Why are doctors ambivalent about patients who misuse alcohol?

What factors determine Belgian general practitioners' approaches to detecting and managing substance abuse? A qualitative study based on the I-Change Model

BACKGROUND

General practitioners (GPs) are considered to play a major role in detecting and managing substance abuse. However, little is known about how or why they decide to manage it. This study investigated the factors that influence GP behaviours with regard to the abuse of alcohol, illegal drugs, hypnotics, and tranquilisers among working Belgians.

METHODS

Twenty Belgian GPs were interviewed. De Vries' Integrated Change Model was used to guide the interviews and qualitative data analyses.

RESULTS

GPs perceived higher levels of substance abuse in urban locations and among lower socioeconomic groups. Guidelines, if they existed, were primarily used in Flanders. Specific training was unevenly applied but considered useful. GPs who accepted abuse management cited strong interpersonal skills and available multidisciplinary networks as facilitators.GPs relied on their clinical common sense to detect abuse or initiate management. Specific patients' situations and their social, psychological, or professional dysfunctions were cited as cues to action.GPs were strongly influenced by their personal representations of abuse, which included the balance between their professional responsibilities toward their patients and the patients' responsibilities in managing their own health as well the GPs' abilities to cope with unsatisfying patient outcomes without reaching professional exhaustion. GPs perceived substance abuse along a continuum ranging from a chronic disease (whose management was part of their responsibility) to a moral failing of untrustworthy people. Alcohol and cannabis were more socially acceptable than other drugs. Personal experiences of emotional burdens (including those regarding substance abuse) increased feelings of empathy or rejection toward patients.Multidisciplinary practices and professional experiences were cited as important factors with regard to engaging GPs in substance abuse management. Time constraints and personal investments were cited as important barriers.Satisfaction with treatment was rare.

CONCLUSIONS

Motivational factors, including subjective beliefs not supported by the literature, were central in deciding whether to manage cases of substance abuse. A lack of theoretical knowledge and training were secondary to personal attitudes and motivation. Personal development, emotional health, self-awareness, and self-care should be taught to and fostered among GPs to help them maintain a patient-centred focus. Health authorities should support collaborative care.

Investigation of the frequency of alcohol related problems in Józsefváros, Budapest. Data and conclusions of three surveys undertaken among doctors and out-patients

The role of permanent alcohol consumption in the development of diseases is well-known. Aims: To study the occurence of alcohol related problems among patients of a municipal pulmonology out-patient clinic as well as in the family practice of three physicians. In addition, a survey was performed among physicians of a municipal health service and also among family practitioners working in the same district by investigating health problems, habits and professional careers of physicians, and their addictive problems, their attitude toward addict patients and their opinion upon chemical dependency. Methods: CAGE-test was used to examine the presence of alcohol problem and a questionnaire was constructed for the study undertaken among physicians. Results: The response rate was 60.18% and 32.98% among patients who visited the pulmonology out-patient clinic and their family physician, respectively. Among those who responded to the test, as many as 6.02% and 4.82% of the cases would need a further medical examination to make clear whether alcohol related health problem was present or not, whilst 9.77% and 11.67% of the patients proved to be alcohol dependent, respectively. The response rate in the survey among physicians was 41.28%. As stated, physicians not only screen the patients for alcohol and drug dependence, but also refer them to a specialist. The general experience seems to oppose this statement. The majority of health professionals considered chemical dependence as a chronic disease, whereas a kind of moral judgment of the problem was also seen, particularly among family physicians. If they had the opportunity to choose whom to treat: an alcoholic or a drug dependent patient, the majority of them would treat patients brought under the first category. The CAGE test revealed alcohol problem in three family physicians, but none in specialists. Nearly all physicians consumed coffee, but the majority of them were non-smokers. As the risk for committing suicide is higher among physicians than in the general population, physicians were interviewed in this regard, too. Three physicians in the sample reported an attempt of suicide, and eleven physicians had suicidal ideas in the past. Although the majority of physicians were satisfied with their physical and mental health, several of them had serious health problems or were treated with depression. At the same time, the majority of physicians were unsatisfied with their financial and professional respect, and had the opinion that a career is unlikely to depend on the professional knowledge. Discussion: Although the relatively low rate of physicians answering the questions did not make it possible to reveal the interrelationships among different variables, the study was able to direct the attention to the risk existing among physicians to commit suicide or use chemical substances. A proposal is made to establish an effective, but discreet and easy way to acquire psychiatric-addictological support. To avoid mental health problems among professionals working in psychiatry, organization of groups headed by someone not belonging to the same institute would be warmly encouraged. Parallel to these, the requirements and the conditions of making a career have to be made clear. On the basis of these surveys, as well as literature data, a continuous test examination of alcohol problem is recommended in the practice of family physicians as well as in the out-patient clinic of such disciplines like pulmonology and gastroenterology. Orv. Hetil., 2012, 153, 1263–1280.

Violations of medical confidentiality: opinions of primary care physicians

BACKGROUND

Physicians should be able to distinguish situations where they need to protect confidentiality from those where they could be obligated to reveal information. Data are scarce concerning physician's attitudes in daily situations where violations of confidentiality are avoidable. Physicians should be aware of situations where patients are identifiable.

AIM

To solicit participation of primary care physicians in a teaching intervention and to explore participants' opinions on violations of confidentiality.

DESIGN OF STUDY

A questionnaire presented seven vignettes describing avoidable violations of confidentiality (for example, without patient consent a physician mentions a politician's illness their spouse). Participants answered on a scale of 0-3 (0=no violation and 3=serious violation). All contacted physicians were invited to a teaching session during which the study results were discussed.

METHOD

Three-hundred and seventy-eight members of the Association of Physicians in Geneva (community physicians) working in primary care medicine, and 130 GPs and internists working at the University Hospital of Geneva (hospital physicians) took part. Physicians' answers were compared to responses from Swiss, UK, and other European law professors, and from 311 medical and law students in Geneva.

RESULTS

Between 4% (case 6) and 57% (case 2), of physicians thought that no violation occurred. Law professors attributed the scores to each case as 3, 3, 2, 3, 2, 3, 3; the means of physicians were: 1.9, 1.4, 0.7, 1.4 (hospital physicians)/1.9 (community physicians), 0.4, 1.6, 2.6. In most cases, physicians' and students' answers were similar. A significantly higher percentage of community physicians than hospital physicians and students thought that a physician violates confidentiality if they provide the list of their patients to the police for the investigation of the theft of a purse in the waiting room.

CONCLUSION

Physicians need to be fully aware of their obligations towards patient confidentiality. Avoidable breaches of confidentiality occur when colleagues and authorities (such as police and those in a judicial context) ask for information.

The injured intoxicated driver: analysis of the conviction process

BACKGROUND

The widespread nature of alcohol-related motor vehicle collisions suggests inadequacies in the system for deterring alcohol use when driving. This study was performed to determine whether hospitalization is a component in a "system failure" that allows injured, alcohol-impaired drivers to escape arrest and conviction for driving under the influence (DUI).

METHODS

We conducted a retrospective review of medical and court records of intoxicated drivers injured in a motor vehicle collision who were transported to our Level I trauma center from January 1, 1997, through December 31, 1998.

RESULTS

Of the 213 intoxicated drivers in our study, 172 (81%) were followed up by law enforcement officials, and 156 (73.2%) were arrested for DUI. Of those who were arrested and completed court hearings, 135 (93.8%) were convicted for DUI.

CONCLUSION

These values are higher than those reported in previous studies and indicate that hospitalization does not "protect" injured, intoxicated drivers in our community.