14 |
drinkanddrugsnews
| 7 February 2011
Treatment |
Psychiatrist’s view
www.drinkanddrugsnews.com
A
s a doctor, asking patients about drug and alcohol use can be a thorny subject.
There’s a joke that the definition of an alcoholic is someone who drinks more than
their doctor, and certainly overindulgence in alcohol can sometimes be viewed as the
norm both by society and medical professionals. The culture of medical school often
encourages binge drinking and medical students’ attitudes towards alcohol and drugs can vary
wildly from the advice they then feel obliged to give to patients. Feelings of embarrassment and
hypocrisy may creep in when it comes to asking a patient about substance use, and doctors
may avoid discussing the issue.
While training, information and screening tools all exist to assess alcohol and drug use,
these are often neglected areas of undergraduate and postgraduate medical education, and
doctors can carry this attitude through medical school and beyond. The definition of ‘social
drinking’ is also hard to clarify, and can lead to confusion or worries that we will offend our
patients by suggesting they differ from ‘normal society’ – it’s often easier to just not ask.
As a psychiatric trainee coming to the end of my core training, I have shown varying ability when
it comes to taking a drug or alcohol history – only when working in my current post in substance
misuse did I realise how little knowledge most junior doctors have of this area of psychiatry.
This made me reflect on my past efforts at taking drug and alcohol histories in acutely unwell
psychiatric patients, for whom substance misuse may be a significant problem. I identified
limited teaching and little liaison between the acute wards and the drug and alcohol team as
potential reasons, and I began
to reflect on what could be done
to improve the service offered
to patients with both psychiatric
and drug and alcohol
difficulties. In order to uncover
the extent of the problem – and
any ways to improve attitudes
and clinical practice – I felt an
audit of how well junior doctors
were performing would be a
good place to start.
The trust where I work has,
over the last year, implemented
a new computerised notes system, which all staff are trained to use. As part of the initial
assessment documentation for all new admissions, there is a dedicated section where the
patient’s drug and alcohol history and current usage should be documented, along with an extra
section to complete if problems are identified – ideal data for looking at whether junior doctors
were recording an adequate drug and alcohol history for new admissions, and whether those with
problems were referred to the drug and alcohol team for further input should they so wish.
The findings were not altogether surprising – a third of patients had no drug and alcohol
history recorded and, in many cases, if it was recorded it was then placed in the general notes
rather than the dedicated section of the admission document. Also, while several patients were
identified as having problems with drugs and alcohol, there was no record of appropriate follow
up being arranged.
I brought up these findings at the weekly drug and alcohol multidisciplinary team meeting,
which led to a discussion about the reasons. We identified a number of barriers to junior doctors
taking and recording a ‘good’ drug and alcohol history, including difficulties eliciting a coherent
and full history from acutely unwell patients, uncertainty as to the definition of ‘problem’ drinking,
uncertainty about when further input and drug and alcohol referral may be appropriate, poor – or
no – training in substance misuse for junior doctors and ward staff, and limited formal links
between wards and drug and alcohol services.
Discussing ways to overcome these, we identified teaching sessions for junior doctors and
ward staff and regular liaison between the wards and drug and alcohol services. However the
latter were not met with much enthusiasm by the ward and a training session for junior doctors
was the only intervention taken up.
When the audit was repeated, there was an improvement in the number of patients from
whom a history was correctly documented, but the follow up and management of those with
alcohol or drug issues was still an area for concern. The main message of this audit for me was
the need for better links and better substance misuse education for ‘general’ psychiatry trainees
and ward staff, and that there still appears to be a sense of apathy and distance towards patients
with these problems.
The preconceptions and attitudes towards alcohol and drug use that doctors begin their
careers with are likely to play a significant role, and how to overcome such feelings and
encourage a more open and educated stance is a battle that is likely to continue.
DDN
Dr Abigail Crutchlow is a CT3 psychiatry trainee at Surrey DAAT’s Abraham Cowley Unit
‘Only when working in my
current post in substance
misuse did I realise how
little knowledge most junior
doctors have of this area of
psychiatry.’
THORNY
ISSUES
P ychiatry trainee
Abigail Crutchlow
considers hy the
non-specialist medical
profession can o ten
sh away from
address ng the drug
and alcohol issues
of its patie ts