Psychiatric Annals

CME Article 

The Effects of Alcohol Use During Medical School

John Hall, MD; Mark S. Gold, MD; Noni A. Graham, MPH; Ray Pomm, MD

Abstract

Physician impairment due to use of alcohol or other drugs is a serious issue affecting not only the impaired but also the family, medical practice, and society. In a study of physicians disciplined by the Medical Board of California, Morrison et al.1 reported alcohol and other drug abuse was the second most common reason physicians were disciplined, at 14%.

Rates of alcohol dependence among physicians are about the same as the general population.2,3 However, recovery rates among physicians impaired by alcohol and other substances are quite remarkable, at more than 85%,4–6 compared with rates among the general population, at 20% to 60%.7

The number of female physicians with alcohol problems is increasing as women gain parity in medical school admissions. Women may enter medical school with less alcohol and drug use by history, but by graduation, they may be more like their male peers. Even so, physicians identified as impaired by drug or alcohol use have remained mostly male for the past 3 decades.

There have been some studies on the characteristics of impaired physicians to help identify those at risk.2,8,9 However, few studies have examined whether there are any features among addicted physicians that have any prognostic value.8 In this article, we examine records of alcohol-dependent physicians to determine if there are any prognostic features that will help us identify those at greatest risk of relapse.

We examined 6-month and 1-year outcome measures for 19 randomly selected Florida physicians who were referred and monitored in 2000 with a primary diagnosis of alcohol dependence. The sample consisted of 18 men and one woman with a mean age of 46.2. During the monitoring phase (aftercare), each physician was required to participate in a specialized monitoring group, undergo randomized urine monitoring at least weekly, and attend at a recovery support group program. Recovery was documented by counselor reports, physician/psychiatrist evaluations, support group attendance records, return to work, and regular random urinalysis.

Information collected and examined on each physician included area of specialty, history of intravenous drug use, history of crack use, medical problems related to substance use, history of cigarette smoking, family history of addiction, use before or during medical school, history of driving under the influence, psychiatric comorbidity (including Axis I and II diagnoses), length of addiction, age of onset of addiction, number of prior treatments, and type of treatment entrance (ie, voluntary or involuntary). Treatment setting varied widely, but all had their progress monitored and reported to the state.

Positive outcome (defined as counselor assessment, clean urine and alcohol testing, recovery group attendance, and full return to work) was documented in 84% of those who met alcohol dependence criteria from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).10 Among the information collected, the only significantly different variable between those who relapsed and those who did not was alcohol used before or during medical school. Heavy drinking and alcohol dependence that had a clear onset before or during medical school, not simply length of dependence in years, was associated with negative outcome. Characteristics of physicians with alcohol dependence are listed in the Table (see page 507).

Compare rates of addiction and relapse among physicians to the general public.

Describe the risk factors for increased alcohol consumption in medical students.

Explain why early alcohol abuse is a risk factor for treatment resistance.…

Physician impairment due to use of alcohol or other drugs is a serious issue affecting not only the impaired but also the family, medical practice, and society. In a study of physicians disciplined by the Medical Board of California, Morrison et al.1 reported alcohol and other drug abuse was the second most common reason physicians were disciplined, at 14%.

Rates of alcohol dependence among physicians are about the same as the general population.2,3 However, recovery rates among physicians impaired by alcohol and other substances are quite remarkable, at more than 85%,4–6 compared with rates among the general population, at 20% to 60%.7

The number of female physicians with alcohol problems is increasing as women gain parity in medical school admissions. Women may enter medical school with less alcohol and drug use by history, but by graduation, they may be more like their male peers. Even so, physicians identified as impaired by drug or alcohol use have remained mostly male for the past 3 decades.

There have been some studies on the characteristics of impaired physicians to help identify those at risk.2,8,9 However, few studies have examined whether there are any features among addicted physicians that have any prognostic value.8 In this article, we examine records of alcohol-dependent physicians to determine if there are any prognostic features that will help us identify those at greatest risk of relapse.

Methods

We examined 6-month and 1-year outcome measures for 19 randomly selected Florida physicians who were referred and monitored in 2000 with a primary diagnosis of alcohol dependence. The sample consisted of 18 men and one woman with a mean age of 46.2. During the monitoring phase (aftercare), each physician was required to participate in a specialized monitoring group, undergo randomized urine monitoring at least weekly, and attend at a recovery support group program. Recovery was documented by counselor reports, physician/psychiatrist evaluations, support group attendance records, return to work, and regular random urinalysis.

Information collected and examined on each physician included area of specialty, history of intravenous drug use, history of crack use, medical problems related to substance use, history of cigarette smoking, family history of addiction, use before or during medical school, history of driving under the influence, psychiatric comorbidity (including Axis I and II diagnoses), length of addiction, age of onset of addiction, number of prior treatments, and type of treatment entrance (ie, voluntary or involuntary). Treatment setting varied widely, but all had their progress monitored and reported to the state.

Results

Positive outcome (defined as counselor assessment, clean urine and alcohol testing, recovery group attendance, and full return to work) was documented in 84% of those who met alcohol dependence criteria from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).10 Among the information collected, the only significantly different variable between those who relapsed and those who did not was alcohol used before or during medical school. Heavy drinking and alcohol dependence that had a clear onset before or during medical school, not simply length of dependence in years, was associated with negative outcome. Characteristics of physicians with alcohol dependence are listed in the Table (see page 507).

Characteristics of Physicians With Alcohol Dependence

Table.

Characteristics of Physicians With Alcohol Dependence

Discussion

The medical school experience is filled with instances where students reward themselves with parties or other special class functions where free alcohol is served. Binge drinking has become common on campus and among medical students. Drinking large amounts in a small amount of time fits the medical students' schedule and does not tend to leave the students impaired for days, like a marijuana binge might. Still, medical students as a group have less tobacco smoking but more marijuana smoking and binge drinking than their peers.

Several studies have demonstrated that medical students are prone to excessive drinking. In fact, instead of moderating or decreasing their alcohol use as one may expect given the large demands on their time, their use actually increases quite dramatically from undergraduate years.11,12 Drinking also increases throughout medical school.

We know that heavy drinking earlier and for longer periods of time does place one at higher risk for developing alcoholism. Our research demonstrates that alcohol use before or during medical school puts alcohol-dependent physicians at risk of having difficulty overcoming their addiction. It also suggests that efforts should be made to educate young physicians early in their medical school career regarding self-regulation and stress management.

Risk Factors

Why are medical students prone to increased amounts of alcohol consumption? First, medical school is a quite competitive environment. Most students go from being at the top of their class to being just average. There also are high expectations from faculty (see one, do one, teach one), adding even more stress. Additionally, they see their colleagues drinking or using medications alternately to study and relax, and they do so in turn.13 Residents are faced with “heavy work-loads, sleep deprivation, difficult patients, poor learning environments, relocation issues, isolation and social problems, financial concerns, cultural and minority issues, information overload, and career planning issues.”14

Prescription use of psychostimulants for binge studying for exams also has increased. Some students start taking cholesterol-lowering medications as they finish pharmacology even though they have levels that most physicians would not consider problematic. Other students take erectile dysfunction medications to be prepared and ready. All of what they learn conspires to reinforce the idea that they can manage themselves through the use of medications, drugs, and alcohol. Most have learned that we have made great progress in psychopharmacology and pharmacology and learn first hand that medications work in their own patients. All of this leads to a “pharmacological optimism”13 that reduces barriers to self-medication.

Finally, development of alcohol dependence may not be noticed immediately or not at all for decades. “Personality changes occur relatively rapidly in opiate and cocaine addiction and much slower with alcohol dependence, which develops over many years.”14 Alcohol consumption is somewhat of a societal norm, especially among the college-aged and older. Many physicians begin training in their 20s and are comparable to others in their age group, as most current drinkers (71%) were ages 25 to 44 in 2002, according to the National Center for Health Statistics.15

Several other personal characteristics are common to many medical students and may put them at risk for alcohol use. Medical students have quite high intellectual abilities. This may lead them into a false belief that intellect, or passing a course in pharmacology, is an addiction-protective factor. Medical students must learn to detach emotionally, to a certain degree, from their patients' illnesses to remain objective. Some students may turn to alcohol or other drugs to help maintain this detachment.

Finally, some go into medicine because of some personal experience with problems either in themselves or in their family. Therefore, they may be genetically predisposed to have problems with drugs or alcohol. Also, physicians are not trained about drugs and alcohol during medical school, and few have experiences in evaluating and treating physician addicts as they rotate through psychiatric clerkships.

These and other characteristics are exemplified in a study by Moore et al.16 in which 12.9% of male physicians in the cohort abused alcohol. The statistically significant medical school prognostic factors to their subsequent alcohol use were: “non-Jewish ancestry (relative odds [RO] = 3.1), lack of religious affiliation (RO = 4.1), cigarette use of one pack or more per day (RO = 2.6), regular use of alcohol (RO = 3.6), anxiety (RO = 1.8) or anger (RO = 1.8) as a reaction to stress, frequent use of alcohol in nonsocial settings (RO = 1.6), past history of alcohol-related difficulty (RO = 3.1), and maternal alcoholism or mental illness (RO = 1.9).” O'Connor and Spickard17 implicated a number of high-risk conditions in the identification of impaired physicians, including domestic break-down, frequent drunkenness, neglect of responsibilities, sexual promiscuity, DUIs, smell of alcohol on breath, ataxic gait, slurred speech, unexplained tremor, and disheveled appearance.

Abstinence and Recovery

Recovery from any addiction is a life-long process requiring maintenance and support. Pharmacologic options against alcohol dependence include disulfiram, naltrexone, nalmefene, acamprosate, and various antidepressants and benzodiazepines. Benzodiazepine use is higher among medical residents than their age-matched peers.18

The way in which a person deals with what Marlatt19 refers to as a “high-risk situation” determines how successful abstinence will be. Abstaining from alcohol use gives a person a sense of increased self-efficacy and more control over the issue. High-risk situations threaten this perception and are the basis for relapse.

Generally, relapse rates for any addictive behavior are high.20 However, Mansky13 reports a recovery rate of more than 90% (allowing for one relapse). Furthermore, physicians seem to do best following abstinence-based treatments. Motivation stems from the physician's ability to return to practice and maintain their medical license.14

Summary

Medical students have less cigarette smoking but more marijuana smoking and binge drinking than peers. Physicians are just as likely as anyone else to develop an alcohol problem. Physicians are poorly educated about drugs and alcohol and have minimal exposure to physician health as a topic or evaluation of physician addicts. Drinkers smoke, and smokers drink. This is especially true of physicians with alcohol dependence. They may also misuse prescription medications and smoke marijuana. While alcohol dependence occurs at rates similar to peers, the likelihood of recovery is much higher. Prevention efforts should begin early and continue throughout medical school. Training should be a focus for medical school education programs to allow for early diagnosis and prompt treatment for physicians' alcohol-related problems.

References

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  7. O'Brien CP, McLellan AT. Myths about the treatment of addiction. Lancet. 1996; 347(8996):237–2340. doi:10.1016/S0140-6736(96)90409-2 [CrossRef]8551886
  8. McGovern MP, Angres DH, Leon S. Characteristics of physicians presenting for assessment at a behavioral health center. J Addict Dis. 2000;19(2):59–73. doi:10.1300/J069v19n02_05 [CrossRef]10809520
  9. Angres DH, McGovern MP, Shaw MF, Rawal P. Psychiatric comorbidity and physicians with substance use disorders: a comparison between the 1980s and 1990s. J Addict Dis. 2003;22(3):79–87. doi:10.1300/J069v22n03_07 [CrossRef]14621346
  10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Publishing; 1994.
  11. Ball S, Bax A. Self-care in medical education: effectiveness of health-habits interventions for first-year medical students. Acad Med. 2002;77(9):911–917. doi:10.1097/00001888-200209000-00023 [CrossRef]12228090
  12. Newbury-Birch D, Walshaw D, Kamali F. Drink and drugs: from medical students to doctors. Drug Alcohol Depend. 2001;64(3):265–270. doi:10.1016/S0376-8716(01)00128-4 [CrossRef]11672941
  13. Mansky PA. Issues in the recovery of physicians from addictive illnesses. Psychiatr Q. 1999;70(2):107–122. doi:10.1023/A:1022197218945 [CrossRef]10392407
  14. Levey RE. Sources of stress for residents and recommendations for programs to assist them. Acad Med. 2001;76(2):142–150. doi:10.1097/00001888-200102000-00010 [CrossRef]11158832
  15. Table 66. Alcohol consumption by persons 18 years of age and over, according to selected characteristics: United States, selected years 1997–2002. Health, United States, 2004, With Chartbook on Trends in the Health of Americans. Hyattsville, MD: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2004. Available at: http://www.cdc.gov/nchs/data/hus/hus04trend.pdf. Accessed May 2, 2005.
  16. Moore RD, Mead L, Pearson TA. Youthful precursors of alcohol abuse in physicians. Am J Med. 1990;88(4):332–336. doi:10.1016/0002-9343(90)90485-V [CrossRef]2327420
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Characteristics of Physicians With Alcohol Dependence

RelapsedSoberTotal
Average age of addiction3528.529.8
Smoke cigarettes33.3%46.2%43.8%
Family history of substance abuse33.3%38.5%37.5%
Comorbid substance abuse33.3%31.3%31.6%
Use before/during medical school100%58.3%66.7%

Educational Objectives

  1. Compare rates of addiction and relapse among physicians to the general public.

  2. Describe the risk factors for increased alcohol consumption in medical students.

  3. Explain why early alcohol abuse is a risk factor for treatment resistance.

Authors

Dr. Hall is associate professor, University of Florida, Department of Psychiatry, Gainesville, FL. Dr. Gold is distinguished professor, University of Florida, Departments of Psychiatry, Neuroscience Anesthesiology, and Community Health and Family Medicine; and chief, Division of Addiction Medicine. Ms. Graham is research coordinator, University of Florida, Department of Psychiatry, Division of Addiction Medicine. Dr. Pomm is medical director, Physicians Resource Network, Fernandina Beach, FL.

Address reprint requests to: John Hall, MD, University of Florida, Department of Psychiatry, SMHU PO Box 117500, Gainesville, FL 32610; or e-mail: jhall@psychiatry.ufl.edu.

The authors have no industry relationships to disclose.

10.3928/00485713-20050601-07

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