THE health impact and overall significance of alcohol and drug problems is well accepted, with general agreement that primary care is a great place to screen.
GPs have consultation opportunities and patient rapport; they have a mandate of continuity of care for the presenting patient and the extended family; they are located in the community and understand the local context; and they deal with the worried well, acute but self-limiting illnesses and lifestyle modifiable chronic disease.
Numerous alcohol and substance misuse guidelines, protocols, screening instruments and checklists exist, reflecting a widespread expectation that routine screening for alcohol and drug misuse problems will take place in the GP consultation.
Cost-saving and cost-effectiveness studies indicate that GPs are well placed to deliver, and funders and planners believe that GPs should do it.
So why doesn’t it always happen?
Barriers to screening include limited consultation time, triage pressures, patient expectations, funding constraints, waiting lists and scarce resources, and GP confidence and knowledge.
But initiatives designed to overcome these, such as targeted GP and practice nurse training, incentives and electronic patient-screening programs, do not bring about sustained changes.
Our New Zealand research team designed a study to identify the challenges in discussion of alcohol and drug use in general practice in an effort to identify some useful recommendations and responses. The research looked in-depth at a set of naturally occurring consultations.
Patients and their GPs consented to video recording of consultations for research into communication in health but did not know that substance misuse discussion would be analysed.
Our multidisciplinary team (GPs, research nurses, addiction doctors, a medical student, a sociologist and a conversation analyst) analysed not just what was said, but how. What did we find out?
On the surface, when drug and alcohol issues were raised in consultations they were not always addressed immediately. Some patient statements of denial or minimisation appeared to be accepted at face-value by the doctor, often with no further questions to clarify the patient’s statements and no brief intervention delivered.
A superficial view of the research could lead to an adverse judgement of the thoroughness of the clinical consultations.
However, conversation analysis reveals a deeper level of interpersonal skills that arise especially in relation to sensitive topics that imply some degree of moral judgement or stigmatisation.
The sociological concept of “face-work” provides a useful way to make sense of such dilemmas. People are constantly working to maintain their own and other’s face in all social interactions. Lifestyle topics such as a patient’s use of alcohol, tobacco or other drugs are inherently face-threatening, because habits that are socially disapproved of can be seen as character blemishes.
By deliberately leaving any reservations unsaid, and not challenging the patient’s denial or minimisation, the doctor has saved face for the patient with a problem that is difficult to admit.
Both the doctor and the patient may well be cognisant that the verbal exchange was incomplete, but by choosing to leave some things unsaid, the doctor gives the patient time to reflect and act on a sensitive issue, without making the patient feel badgered or lectured. In this way, face-work is pivotal to establishing and maintaining rapport.
The technique of employing face-work has been documented in other sensitive health professional interactions, yet its importance to the success of general practice consultations has been under-recognised until quite recently.
The concept of face-work also helps to explain why the availability of clinical guidelines, screening tools, training sessions and screening incentives might appear to make little difference to general practice outcomes.
The use of screening questionnaires can break up the natural conversation flow and inserts an artificial interaction with a rigid line of questioning in a systems- or doctor-focused manner, rather than focusing on the patient. GPs prefer the patient-focused approach.
However, while it is helpful to identify this additional gap in our understanding of the complex nature of the GP consultation, it is also important to ensure that patient information gleaned indirectly should not reside solely in the GP’s head.
Good clinical documentation should ideally acknowledge what was mutually understood and what was left unsaid. The next health professional to see the patient would benefit from reading a short clinical note such as “patient hinted substance misuse but not explored today” or “in denial re alcohol intake”.
A key message to take away from this New Zealand research is that if alcohol and drug issues are alluded to within the consultation, that fact should at least be documented.
Ensuring that intelligence obtained in the course of a consultation is documented will help to avoid future errors of omission. Good documentation also confers some medico-legal advantage, should that need ever arise in the future.
Dr Helen Moriarty is a senior lecturer and Ms Maria Stubbe is a research director in the Department of Primary Health Care and General Practice at the University of Otago, Wellington, New Zealand.
Acknowledgements: the authors wish to acknowledge the co-authors and the research support team at University of Otago involved in the Family Practice article, and the patients and doctors who so generously donated their consultation recordings for research purposes.
Detailed references available on request to firstname.lastname@example.org
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