Monday 15 November 2010
spiked is publishing a series of articles based on talks given at the Battle of Ideas festival, which took place on 30 and 31 October at the Royal College of Art in London. Here, Dr Michael Fitzpatrick argues that while levels of alcohol consumption might well be problematic, the idea that a doctor’s ‘brief intervention’ might be the solution is simply deluded.
One of my responsibilities as a GP in our practice is that I keep the book of the dead - an audit of every patient death at the practice. This involves getting together to discuss whether we can learn anything from a particular death, whether it was well managed, badly managed and so on. And one of the interesting things over the past year is that we’ve had only three deaths of people under 50 and they’ve all been related to alcohol.
This, I think, reflects the general perception that there is a significant problem with alcohol. I doubt there’s few people who have not experienced the destructive effects of alcohol in their own lives, whether its someone in their family or in their own circle of friends. It’s a well-recognised social problem that is probably on the increase.
What I want to concentrate on is the efficacy of medical intervention in this phenomenon - what is known as a brief intervention. Now, a brief intervention has been studied by NICE and other bodies as the most effective form of intervention in dealing with the problem of alcohol. As time has gone by the intervention has got shorter and has become more effective. We used to talk to patients for about 10 or 15 minutes – it’s now down to just five minutes.
The efficacy of the brief intervention has been discussed for quite a few of years, not to mention lauded in various medical publications, but in the past six months it has really made its way into general practice. Now we have countless templates which we use to guide consultations with all sorts of patients with all sorts of problems. Every single template, whether it is for a diabetes sufferer or a high blood pressure patient, raises the issue of alcohol consumption, which means that doctors will ask people about their alcohol consumption.
So while you may go to your doctor with an ingrowing toenail or a boil on your finger, your doctor will have to ask you about your alcohol consumption so that he or she can complete the template. When your doctor says ‘I’m not interested in your finger or your toe, tell me about how much you drink’, it’s a strange scenario. But it’s coming to a surgery near you if it hasn’t already.
The basis for this notion is the idea that this five-minute discussion between GP and patient is the answer to the greatest public health panic of our time. And what does this discussion involve? It involves sitting down and the doctor saying ‘Look, how much do you really drink?’ The doctor will then get the chart out showing how to calculate the units of alcohol in a pint, in a glass of wine and so on, before turning to the chart which very helpfully indicates the destructive effects of alcohol on every single organ of the body.
The terms in which this is posed are quite interesting. It indicates the extent to which the world of public health has become so contemptuous towards the public that it is exempted from the requirements of political correctness. People will remember recently that the UK minister of health Anne Milton wanted to be able to call obese people ‘fat’ – anyone who is overweight can be abused in these terms. And likewise for heavy drinkers: if you drink too much you are told that you can have children who are ‘retarded’ and ‘deformed’.
So, the children of people who drink too much do not have ‘learning difficulties’, they are ‘retards’. I am surprised public health officials don’t talk about spastics and mongols given that Down’s syndrome was for many years entirely attributed to alcohol until it was discovered to be a chromosomal disorder.
So you have this discussion, and the patient might say, ‘I didn’t know I was drinking so many units, I didn’t realise it could have such a wide range of effects on every organ of my body.’ To which the doctor can respond: ‘Well let me suggest to you ways in which you might be able to reduce your consumption.’ And there is indeed a whole list of options available to GPs, such as going to the gym after work instead of for a drink. These are the sorts of suggestions that feature as part of the brief intervention.
I’ve been sent on a course on motivational interviewing so I supposedly know about how to motivate the patient – or at least I’ve been trained in it. The idea is that this intervention has been studied exhaustively by bodies who evaluate the efficacy of the intervention with the utmost statistical rigour.
But think about it for a minute. We’ve got a major social problem, it’s destroying people’s lives on a vast scale. And one five-minute chat with doc later, and it’s all sorted. It couldn’t possibly be true. It’s wishful thinking on a cosmic scale.
If you look at all these studies they’ll cite references allowing you to look at how they have arrived at their conclusions. First of all they involve a small sample of people. Secondly anyone with harmful levels of drinking will be excluded and only those with hazardous levels of drinking will be included. Thirdly the sample patients are only followed up for a short period of time – six months at the maximum. Fourthly, the goal posts are subtly moved so that the desired outcome is not abstinence nor even a reduction of drinking to safe limits: it is simply a reduction or a reduced number of binge episodes. And having done all that those conducting the test can confidently assert: ‘the practice of brief intervention clearly works very, very well’.
It’s simply deluded. So, although there is a problem that has medical consequences, here it becomes a medical problem for which there is a medical solution. In historical terms, there are economic, cultural factors which affect levels of alcohol consumption. But there is no medical solution to this problem.
Furthermore, the idea of there being a medical solution is not itself without its own problems not least because it is very bad medicine. It’s a practice that claims the authority of medical science for an intervention which is actually of an entirely moralistic, crusading character. We have got the Band of Hope and the Salvation Army without the brass band now marching through your surgery.
The other problem is that this is going to be visited upon the entire population. It is not targeted at the damaging and serious drinkers, it’s going to be targeted at everybody. It is ironic that a doctor’s authority is invoked to play this role at the very time when the notion of the authoritative, paternalistic doctor is supposed to be a thing of the past: the sort of doctor who tells people how to live their lives that is now being reconstructed.
And it is very bad for patients, too. It is intruding upon their own medical consultation with an entirely different agenda, a manipulative, intrusive, authoritarian one which not only does not solve the specific problem, it opens up a whole new set of problems.
reprinted from: http://www.spiked-online.com/site/article/9894/