Physicians, like many adults in the general public, enjoy drinking an alcoholic beverage in a socially-appropriate context when they are not taking call. But what happens when casual drinking becomes a problem? Nine out of 10 doctors recognize when they’ve reached their alcohol limit and stop drinking. However, an estimated 10% of doctors allow alcohol to adversely affect their overall well-being, health, and medical practices (1).
The National Institute of Health (NIH) suggests a man—younger than 65 years of age—not have more than 14 drinks a week, and a woman—who is not pregnant or attempting to become pregnant—not exceed more than seven drinks per week (2). If you or a colleague drink more than that, an unhealthy drinking habit may be emerging. Rigorously honest self-evaluation or peer-reporting is the next necessary step to avoid developing more serious issues of alcoholism.
Reporting Harmful Behaviors Benefits the Medical Community
The American Medical Association (AMA) Code of Ethics, considered the most widely accepted ethics guide for physicians, requires all doctors to promote personal health and wellness and to promptly inform relevant authorities of an impaired or incompetent colleague (3). Yet, one in three (36%) physicians surveyed in a recent national poll said they’ve had firsthand knowledge of a physician struggling with drug and/or alcohol misuse and yet did nothing.
Some of the reasons these surveyed doctors gave for ignoring harmful behaviors included: “someone else would take care of the problem,” “nothing would happen as a result of the report,” “fear of retribution,” and feelings of being ill-prepared to deal with an unstable colleague (4).
If we are to continue safeguarding patients’ care and doctors’ health, 100% of physicians must trust in the confidentiality and effectiveness of the reporting process. Together we can build a supportive network of peers to assist those hoping to end unhealthy drinking habits and become sober. Based on over 20 years of experience working with and mentoring fellow physicians with alcohol dependencies, I know how much bravery is required to request help from others. So I gently suggest you simply begin by answering a few straightforward questions to see if you have the symptoms of a Substance Use Disorder (SUD).
Two Feasible Questionnaire Tools to Help Physicians Discover a Fuller Spectrum of Problem Drinking
1. The CAGE Questionnaire
The ever present stigma and shame associated with alcoholism and recovery can deter any physician—who may be struggling with unsafe alcohol consumption—from disclosing her/his compromised behaviors to a hospital’s wellness committee or colleague. However, they may have enough courage to answer four simple questions regarding their past behaviors.
John Ewing, MD, the Director of the Bowles Center for Alcohol Studies at the University of North Carolina at Chapel Hill, deserves credit for developing the CAGE questionnaire. Well-known to most primary care physicians, the CAGE is a brief, four-question survey that can quickly identify when a high risk alcohol problem is present; one can recall the word C-A-G-E as a memory aid to remember to ask:
♦ Have you ever felt you should Cut down on your drinking?
♦ Have people Annoyed you by criticizing your drinking?
♦ Have you ever felt bad or Guilty about your drinking?
♦ Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?
Each question is answered ‘Yes’ or ‘No.’ One ‘Yes’ is presumed to be within the range of normal drinking. Two or more affirmative answers strongly suggest an unhealthy drinking habit (5). This requires further investigation, as discussed below. You can access the full CAGE questionnaire here.
2. The AUDIT Questionnaire
If you or a colleague would like to gather more sensitive alcohol screening information, I would suggest using the Alcohol Use Disorders Identification Test (AUDIT). Developed by the World Health Organization, this multiple-choice questionnaire employs 10 questions to recognize a fuller spectrum of alcohol use ranging from:
1. risky use, to
2. problem drinking, to
3. alcohol abuse or harmful use, all the way up to
4. true alcohol dependence, or alcoholism (6)
Researchers have found the AUDIT is over 90% sensitive across all gender and ethnic groups. Like the CAGE, this questionnaire is also scored on a point system. The first eight questions have five possible responses, and the last two questions have three possible answers. Each possible response carries a number score with it, and at the end of the questionnaire, all the numbers are summed and then totaled.
For illustrative purposes I’m listing the 10 questions here, so you can compare them to the four CAGE questions above. But to fully comprehend the power of the AUDIT, you will want to read the possible answers to each question. You can access the complete AUDIT screening tool here.
It should be noted for the purpose of this screening test, a drink is defined as follows: 1) a single small glass of beer (8 ounces; 1/2 pint), 2) a single shot or measure of liquor/spirits, 3) a single glass of wine.
1) How often do you have a drink containing alcohol?
2) How many drinks containing alcohol do you have on a typical day when you are drinking? (definition of a drink above)
3) How often do you have 6 or more drinks on one occasion?
4) How often during the last year have you found that you were not able to stop drinking once you had started?
5) How often during the last year have you failed to do what was normally expected from you because of drinking?
6) How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
7) How often during the last year have you had a feeling of guilt or remorse after drinking?
8) How often during the last year have you been unable to remember what happened the night before because you had been drinking?
9) Have you or someone else been injured as a result of your drinking?
10) Has a relative, friend, doctor, or other health professional expressed concern about your drinking or suggested you cut down?
Preparing your answers for evaluation
To Screen Yourself
I would recommend asking someone whom you trust to review your answers to each question to see if they concur with your responses. Be prepared for disagreements on one—or even several—answers, particularly with the AUDIT; the normal minimization and rationalization we have all seen with our patients may subconsciously affect your answers.
When you two disagree on the answer to a particular question, talk it out. Tell your confidant why you selected the answer you did, then listen to him/her describing why they chose a different answer for you. The goal of constructively discussing your answers is to select a specific answer to each question, because the statistical validity of the AUDIT requires a summed score from all 10 questions.
When you two have reached a general consensus on your answers, review your answers together. The WHO advises, “Scores between 8 and 15 are most appropriate for simple advice focused on the reduction of hazardous drinking. Scores between 16 and 19 suggest brief counseling and continued monitoring. Scores of 20 or above clearly warrant further diagnostic evaluation for alcohol dependence (7).”
To Screen a Colleague
You might consider showing one or both questionnaires to a friend or colleague whose health and wellness concerns you. Follow the steps above as you offer to review their answers to each question.
So I might have a problem—now what do I do?
If either the CAGE or AUDIT questionnaires identifies a potential problem, there are some anonymous resources who are willing to help you determine whether a problem truly exists. These include your state’s Physicians Health Program (PHP), if one is available in your state. You can go here to find out: Federation of State Physicians Health Program. Alternately, there are the many nationally-recognized evaluation centers, some associated with treatment programs, which specifically specialize in helping physicians. Some examples are listed here.
The Path to Achieving Long-Term Sobriety
As we strive to lessen the stigma of recovery, it’s essential for recovering physicians to be surrounded with a community of supportive peers. As I shared in the Missouri Physicians Lifeline, long-term sobriety becomes the norm when individuals have a wealth of ‘recovery capital’ to draw upon—to both initiate and then maintain sobriety (8). These reserves can be built through reassuring relationships with encouraging family members and/or friends, as well as through education and peer support via mutual aid groups.
It’s most important to remember physicians indeed do get better! In fact, 75 to 90% of physicians enrolled in a PHP for monitoring of a substance use disorder have long-term sustained recovery when measured at 5 years (9). This rate is much greater than the rates among the general population of individuals in recovery. Wellness committees at hospitals, International Doctors in Alcoholics Anonymous (IDAA) and other 12-Step organizations are all groups staffed and ready to assist you and/or a colleague desiring to end their alcohol dependence.
If you are unsure or wondering whether you or someone else has a problem, click here for a statistically validated, step-by-step guide you can use to determine if you, a colleague, or a friend has a true drinking problem. For help with the guide, or assistance interpreting your results, feel free to contact Intentional Sobriety—we stand ready to help in whatever situation you may find yourself. You may contact us for confidential help anytime by emailing DrRobb@IntentionalSobriety.com or calling my personal cell at 314.680.1632.
Robb Hicks, MD, is a Certified Physician Development Coach and the Founder and President of two companies. HEAL Your Career is a professional career consulting and life fulfillment coaching firm, and Intentional Sobriety helps recovering professionals stop relapsing, so they stay sober forever, face life successfully, and become happy, joyous & free. To learn more about what coaching is, and the power coaching creates in industry worldwide, please click here.
1. Cicala, MD, R. (2003, July). Substance abuse among physicians: What do you need to know. Hospital Physician. Pp.39-46. Available at http://www.turner-white.com/pdf/hp_jul03_know.pdf.
2. Sensible Drinking Guidelines and an international comparison of healthy drinking guidelines. (2012, January).Alcohol in Moderation.Available at http://www.drinkingandyou.com/site/pdf/SENSIBLE%2520DRINKING.pdf.
3 .Physician health and wellness. (2004, June). American Medical Association. Available at http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion90305.page.
4. DesRoches, DrPh, C., Rao, PhD, S., et al. (2010). Physicians’ perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. JAMA: Journal of the American Medical Association, 304 (2): pp. 187-193. Available athttp://jama.jamanetwork.com/article.aspx?articleid=186214
5. Ewing, J.A. (1984). Detecting alcoholism: The CAGE questionnaire. JAMA: Journal of the American Medical Association, 252, pp. 1905–1907.
6. Alcohol Alert. (2005, April). National Institute on Alcohol Abuse and Alcoholism. Available at http://pubs.niaaa.nih.gov/publications/aa65/AA65.htm.
7. Babor, T., Higgins-Biddle, J. Saunders, J., Monteiro, M. (2001). The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care (Second Edition). World Health Organization.
8. Hicks, MD, R. (2014, March). Social Factors Predict Long-Term Recovery and Inﬂuence United Kingdom’s Treatment Programs. The Missouri Physician Lifeline, p. 3. Available at http://themphp.org/Portals/0/Newsletter/MARCH%202014%20(1).pdf.