Sunday, August 30, 2020

Why I Don't Tell Alcoholics to Quit Drinking.


I have seen many alcoholics during my gastroenterology career.  It is likely in the majority of cases that I was not aware of their abuse history.  Patients often deny or minimize their alcohol history when queried. 

“Do you use alcohol regularly?”

“Only socially.”

At this point the physician and the patient engage in a linguistic tete-a-tete on the precise meaning of ‘socially’.

Patients are more forthright about their habits when they have a medical condition that has a clear an obvious connection to alcohol, such as jaundice or liver injury.  And, if family members are present, they often serve as fact checkers and truth tellers.

What is my approach to these patients?   Do I wave my arms and preach like an evangelist that they should throw their bottles away?   Do I tell them that they must quit or face medical damnation?  Do I threaten to sever them from my practice if they persist with their addiction?   I have adopted a rather different approach.  I do not advise alcoholic patients to quit their drinking.  Yes, I know that this may sound like an abdication of my responsibility to protect my patients’ health, but I do not see it that way. So before you report me to the state medical board, here me out.

I certainly do not endorse or otherwise support injurious addictions.  I wish that everyone could unshackle themselves from their suffocating tentacles.  And I conduct my personal life in a rather abstemious manner with regard to spirits and hard drink.  But, I do not directly implore patients to cease and desist as I believe that they must make this decision themselves as the very first step in their hoped for recovery.  In my experience, all successful recoveries start from within, not from without.  

I lay out the hard medical facts to these patients with clarity and candor.  I discuss the natural history of the disease and the dreadful and irreversible complications that they are at risk to suffer.  I review their available medical data emphasizing that their lab reports and imaging studies may not accurately reflect the depth of injury present in their liver and other organs.  For example, a patient with cirrhosis of the liver may paradoxically have completely normal liver blood tests.