Public perceptions of alcohol use by physicians.

Objectives: The objective of this study was to assess public perceptions of alcohol use by physicians on duty.

Methods: A random telephone survey of 408 adults in one Tennessee county was used.

Results: Only 1% of the respondents reported that they suspected that a physician with whom they were in professional contact during the last year had used alcohol. Only 7% reported encountering physicians whom they suspected of having used alcohol while on duty. When queried about their beliefs, 98% disagreed that social drinking is acceptable while on duty, 92% believed that physicians should not have even a single drink while on duty, and 91% believed that doctors have an obligation to inform patients that they have consumed an alcoholic beverage before advising or treating them.

Conclusions: Patients rarely suspect that physicians use alcohol while on duty and are highly intolerant of this practice. Physicians can only gain in prestige and public confidence by adding categoric proscriptions about alcohol use on duty to their ethical codes.

Key Words: alcohol use, code of ethics, physicians on duty, public perceptions

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Much literature addresses potential impairment of physician judgment by alcohol. (1-4) Some medical literature discusses whether physicians should attend to an emergency if they have been drinking while they are not on call. (5,6) Other literature addresses whether physicians can drink while on duty. For example, the American Medical Association (AMA) Code of Medical Ethics (AMA 1998) section E-8.15 entitled "Substance Abuse" states that "It is unethical for a physician to practice medicine while under the influence of a controlled substance, alcohol, or other chemical agents which impair the ability to practice medicine," but does not explicitly state whether any alcohol can be used. (7) The AMA House of Delegates has also offered a policy (H-30.960) (AMA 2003) that "(1) urges that physicians engaging in patient care have no significant body content of alcohol and (2) urges that all physicians, before being available for patient care, refrain from ingesting an amount of alcohol that has the potential to cause impairment of performance or create a 'hangover' effect." (8) However, this statement does not indicate whether physicians have an obligation to refrain from drinking while on duty. The use of the term "urge" implies that physicians have the discretion to make the final decision, whereas the phrase "refrain from ingesting an amount of alcohol" implies that some use of alcohol is permissible.

A recent survey of physicians' perceptions of alcohol use by themselves and their colleagues while on call suggests a conflict between physicians' perceptions about the use of alcohol while on call and their duty to inform their patients of such use. (9) Therefore, we decided to investigate the public's perceptions of alcohol use by physicians who are on duty to see if there might be a disparity between physician and public perceptions. We hypothesized that the public would perceive that alcohol use by physicians while on duty would be rare and that they would be less tolerant about such use than physicians were in another study. (9)

Materials and Methods

We developed a telephone survey to probe public perceptions of alcohol use by physicians that was very similar to a survey we recently administered to physicians about alcohol use by themselves and their colleagues. (9)

The survey was administered to adult residents of Hamilton County, Tennessee, by trained telephone survey interviewers at Wilkins Research Services (Chattanooga, TN) between November 30 and December 5, 2002, using random computer dialing of household telephone numbers by the VOXCO Computer Automated Telephone Interviewing (CATI) system. If a respondent refused to participate in the survey or was not an adult who was most responsible for the medical care of his or her family, the computer dialed the next number randomly. The surveys were conducted with the use of a desktop computer, enabling the survey data to be entered while the survey was conducted. Survey data were cleaned, edited, and checked for duplicate entries.

Data were analyzed by means of S-Plus, version 6.1 statistical software (Insightful Corp, Seattle, WA). Responses were tallied and binomial 95% confidence intervals calculated using the binconf function in Harrell's Hmisc library. For this hypothesis-generating study, two-sided probability values of less than 0.05 were considered significant.

Results

Approximately 816 persons were contacted; 408 acknowledged being adults who were most responsible for their family's medical care and agreed to complete the interview. The majority of respondents were female (73%), 35 years of age or older (87%), white (85%), and had at least a high school education (87%) (Table 1). Thirty-seven percent had incomes of less that $25,000, 70% less than $50,000, and 30% $50,000 or more. Only 5% had no health insurance. Of the respondents, 35% acknowledged having drunk at least one alcoholic beverage in the last month.

Our respondents had had frequent contacts with physicians in the previous year: 68% had personally seen a physician at least 3 times, and 67% had accompanied a family member and were present during treatment by a doctor (Table 2). Though the wording of our questions does not allow exact calculation of the number of physician contacts per respondent, by assuming an average for each range (ie, "3 to 5 times" averages 4 and "6 or more times" averages 7), we calculate that our 408 respondents had approximately 2,776 physician contacts (average, 6.8) in the previous year.

Only 3 respondents (1%) reported that they suspected that a doctor had recently consumed alcoholic beverages in the last year (on at least 9 different occasions involving 3 different doctors), for an approximate point estimate of 3 suspicions per 1,000 contacts. Overall, only 7% of respondents agreed that they had ever encountered physicians whom they suspected of having used alcohol while on duty.

When asked about their beliefs about the use of alcohol by physicians on duty, 97.5% (95% confidence interval [CI], 95.5, 98.7) of respondents disagreed that social drinking is acceptable while on duty and 91.9% (CI, 88.9, 94.2) believed that physicians should not have even a single drink while on duty (Table 3). Only approximately 3% believed that alcohol use while on duty is a private matter, and 90.7% (CI, 87.5, 93.1) believed that doctors have an obligation to inform patients that they have consumed an alcoholic beverage before advising or treating them.

Discussion

Commendably for the medical profession, our study suggests that patients infrequently perceive that physicians use alcohol before treating them. Our survey suggests that they suspect use of alcohol only approximately 3 times per 1,000 professional contacts. To our knowledge, similar studies have not been conducted by other professions that would allow comparisons.

Physicians may suspect alcohol use by colleagues more frequently than patients do. In a physician survey by Ahmad et al, (9) 64% of physicians reported having encountered physicians whom they suspected had used alcohol while on call and 27% reported having encountered physicians impaired by alcohol while on call, compared with 7% and 6%, respectively, in the present study. There are several possible reasons for these differences. Physicians may be more sensitive detectors of alcohol use by their colleagues than patients, since they are trained to detect and treat alcoholism. Physicians also see their colleagues on duty more frequently than patients do and therefore would have more opportunity to detect use of alcohol. Another possible explanation is that alcohol use by physicians who are on call may be more prevalent than alcohol use during regularly scheduled work hours. The patients in our study may have visited their physician contacts primarily during scheduled hours, whereas the physicians in the study by Ahmad et al may have seen their colleagues both during scheduled patient-seeing hours and while on call.

Our study finds that patients are intolerant of alcohol use by physicians who are on duty. While in the Ahmad et al study, physicians were conflicted about whether doctors have an obligation to inform patients that they have consumed an alcoholic beverage before advising or treating them, with 53% agreeing that they have such an obligation, there was little discord among patients, with 91% responding that physicians have an obligation to inform. (9) Patients most likely perceive that use of alcohol by physicians who care for them might affect their medical care.

Although 26% of physicians in the Ahmad et al (9) study believed that use of alcohol while on call is a private matter, only about 3% of patients agreed. Though we were unable to specifically explore the issue of patients' feelings about alcohol use by physicians on call because of the verbal burden such querying would have added to this telephone survey, we suspect that patients would also have been intolerant of the use of alcohol by on-call physicians.

Society has developed two standards for the use of alcohol while performing potentially dangerous activities. It has considered some activities, such as driving, to be safe as long as a maximum blood alcohol level (such as 0.08 or 0.1) is not exceeded, (10) whereas for other activities, such as piloting an airplane, all use of alcohol is proscribed. (11) Our study suggests that the public believes that alcohol use by physicians who are on duty falls into the latter category.

Physicians are widely divided on whether they are obligated to tell a patient if they have taken alcohol before treating them, with 53% of physicians feeling that they have such an obligation. (9) Patients are not at all conflicted, with 91% feeling that physicians have such an obligation, that is, that alcohol use by physicians when they are on duty is a public and not a private behavior. According to the principal of informed consent, physicians are required to inform patients of risks they undertake in treatment. Although some ethicists argue that physicians are not required to communicate highly improbable risks, ethicists have tended to agree either that patients should be informed of all risks a reasonable person would want to know or all risks a particular individual wants to know. (12) Our study suggested that most patients want to know.

Physicians, perhaps more than other professionals, because of their role as healers and counselors and the high-stress quality of their jobs, need to find time to relax unburdened by the pressures of public scrutiny, free to enjoy themselves in whatever way they will, including the use of alcohol. In addition, some use of alcohol may be beneficial to their health. (13,14) Our survey suggests that patients do not believe that on-call times are appropriate for this type of stress relief.

Our study suggests that patients suspect alcohol use by physicians at such a low rate that it is not much of a problem in public perception. However, use of alcohol by physicians may be more of a problem to physicians' colleagues who are more suspicious about the use of alcohol by physicians who are on call. So far, the medical profession and the public have left this decision up to the discretion of individual physicians. In effect, without public debate, drinking on call has been treated as private behavior. Though this approach may not be wrong, we need to remember that John Stuart Mill, in his classical description of liberalism, (15) advocated that a zone of privacy provides important benefits, ones worthy of protection because of their role in giving us as wide a range as possible to express who we are as individuals. The question society and the medical profession need to face directly to resolve these confusions is: "Can physicians have their privacy, in drinking while on call, and protect their patients too?" Although some physicians think that this is possible, patients appear to disagree.

Our study has several limitations. Though a telephone survey is a cost-effective and expeditious method to sample a population, it samples from telephone owners who may be more affluent and differ in other important characteristics from the general population. (16) For example, our respondents were more often white, older, and more often on Medicare than the average person in Hamilton County. (17) Nonetheless, we were seeking a population that had contact with medical professionals, and this methodology increased our chance of doing so. Another limitation is that we randomly sampled adults in one county, in one state, and in one region of the country. A similar study needs to be replicated in other areas of the country. Finally, the wording of our questions precludes exact rate estimates, though they would have been low under a variety of assumptions.

Conclusion

Our telephone survey of patients' perceptions about alcohol use by physicians who are on duty suggests that patients are rarely suspicious about use of alcohol by physicians and are highly intolerant of this practice. In light of our findings, the AMA code of ethics should incorporate a statement on the use of alcohol by physicians who are on duty.

Table 1. Characteristics of adult respondents

Characteristic (number responding)                   %

Female sex (408)                                     73
Race (402)
  White                                              85
  Black                                              13
  Other                                               2
Age (406)
  18 to 24                                            5
  25 to 34                                            8
  35 to 54                                           35
  55 to 64                                           19
  [greater than or equal to]65                       33
Education (401)
  Less than high school                              13
  High school or equivalent                          31
  Some college or technical school                   27
  College or professional                            29
Insurance (403)
  Private                                            57
  Medicare                                           24
  Medicaid                                            8
  Medicare and Medicaid                               6
  None or don't know                                  5
Income (376)
  Less than $25,000                                  37
  $25,000 to less than $50,000                       33
  $50,000 or more                                    30
At least one drink (a) of any alcoholic beverage     35
  in past month (402)

(a) Defined as one can or bottle of beer, one glass of wine, one can or
bottle of wine cooler, one cocktail, or one shot of liquor.

Table 2. Respondent perceptions of the use of alcohol by physicians

Query (number responding)                                        n    %

Number of times personally treated in a medical facility
  (a) in last year (404)
  0                                                               30   7
  1 or 2 times                                                    95  23
  3 to 5 times                                                   117  39
  6 or more times                                                159  39
  Don't remember but at least once                                 7   2
Number of times accompanied a family member and were present
  During treatment in a medical facility (a) in last year (408)
  0                                                              133  33
  1 or 2 times                                                   112  27
  3 to 5 times                                                    68  17
  6 or more times                                                 85  21
  Don't remember but at least once                                10   2
Occasions in the last year when you were physically present        3   1
  when you suspected the doctor had recently consumed alcohol
  (408)
I have encountered physicians whom I suspect have used alcohol    30   7
  on duty (408)
I have encountered physicians whom I suspect were impaired by     26   6
  alcohol when they were on duty (408)

(a) Doctor's office, clinic, hospital, emergency room, or other medical
setting.

Table 3. Respondent perceptions about use of alcohol by on-duty
physicians (n = 408)

                                 Response % (95% confidence interval)
Statement about physicians       Agree              Disagree

Social drinking is acceptable    ...                97.5 (95.5, 98.7)
  while on duty.
Physicians should not even have  91.9 (88.9, 94.2)  ...
  a single drink while on call.
Doctors have an obligation to    90.7 (87.5, 93.1)  ...
  inform patients they have
  consumed an alcoholic
  beverage before advising or
  treating them.
Alcohol use while on duty is a   ...                97.3 (95.2, 98.5)
  private matter.

Acknowledgments

The authors are grateful to Ms. Ione Farrar of the Community Research Council for her help with design of the questionnaire and survey implementation. The Department of Medicine paid the costs of the phone survey.

Accepted August 10, 2004.

References

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2. Aach RD, Girard DE, Humphrey H, et al. Alcohol and other substance abuse and impairment among physicians in residency training. Ann Intern Med 1992;116:245-254.

3. Bohlmann BJ. Covering for impaired residents. Ann Intern Med 1992;117:267-268.

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6. Stewart JAD. Doctors who do not feel sober enough to drive should avoid helping in medical emergencies. Br Med J 1998;317:1158.

7. American Medical Association. Opinion on practice matters, substance abuse, in Code of Medical Ethics. Chicago, AMA. 1998-1999, ed 8, 15, pp 153-154.

8. American Medical Association. Policy Finder Section, Under House of Delegates. Available at: http://www.ama-asn.org. Accessed March 25, 2003.

9. Ahmad T, Wallace J, Peterman J, Desbiens NA. Doctors' perceptions of drinking alcohol while on call: questionnaire survey. Br Med J 2002;325:579-580.

10. National Highway Traffic Safety Administration. Fact Sheet at Traffic Safety and Occupant Protection/Injury Prevention/Impaired Driving/Impaired Driving Facts. Available at: http://www.nhtsa.dot.gov. Accessed March 25, 2003.

11. Federal Aviation Regulations, 91.17 in Aviation Flight Standards Service. Available at: http://www.faa.gov/avr. Accessed March 25, 2003.

12. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics. New York, McGraw-Hill, 1998, ed 4, pp 55-56.

13. Ellison RC. Balancing the risks and benefits of moderate drinking. Ann N Y Acad Sci. 2002; May;957:1-6.

14. Alcohol: lift a glass (but not too many) to health. Harv Health Letter 2002;27:3.

15. Mill JS. On Liberty. Indianapolis, Hackett, 1978, pp 73-92.

16. Hinkle AL, King GD. A comparison of three survey methods to obtain data for community mental health program planning. Am J Com Psych 1978;6:389-397.

17. Statistics in Hamilton County. Community Research Council. Available at: http://www.researchcouncil.net/HamCo2000.htm. Accessed January 16, 2003.

RELATED ARTICLE: Key Points

* Patients rarely suspect that physicians use alcohol while on duty, and are intolerant of this practice.

* Ninety-two percent believed that physicians should not have even a single drink while on duty.

* Ninety-one percent believed that doctors have an obligation to inform patients if they have used alcohol before treating or advising them.

Norman A. Desbiens, MD, Mukta Panda, MD, Neema Doshi, PHD, and James Peterman, PHD

From the Department of Medicine, University of Tennessee College of Medicine-Chattanooga Unit, Chattanooga, TN, and the Department of Philosophy, The University of the South Sewanee, TN.

This study was approved by the Institutional Review Board of the University of Tennessee College of Medicine-Chattanooga Unit.

Reprint requests to Dr. Norman A. Desbiens, Department of Medicine, University of Tennessee College of Medicine-Chattanooga Unit, 975 East Third Street, Box 94, Chattanooga, TN 37403. Email: [e-mail]