Journal of General Internal Medicine

, Volume 21, Issue 9, pp 966–972

How primary care providers talk to patients about alcohol a qualitative study

  • Kinsey A. McCormick
  • Nancy E. Cochran
  • Anthony L. Back
  • Joseph O. Merrill
  • Emily C. Williams
  • Katharine A. Bradley
Original Articles


BACKGROUND: Alcohol misuse is a common and well-documented source of morbidity and mortality. Brief primary care alcohol counseling has been shown to benefit patients with alcohol misuse.

OBJECTIVE: To describe alcohol-related discussions between primary care providers and patients who screened positive for alcohol misuse.

DESIGN: An exploratory, qualitative analysis of audiotaped primary care visits containing discussions of alcohol use.

PARTICIPANTS: Participants were 29 male outpatients at a Veterans Affairs (VA) General Internal Medicine Clinic who screened positive for alcohol misuse and their 14 primary care providers, all of whom were participating in a larger quality improvement trial.

MEASUREMENTS: Audiotaped visits with any alcohol-related discussion were transcribed and coded using grounded theory and conversation analysis, both qualitative research techniques.

RESULTS: Three themes were identified: (1) patients disclosed information regarding their alcohol use, but providers often did not explore these disclosures; (2) advice about alcohol use was typically vague and/or tentative in contrast to smoking-related advice, which was more common and usually more clear and firm; and (3) discomfort on the part of the provider was evident during alcohol-related discussions.

LIMITATIONS: Generalizability of findings from this single-site VA study is unknown.

CONCLUSION: Findings from this single site study suggest that provider discomfort and avoidance are important barriers to evidence-based brief alcohol counseling. Further investigation into current alcohol counseling practices is needed to determine whether these patterns extend to other primary care settings, and to inform future educational efforts.

Key words

alcohol drinking primary care communication physician-patient relations 


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  1. 1.
    Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems: A Report of the Committee for the Study of Treatment and Rehabilitation for Alcoholism. Washington, DC: National Academy Press; 1990.Google Scholar
  2. 2.
    U.S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Ann Intern Med. 2004;140:554–6.Google Scholar
  3. 3.
    Bertholet N, Daeppen JB, Wietlisbach V, Fleming M, Burnand B. Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Arch Intern Med. 2005;165:986–95.PubMedCrossRefGoogle Scholar
  4. 4.
    Moyer A, Finney JW, Swearingen CE, Vergun P. Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction. 2002;97:279–92.PubMedCrossRefGoogle Scholar
  5. 5.
    Whitlock EP, Polen MR, Green CA, Orleans T, Klein J. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004;140:557–68.PubMedGoogle Scholar
  6. 6.
    Ballesteros J, Duffy JC, Querejeta I, Arino J, Gonzalez-Pinto A. Efficacy of brief interventions for hazardous drinkers in primary care: systematic review and meta-analyses. Alcohol Clin Exp Res. 2004;28:608–18.PubMedCrossRefGoogle Scholar
  7. 7.
    Wallace P, Cutler S, Haines A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. BMJ. 1988;297:663–8.PubMedGoogle Scholar
  8. 8.
    Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers: a randomized controlled trial in community-based primary care practices. JAMA. 1997;277:1039–45.PubMedCrossRefGoogle Scholar
  9. 9.
    Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings. Med Care. 2000;38:7–18.PubMedCrossRefGoogle Scholar
  10. 10.
    Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcohol Clin Exp Res. 2002;26:36–43.PubMedGoogle Scholar
  11. 11.
    Samet JH, Rollnick S, Barnes H. Beyond CAGE: a brief clinical approach after detection of substance abuse. Arch Intern Med. 1996;156:2287–93.PubMedCrossRefGoogle Scholar
  12. 12.
    Barnes HN, Samet JH. Brief interventions with substance-abusing patients. Med Clin North Am. 1997;81:867–79.PubMedCrossRefGoogle Scholar
  13. 13.
    Rush B, Ellis K, Crowe T, Powell L. How general practitioners view alcohol use: clearing up the confusion. Can Fam Physician. 1994;40:1570–8.PubMedGoogle Scholar
  14. 14.
    Hasin D, Grant B, Dufour M, Endicott J. Alcohol problems increase while physician attention declines. Arch Internal Med. 1990;150:397–400.CrossRefGoogle Scholar
  15. 15.
    D’Amico EJ, Paddock SMBA, Kung F. Identification of and guidance for problem drinking by general medical providers. Med Care. 2005;43:229–36.PubMedCrossRefGoogle Scholar
  16. 16.
    Edlund MJ, Unutzer J, Wells KB. Clinician screening and treatment of alcohol, drug, and mental problems in primary care: results from healthcare for communities. Med Care. 2004;42:1158–66.PubMedCrossRefGoogle Scholar
  17. 17.
    Babor TE, Higgins-Biddle J, Dauser D, Higgins P, Burleson JA. Alcohol screening and brief intervention in primary care settings: implementation models and predictors. J Stud Alcohol. 2005;66:361–8.PubMedGoogle Scholar
  18. 18.
    Funk M, Wutzke S, Kaner E, et al. A multicountry controlled trial of strategies to promote dissemination and implementation of brief alcohol intervention in primary health care: findings of a World Health Organization collaborative study. J Stud Alcohol. 2005;66:379–88.PubMedGoogle Scholar
  19. 19.
    Arborelius E, Thakker KD. Why is it so difficult for general practitioners to discuss alcohol with patients? Fam Practice. 1995;12:419–22.CrossRefGoogle Scholar
  20. 20.
    Lock CA, Kaner E, Lamont S, Bond S. A qualitative study of nurses attitudes and practices regarding brief alcohol intervention in primary health care. J Adv Nurs. 2002;39:333–42.PubMedCrossRefGoogle Scholar
  21. 21.
    Beich A, Gannik D, Malterud K. Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners. BMJ. 2002;325:1–5.CrossRefGoogle Scholar
  22. 22.
    Bander KW, Goldman DS, Schwartz MA, Rabinowitz E, English JT. Survey of attitudes among three specialities in a teaching hospital toward alcoholics. J Med Educ. 1987;62:17–24.PubMedGoogle Scholar
  23. 23.
    Aira M, Kauhanen J, Larivaara P, Rautio P. Differences in brief interventions on excessive drinking and smoking by primary care physicians: qualitative study. Prev Med. 2004;38:473–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Aira M, Kauhanen J, Laricaara P, Rautio P. Factors influencing inquiry about patients’ alcohol consumption by primary health care physicians: qualitative semi-structured interview study. Fam Practice. 2003;20:270–5.CrossRefGoogle Scholar
  25. 25.
    Aalto M, Pekuri P, Seppa K. Obstacles to carrying out brief intervention for heavy drinkers in primary health care: a focus group study. Drug & Alc Review. 2003;22:169–73.CrossRefGoogle Scholar
  26. 26.
    Anderson P, Kaner E, Wutzke SE, et al. Attitudes and managing alcohol problems in general practice: an interaction analysis based on findings from a WHO collaborative study. Alcohol Alcohol. 2004;39:351–6.PubMedGoogle Scholar
  27. 27.
    Cornuz J, Ghali WA, Di Carlantonio D, Pecoud A, Paccaud F. Physicians’ attitudes towards prevention: importance of intervention-specific barriers and physicians’ health habits. Fam Pract. 2000;17:535–40.PubMedCrossRefGoogle Scholar
  28. 28.
    Thom B, Tellez C. A difficult business: detecting and managing alcohol problems in general practice. Br J Addict. 1986;81:405–18.PubMedCrossRefGoogle Scholar
  29. 29.
    Fihn SD, McDonell MB, Diehr P, et al. Effects of sustained audit/feedback on self-reported health status of primary care patients. Am J Med. 2004;116:241–8.PubMedCrossRefGoogle Scholar
  30. 30.
    National Institute on Alcohol Abuse and Alcoholism, U.S. Department of Health and Human Services, National Institute of Health. Helping Patients Who Drink Too Much: A Clinician’s Guide. Rockville, MD: 2005.Google Scholar
  31. 31.
    Bradley KA, Kivlahan DR, Bush KR, McDonell MB, Fihn SD. Variations on the CAGE alcohol screening questionnaire: strengths and limitations in VA general medical patients. Alcohol Clin Exp Res. 2001;25:1472–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Bradley KA, Bush K, McDonell MB, Malone T, Fihn SD. Screening for problem drinking: comparison of CAGE and AUDIT. J Gen Intern Med. 1998;13:379–88.CrossRefGoogle Scholar
  33. 33.
    Bradley KA, Epler A, Bush K, et al. Alcohol-related discussions during general medicine appointments of patients who screen positive for atrisk drinking. J Gen Intern Med. 2002;17:315–27.PubMedGoogle Scholar
  34. 34.
    Crabtree BF, Miller WL, eds. Doing Qualitative Research. 2nd ed. Thousand Oaks, CA: Sage Publications Inc; 1999.Google Scholar
  35. 35.
    Drew P, Chatwin J, Collins S. Conversation analysis: a method for research into interactions between patients and health-care professionals. Health Expect. 2001;4:58–70.PubMedCrossRefGoogle Scholar
  36. 36.
    Maynard DW, Heritage J. Conversation analysis, doctor-patient interaction and medical communication. Med Educ. 2005;39:428–35.PubMedCrossRefGoogle Scholar
  37. 37.
    Roter DL, Frankel RM, Hall JA, Sluyter D. The expression of emotion through nonverbal behavior in medical visits. mechanisms and outcomes. J Gen Intern Med. 2006;21(Suppl 1):S28-S34.PubMedCrossRefGoogle Scholar
  38. 38.
    Beck RS, Daughtridge R, Sloane PD. Physician-patient communication in the primary care office: a systematic review. J Am Board Fam Pract. 2002;15:25–38.PubMedGoogle Scholar
  39. 39.
    Wenrich MD, Paauw DS, Carline JD, Curtis JR, Ramsey PG. Do primary care physicians screen patients about alcohol intake using the CAGE questions? J Gen Intern Med. 1995;10:631–4.PubMedCrossRefGoogle Scholar
  40. 40.
    Epstein RM, Morse DS, Frankel RM, Frarey L, Anderson K, Beckman HB. Awkard moments in patient-physician communication about HIV risk. Ann Intern Med. 1998;128:435–42.PubMedGoogle Scholar
  41. 41.
    Merrill JO, Rhodes LA, Deyo RA, Marlatt GA, Bradley KA. Mutual mistrust in the medical care of drug users: the keys to the “Narc cabinet.” J Gen Intern Med. 2002;17:327–33.PubMedGoogle Scholar
  42. 42.
    Meredith LS, Mazel RM. Counseling for depression by primary care providers. Int J Psychiatry Med. 2000;30:343–65.PubMedCrossRefGoogle Scholar
  43. 43.
    Yarnall KSH, Pollak KL, Ostbye T, Krause KM, Micchener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93:635–41.PubMedGoogle Scholar
  44. 44.
    Larsson US, Saljo R, Aronsson K. Patient-doctor communication on smoking and drinking: lifestyles in medical consultations. Soc Sci Med. 1987;25:1129–37.PubMedCrossRefGoogle Scholar
  45. 45.
    Russell NK, Roter DL. Health promotion counseling of chronic-disease patients during primary care visits. Am J Public Health. 1993;83:979–82.PubMedCrossRefGoogle Scholar
  46. 46.
    Green CA, Perrin NA, Polen MR. Gender differences in the relationships between multiple measures of alcohol consumption and physical and mental health. Alcohol Clin Exp Res. 2004;28:754–64.PubMedCrossRefGoogle Scholar
  47. 47.
    Klatsky AL, Armstrong MA, Friedman GD. Alcohol and mortality. Ann Intern Med. 1992;117:646–54.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2006

Authors and Affiliations

  • Kinsey A. McCormick
    • 1
    • 2
  • Nancy E. Cochran
    • 3
    • 4
  • Anthony L. Back
    • 2
  • Joseph O. Merrill
    • 2
    • 5
  • Emily C. Williams
    • 2
    • 6
  • Katharine A. Bradley
    • 1
    • 2
    • 6
    • 7
    • 8
  1. 1.Northwest Health Services Research and Development Center of ExcellenceVA Puget Sound Health Care SystemSeattleUSA
  2. 2.Department of MedicineUniversity of WashingtonSeattleUSA
  3. 3.White River Junction VA Hospital, White RiverJunctionUSA
  4. 4.Department of Medicine and Community and Family MedicineDartmouth Medical SchoolHanoverUSA
  5. 5.Harborview Medical CenterSeattleUSA
  6. 6.Center of Excellence in Substance Abuse Treatment and EducationVA Puget Sound Health Care SystemSeattleUSA
  7. 7.Primary and Specialty Medical Care ServiceVA Puget Sound Health Care SystemSeattleUSA
  8. 8.Department of Health ServicesUniversity of WashingtonSeattleUSA
  9. 9.VA Puget Sound Health Services Research and DevelopmentSeattle

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