straight out of the alcohol counselor playbook. In this situation, the doctor is fairly certain that the cause of elevated liver enzymes is due to alcohol abuse, and has ruled out other causes.
Strategy 1: Ask Permission. (“Would it be alright with you if…?”)
To start any challenging conversation, ask permission. Nine times out of ten your patient will give you permission to proceed. It sounds something like this:
Doctor: Would it be alright with you if we reviewed this lab work together and I gave you my impressions?
Patient: “Well, yeah – you’re the doctor.”
Doctor: “Ok, great! So everything looks normal, except for your liver enzymes. Yours are slightly elevated, which could mean a few things. The most concerning one is the possibility that this could be exacerbated by your alcohol intake. I'm concerned about liver damage.”
Think of having a tough conversation the way you think of any clinical procedure. Would you stab a patient with a vaccine needle before asking their permission? Obviously not. Would you sedate a decisional patient for an MRI without first securing consent? Nope.
This is why we ask our patients for their permission to talk about unpleasant things. Substance abuse interventions are invasive, frightening, and threatening – if we perform them without asking permission.
Whenever I train doctors, I get the inevitable question: What happens if the patient says "No"?
Tempting as it is to charge ahead without asking permission, you are wasting your time and energy providing unsolicited information. When patients consent to your offer of health information, they give you buy-in. Imagine a conversation without buy-in:
Doctor: “So I looked at your labs, and your liver enzymes are slightly elevated. This means that you are probably drinking too much. Even if you’re drinking moderately, you need to stop. You don’t want to get fatty liver disease.”
Patient: (taken aback) “Um, ok. I'm not drinking that much, though."
[Power struggle ensues.]
Ok, ok - you're wondering what the heck to do in the unlikely event your patient DOES NOT give you permission to offer information. Now it is time to review the risks and benefits of consent. In the same way you give your patients INFORMED CONSENT to refuse recommended procedures, such as MRIs, you then offer informed consent regarding their refusal.
Doctor: “Would it be alright with you if we reviewed this lab work together and I gave you my impressions?”
Doctor: “Ok. I respect your choice, but also want you to know that I have some concerns. I want to talk about those concerns, because I am worried about your health. I have some ideas of how I can help. At the end of the day, it’s your decision to let me know if you want to talk about what has me so worried.”
Patient: “Wait, what?!”
If that conversation sounds ridiculous, that’s because it IS ridiculous. Patients trust your medical authority, and, quite naturally, let you lead the conversation. Most of the time, they will say "Yes" when you ask for their permission. Take a moment to ask, which will secure buy-in from your patient and activate them into the conversation.
Strategy 2: Elicit-Provide-Elicit (“What do you know about…?)
This comes straight out of Miller and Rollnick’s Motivational Interviewing approach. It is extremely fast and effective.
Step 1: Elicit. Engage the patient by eliciting their understanding of the subject at hand.
Step 2: Provide. Provide information based on your expertise.
Step 3: Elicit. After providing information, you once again elicit the patient’s understanding. This ensures no feedback is wasted because the patient will understand exactly what you mean.
Here's how this looks:
Doctor: (Elicit) “What do you know about fatty liver disease?”
Patient: “It’s something fat people get, right? Or old people.”
Doctor: (Provide) “You’re right that people who are overweight can get fatty liver disease. There’s a second kind of fatty liver disease, though – one that is just as serious – which is caused simply by consumption of alcohol. People can be quite thin and fit – and young – and still get alcoholic fatty liver disease. Fatty liver disease is the precursor to cirrhosis. It leads to liver failure. And the first sign of fatty liver disease is a blood panel with slightly elevated liver enzymes. As I look at your lab work, I am very concerned about the level of liver enzyme I am seeing. ‘Slight’ elevation is actually quite serious when it comes to the liver. It could be that even a slight amount of alcohol is making you sick.” (Elicit) “What do you make of that?”
Check it out! You just gave your patient extremely important information – tailored to their health – without accusing them of being a raging alcoholic. Elicit-Provide-Elicit allows for a graceful confrontation to occur without slipping into the 3 Fatal Errors doctors make when confronting alcohol abuse. Most patients will experience discomfort and panic as they internalize the information - in a good way. Your goal is to help them become uncomfortable with their current drinking behavior.
Strategy 3: Clinical comparisons. (“Based on my experience, I've…”)
Even if you are a newly minted graduate of your residency program, your experience as a doctor encapsulates all of the wonderful knowledge and actual clinical experience you have had thus far. Because we have a culture of respecting the authority and expertise of medical doctors, descriptions of your experience have a major impact.
The key is to avoid making it sound too personal or accusatory as you frame the statement. Avoid ultimatums. If you say, “Based on my experience, you…” then you have failed. Remember - we don't want to make your patient angry or defensive. Speak very, very broadly when you start by only describing general patient situations you have worked with. This allows your patient can draw their own conclusions.
Doctor: “Based on my experience, you need to cut out drinking. It’s the only way to be safe. I’m not saying you need to quit drinking forever, but you should really quit drinking today. It’s the best way to get your liver enzymes back to normal. If you don't stop, you'll end up with liver failure like my other patients.”
Doctor: “Based on my experience, I’ve seen patients with elevated liver enzymes cut out alcohol, completely, and get their numbers back to a healthy range. My goal isn’t to force patients to give up alcohol forever, but rather, to help them stay healthy and to monitor their labs. Those patients have felt really good once their numbers are in that healthy range.”
Can you hear the difference between the two statements? In the Wrong Way, the doctor tells the patient what to do (quit drinking), whereas in the Right Way, the doctor describes what works (quitting drinking), thus empowering the patient with information. You want to invite the patient to make a choice.
It might seem like splitting hairs, but ask yourself this: Have you ever responded well to someone telling you what to do? To feeling as though your freedom and sense of choice is being taken away? Probably not. Employ the Right Way.
Strategy 4: Confusion. ("I'm confused. Can you help me understand this?")
This is a favorite of newbie substance abuse counselors because it is easy, direct, and confrontational without being mean. It is the perfect strategy for when you and your patient are stuck due to their lack of honesty or willingness to work with you. Employ it without a hint of sarcasm.
Patient: “I don’t drink alcohol.”
Doctor: “I’m confused. On the one hand, you don’t identify as a drinker. On the other, it looks like your liver enzymes are elevated, even though you’re not overweight. Most doctors would assume there is at least some alcohol consumption here, just based on the labs. I trust you, and want us to trust each other. Can you help me understand this?”
The hang-up doctors have with the Confusion strategy relates to ego. It doesn't feel good to verbalize that you do not know. Again, this makes sense: your attending physician in residency would have humiliated you in front of your colleagues if you had said, “I’m confused…can you help me understand this?” during hospital rounds.
The beauty of Confusion is this: your patients know that you do know. This is why you don't want to be sarcastic. Act warm and concerned. Patients appreciate the olive branch you offer with Confusion, which gives them an opportunity to be honest.
Try Confusion once. You won’t regret it.
Strategy 5: The Dilemma. ("Here's my dilemma...")
This is an upgrade to Confusion, and has the benefit of feeling collaborative if you can pull it off with grace and tact. The pitfall? It requires you to present yourself with even greater humility than you do with Confusion. But it works really, really well.
Patient: “I don’t drink alcohol.”
Doctor: “You have told me that before. Here’s my dilemma: on the one hand, I believe you when you tell me that you don’t drink alcohol. On the other, my clinical training and experience at this point would tell me that I should be talking with you about possible alcohol use, since your liver enzymes are elevated and you’re not overweight. I just want to help, but am unsure of how to move forward.”
Now is the really, really hard part: you wait. You will let the silence envelop your patient and wait for a response. You will widen your eyes with genuine concern. You will let them fill the silence.
I hear the naysayer reading this: What if the patient denies drinking alcohol? Don’t worry – the Dilemma gives you space to address this, too. Just employ Asking Permission while you do it.
Patient: “I get that you’re worried about alcohol use, but I really don’t drink. I don’t think we need to talk about it since it’s a non-issue.”
Doctor: “Thank you for letting me know. (Asking Permission): Is it alright with you if I just give you some information, since that’s part of what my job requires at this point? You and I can move on after this, but it’s important for me to say what my professional expertise dictates. At a minimum, this is information that could benefit you in the event that you ever find yourself in a drinking situation, since your liver enzymes are elevated. Your health is my top concern.”
Patient: “Ok. I understand that you have to do what you have to do. It’s liability. I get it.”
Doctor: “Thank you. And if it’s also ok with you, I want us to keep this on the agenda to talk about in the future, in case you find that at some point you are in a drinking situation, or a special occasion, where you might have some alcohol. A wedding, for example.”
Patient: “Ok. Go ahead.”
The Dilemma creates an opening even when the patient is in complete denial or at the point of shutting down. By repackaging the situation as a dilemma – one you do not know the answer to – you are inviting the patient to take responsibility. You provide important information with an attitude of caring and concern. It might not feel authoritative, but the task here is in creating an opening. The patient has been invited to be honest with you – even if that occurs in the future. Or with an alcohol counselor.
This is the hardest part for doctors, hands down: not knowing the final outcome when your patient leaves the office. But if your patient has listened to you, acknowledged what you said, and demonstrated interest in your opinion, you have been clinically effective.
Most doctors I talk to want to hear their patient make a grandiose commitment prior to ending the appointment: “That’s it, I’m going to AA and quitting forever!” Unfortunately, behavior change simply does not work like that. (Remember that gym membership you've been meaning to cancel?) Behavior change takes time.
However, (and I want you to really internalize this – to allow its truth to settle in) you, the doctor, are the first stop. You are the most influential person in getting your patient to change. A patient who hears their doctor express genuine concern develops radical willingness.
Even if your patient gives you no indication of wanting to quit alcohol forever, he subsequently comes into my office and says, “Sarah, I want to quit drinking. My doctor told me I have to.”
Allow me to offer you a “Based on My Experience” reflection: by the time your patient has lab work revealing slightly elevated liver enzymes, they undoubtedly have been confronted by countless people who are concerned about their drinking – significant others, close friends, and family members. They may have fabulous jobs, but their productivity is stagnating. Their lives are more chaotic than their labs even begin to reveal.
I truly believe that you, as a doctor, can make the biggest impact in the lives of alcohol abusers. You provide extraordinary motivation for patients to turn their lives around.
As an alcohol counselor, I am endlessly grateful for your service. Please accept these strategies as a gift of gratitude. Hopefully this makes your work a little bit easier in the trenches of behavior change. SS