Journal Club Alcohol and Health: Current Evidence November–December 2006

Featured Article How primary care providers talk to patients about alcohol: a qualitative study McCormick KA, et al. J Gen Intern Med. 21(9):966–972.

Study Objective To describe… –alcohol-related discussions between primary care clinicians and their patients who screen positive for unhealthy alcohol use

Study Design Qualitative analysis of audiotaped outpatient visits –14 (total) primary care physicians and nurse practitioners –29 of their patients (of 840 with unhealthy alcohol use who were participating in a larger quality improvement study) All patients were male veterans who… –drank >14 drinks per week or >5 drinks per occasion, –scored >1 on the CAGE alcohol screening questionnaire, or –reported ever having had a drinking problem

Assessing an Article on Qualitative Research Are the results valid? What are the results? How do the results of this study help me care for patients?

Are the Results Valid? Were participants relevant to the research question and was their selection well reasoned? Were the data collection methods appropriate for the research objectives and setting? Was the data collection comprehensive enough to support rich and robust descriptions of the observed events? Were the data appropriately analyzed and the findings adequately corroborated?

Were participants relevant to the research question and was their selection well reasoned? Focusing on patients with unhealthy alcohol use for a study on clinician-patient alcohol discussions makes sense. Restricting the sample to male veteran participants of a quality improvement study who were willing to be audiotaped and who had a scheduled office visit might have limited the range of discussions. The fact that participants were not told that the study’s focus was on alcohol discussions is a strength.

Were the data collection methods appropriate for the research objectives and setting? Data were collected by audiotape, which was appropriate to describe discussions. Additional methods could have made the descriptions richer (see next slide).

Was the data collection comprehensive enough to support rich and robust descriptions of the observed events? Audiotape data included words, sequence, timing, and patient responses to clinician statements. The following might have offered a richer picture: –Videotaping or direct observation –Review of clinician notes –Patient interviews after the visit

Were the data appropriately analyzed and the findings adequately corroborated? Yes. –Two authors listened to and coded the tapes. –Excerpts were grouped into categories. –All authors reviewed 3 interim versions of themes and asked questions in an iterative process.

What Are the Results? How evocative and thorough is the description? How comprehensive and relevant are the theoretical conclusions?

Results: 3 Themes Patients often disclosed consuming large amounts of alcohol and/or experiencing negative consequences from drinking. –But, clinicians often did not explore these disclosures. –They commonly responded by changing the subject, minimizing the significance of their patients’ drinking, or pursuing a nonalcohol-related issue. Clinician discomfort (hesitation, stuttering, inappropriate laughter, and ambiguous statements) was evident when discussing alcohol but not other topics.

Results: 3 Themes (cont.) Advice about drinking was tentative and vague while advice about smoking was more common, decisive, and specific.

How evocative and thorough is the description? The results are described clearly. The story of how primary care clinicians discuss alcohol with their patients emerges. Many examples of the discovered themes are provided through verbatim excerpts from the audiotapes.

How comprehensive and relevant are the theoretical conclusions? The authors did not conduct this study to develop or test theory. However, they do provide theoretical context. –They note that clinician communication can shape the medical encounter and influence quality of care, which can affect health outcomes. –More specifically, clinicians’ words have underlying meaning and can impact the quality and outcome of alcohol discussions.

How comprehensive and relevant are the theoretical conclusions? (cont.) Patients may become more proactive in discussing alcohol if they realize that some clinicians have discomfort with such discussions. Clinicians may be surprised to hear what they might be saying during patient encounters. Readers and researchers can use these results to develop educational or other interventions to address obvious limitations in these discussions.

How Do The Results of This Study Help Me Care for Patients? Does this study help me understand the context of my practice? Does this study help me to understand my relationships with my patients and their families?

Does this study help me understand the context of my practice? Clinicians may recognize these discussions from their own practices. They may also recognize that the discomfort with alcohol discussions highlighted in this study is… –similar to the discomfort they feel discussing other challenging health topics.

Does this study help me to understand my relationships with my patients and their families? This study may be an eye-opener for clinicians who are puzzled by the behavior of people with unhealthy alcohol use. Clinicians may need skills training and work to become comfortable with alcohol discussions and to provide less vague, more specific advice. Strengthening these skills has the potential to improve clinician-patient relationships and outcomes of care.

Summary/Clinical Resolution Brief alcohol counseling—an evidence-based practice— has been poorly disseminated into primary care practice. This study suggests that clinicians’ discomfort with, avoidance of, and limited skills in assessing and advising patients with unhealthy alcohol use are partly to blame. Training alone is not sufficient to increase alcohol-related counseling. But, these findings indicate that… –educational initiatives to improve primary care clinicians’ comfort levels and skills are necessary.