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Why primary care physicians avoid treating alcoholics

From the April 1999 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

By S. Spence Meighan, FACP

Some time ago, after many years of heavy drinking, my denial mechanisms gave out and I entered a treatment program for my chronic alcoholism. During my drinking period, I had seen many physicians, had been examined on many occasions without comment and was even approved for a life insurance policy some six months before finally seeking treatment.

I was aware that my health was deteriorating. My liver was enlarged, several splotchy red spots had appeared on my face, I had some abdominal pains (relieved when I bore down) and I began noticing that objects seemed to move in the periphery of my field of vision.

My internist seemed uncomfortable talking to me and recommended me to a psychiatrist, a heavy smoker, who advised me to stop drinking. But if I threw some craziness in his direction, he would seize upon it for analysis and would leave my alcoholism alone. My internist then recommended a treatment program, but he did not know much about how the program worked or what would happen to me there. I was not at all sure that I liked the idea of this treatment program, and I tried to delay accepting the fact that I needed it.

Eventually, I developed abdominal pain and was admitted to the hospital. During this period, two men arrived to see me. Russ owned a paint store and Robby sold insurance. They were members of Alcoholics Anonymous (AA) who had just "dropped by." For the very first time in my life, someone was talking to me about my illness and making sense. They knew what I was feeling; they too had experienced "inside shakes" and "blackouts." They told me that if I followed the AA program, I could recover and enjoy a normal life. Russ said I could benefit from the experience and could even end up a stronger person. It was hard to believe what they were saying, but their authenticity was very convincing.

I went into treatment, and many of their predictions came true. But at the time, I remember wondering why these lay people could talk to me about my illness so much better than my medical colleagues. Since that time, I have often wondered why physicians have such a hard time dealing with alcoholic patients.

There can be no doubt that alcoholism is a serious disease. Many people die from it, and even more suffer serious morbidity. Its cost to industry is enormous; substandard performance, absenteeism, industrial accidents and worker compensation claims, both real and spurious, take an enormous economic toll.

Measuring the true prevalence of alcoholism is difficult, in part because sufferers do a sophisticated job of hiding their illness. We know that alcoholism is the fourth leading cause of death between the ages of 35 and 55, but the problem goes beyond those statistics. A significant number of accidents and suicides are due to alcoholism, and when the various fatalities due to other sequelae of alcoholism such as homicide, hepatic cirrhosis and overdose are added, the problem becomes even more significant.

So we have a disease that is very prevalent, causes enormous mortality, has morbidity intimately associated with social disasters such as violence and crime, is very costly to industry and has a hopeful prognosis when the patient enters an effective treatment program. Yet the majority of physicians are very reluctant to become involved in this illness. Why? Here are my ideas:

  • Ignorance. Many physicians simply do not have enough information about alcoholism. Training in medical school and residency programs often is fragmentary or worse. Young physicians may learn to ignore the disease as an entity and instead focus on its medical complications and coexistent illnesses. In addition, some physicians are embarrassed by feelings of incompetence because they do not know how to approach alcoholic patients.

    Because the main symptom of the disease is denial, alcoholism often remains hidden. Quite frequently, however, the stigmata are there to be observed by the perceptive physician. Features such as liver palms, telangiectasis, characteristic skin color, unexplained bruises, pyorrhea, tremors, episodes of amnesia, sweating, heavy smoking, hypertension, paroxysmal tachycardia, smell of alcohol on the breath, liver enlargement, amenorrhoea, impotence, seizures and so on are there for all to see.

    But quite often, physicians allow their own denial systems to take over. And when both the physician and patient engage in simultaneous denial, the disease becomes invisible.

  • Poor results. Part of the problem is that young physicians may have learned to expect poor outcomes when treating alcoholism. When motivated individuals are enrolled in good treatment programs, treatment can succeed and up to 70% of alcoholics stay sober. For some alcoholics, however, a variety of factors such as joblessness and lack of family support collude to create a poor prognosis. Because medical students and residents often see this type of alcoholic, young physicians may view treating all alcoholics as hopeless, an attitude that may go unchallenged in later practice.
  • Puritanism. Many physicians are products of a middle class puritan tradition. While they may have been taught that alcoholism is a disease, many believe that the illness is a moral problem manifesting willful misbehavior. These physicians may also wonder why they have to get involved with this kind of patient when there is more important work to be done.
  • Personal experience. A related factor is the presence of alcoholism in the physician's own family, especially if the family member never successfully dealt with the problem. Such experience taints the outlook of the clinician.

    In addition, when physicians who are themselves drinkers see an alcoholic patient, their own personal habits are called into question. In such cases, the physician's own denial mechanisms tell him to avoid the patient and the diagnosis.

  • Fear. Physicians may fear losing a patient if they diagnose alcoholism, particularly if they don't know how to present the diagnosis in a way that patients can handle. Many patients resent being given this diagnosis, and there is still great prejudice against the label of alcoholism.
  • Time constraints. In an era when primary care physicians are expected to see large numbers of patients, the arrival of an alcoholic is nothing short of organizational bad news. Establishing a relationship, breaking through denial mechanisms and convincing the patient that he has to abandon alcohol does not fit into the tight schedule of many primary care physicians.

Should the failure to treat chronic alcoholism by the primary care doctor be regarded as a casualty of managed care? Even before the advent of health plans, primary care physicians seldom showed great enthusiasm for tangling with this difficult therapeutic problem. Contemporary financial arrangements in practice give physicians a convenient excuse to continue to avoid the problem. There's just no time for this work.

The presence of so many obstacles raises a legitimate question of whether primary care doctors can be expected to get involved with treating alcoholic patients at anything more than a superficial—and usually ineffective—level. The question remains: Is it the responsibility of primary care physicians to get involved in the treatment of patients with chronic alcoholism? If not, then we can continue to ignore the problem with a clear conscience. But if it is our responsibility, we must decide the nature and extent of what our involvement might be.

Am I missing something? Is there some solution to this problem that I'm not seeing?

Dr. Meighan is a health care consultant in Portland, Ore., who specializes in hospital-physician relationships.

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