Alcohol and Alcoholism Vol. 37, No. 4, pp. 370-374, 2002
© 2002 Medical Council on Alcohol
ONE HUNDRED ALCOHOLIC DOCTORS: A 21-YEAR FOLLOW-UP
2 Saxfield Drive, Baguley Hall, Manchester M23 1PY, UK
Received 29 August 2001; first review notified 12 December 2001; accepted 28 January 2002
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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— Aims: This paper reports the long-term recovery rate among 100 alcoholic doctors over a 21-year period. Included are 20 doctors who relapsed and re-recovered, 10 who died of non-alcohol related causes and eight who died of alcohol-linked causes. Also reported are abstinence, attendance at self-help group meetings, mortality and employment. Methods: Selected doctors were the first 100 consecutive alcoholic doctors to become members of the North West Doctors and Dentists Group (NWDDG) between 1980 and 1988. Information sources combine prospective data obtained from each doctor at the time of first contact with the results of questionnaires distributed in 1988 and 2001 and continuing prospective reporting of mortality by relatives. Results: There is a 9% incidence of oral or oesophagopharyngeal cancer. Reported mortality, mostly by relatives, revealed that 24 doctors died directly of their alcoholism. We observed a 73% recovery rate for a 17-year average duration, over a 21-year period. Comparison of recovery with abstinence showed a strong correlation. For the first 6 months of recovery, there was also a strong relationship between recovery and attending meetings of self-help groups. This relationship is not sustained in the long term, though 14 doctors with an average recovery of 20 years still attend meetings regularly. Of 56 doctors currently known to have survived, 29 have retired and 27 are still working as doctors. Three doctors have been drinking normally for an average of 17 years.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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There is a dearth of reports on long-term recovery among alcoholic doctors. In a MedLine search of the literature for the past 15 years, the two longest reports found were for an 8-year (Shore, 1987
) and 9-year (Reading, 1992) follow-up. Both reports have an average recovery interval of the order of 5 years. The current report therefore provides a unique insight into recovery by 100 alcoholic doctors over a follow-up period of 21 years with an average recovery duration in excess of 17 years.
The North West Doctors and Dentists Group (NWDDG) is an autonomous self-help group, founded in 1980, to help professionals with a substance misuse problem. The ratio of general practitioners to hospital doctors is 2.6:1, compared with 1:1.2 for all doctors in England (Department of Health and Social Security, 1987). Various sources of referral to the NWDDG are indicated in Table 1.
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The group has no prescriptive therapeutic role and does not compromise with abstinence as its primary objective, nor does the group see itself as a substitute, but, rather, as a supplement, to any other self-help group. There is an associated Families Group which provides support for families as well as sustaining family contacts, which is important to prospective mortality reporting. Meetings are held on the third Sunday of each month. A confidential mailing list of as many members as possible has been maintained since 1980, and an invitation is sent monthly to each listed member. In addition, I have kept an annual contact with surviving members by means of a Christmas or New Year telephone greeting. A close and supportive relationship has been maintained for 21 years between the NWDDG and consultant clinicians in the North West of England who have a special interest in substance abuse.
The aims of the present study were to: (1) evaluate the outcome by March 2001 for the first 100 consecutive doctors who joined the group between 1980 and 1988; (2) determine their duration of recovery, over a period of 21 years; (3) relate this recovery to duration of abstinence and attendance at meetings of the NWDDG and Alcoholics Anonymous (AA); (4) assess the frequency and duration of relapse; (5) report mortality; (6) establish current employment status.
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SUBJECTS AND METHODS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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This survey presents a gathering and integration of eight sources of information spanning 21 years of the history of the NWDDG as shown in Table 2
. There were no exclusions. Every one of the 100 original doctors was included, even if lost, and recovery percentages therefore relate to all 100 doctors. Though possibly desirable, blood analysis for alcohol or liver function was impracticable for such widely dispersed doctors. Also a single point-in-time result may be of limited value.
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The following definitions were adopted. Duration of abstinence is a period of uninterrupted abstinence from alcohol expressed to the nearest 6 months. Duration of recovery is a period of abstinence, expressed to the nearest 6 months, which may be interrupted by relapse with re-recovery. Relapse is defined as a period of any return to drinking. The criterion for attendance at meetings of the NWDDG is four monthly meetings per year or more. The criterion for attendance at AA meetings is attendance at two meetings a month or more. Doctors who die abstinent of causes other than alcoholism are counted as having recovered. Doctors lost to follow-up are assumed to be neither alive nor to have recovered.
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RESULTS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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Tracing doctors
The available addresses of 15 doctors were found to be incorrect. Eight were traced from the Medical Register, five from the General Medical Council Register, one from the National Health Service Records Office and one from an Electoral Register.
Questionnaire return and reliability
Of the 66 questionnaires distributed in 2001, 39 were returned by 39 doctors and 18 completed by telephone. The relatives of four doctors reported their recent relapse and deaths which were directly related to alcoholism bringing the total questionnaire response to 61 (92.4%). A test of questionnaire reliability compared the date of first contact claimed on the questionnaire with the known date from the prospective data. Of the 57 completed questionnaires, 51 corresponded to within 6 months, of which 36 corresponded to within a month. One doctor overestimated by 7 months. Three underestimated by 7 months, 8 months and 2 years. Two had entered the correct year, but had omitted the month. Errors and omissions were corrected by telephone. Bearing in mind the long interval of memory recall, it is reasonable to assume that the reported length of recovery and abstinence are reliable to the nearest 6 months.
Outcome
By 1988, there were 76 surviving doctors reported to have had an initial 6 months uninterrupted abstinence and a continued recovery for an average duration of 5 years. By 1997, four more doctors were reported to be alive and in recovery, bringing the total believed to have recovered by 1997 to 80. The outcome in March 2001 for these 80 doctors is shown in Table 3.
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Should any of the doctors described as lost in Table 2
be alive and abstinent, the recovery rate should increase. The three doctors who now drink normally take amounts of alcohol well within the accepted weekly limit for safe drinking. None found alcohol to be a cause of any problem for them and this information was confirmed by a spouse for two doctors and a general practitioner for the third. All three scored 4 on the CAGE questionnaire (Mayfield et al., 1974). One doctor who claimed controlled drinking, but is not considered to have recovered, consumed an amount of alcohol within acceptable safe levels, but made three telling statements: ‘The obsession is still there’, ‘Alcohol is a daily problem’ and ‘Both my wife and I have to exercise daily control’. These statements do not typify recovery and were confirmed by a spouse.
The overall recovery rate for the 100 doctors over a 21-year period is shown in Table 4.
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Abstinence
The claimed duration of abstinence was confirmed with all nominated persons. None of the returned questionnaires lacked a nominee and none of the doctors who provided telephone questionnaire responses objected to a named nominee. This repeats a similar experience with the 1988 survey. A strong relationship between recovery and abstinence is shown in Fig. 1
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Attendance at meetings of the NWDDG and AA
The relationship between initial recovery (6 months abstinence) and attendance at meetings of the NWDDG and AA is shown in Table 5
. It is clear that attending meetings has a positive relationship with recovery. All 13 doctors who were not abstinent for the first 6 months subsequently died of alcoholism.
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The 51 currently abstinent doctors had an average attendance at the NWDDG of 5.6 years, and 11 claimed continuing regular attendance, which was confirmed by the group's records of attendance. Fifteen claimed to be still attending AA, though there is no way of confirming this. The average claimed duration of attendance at AA is 8.2 years. The relationship between continued recovery and attending meetings is shown in Table 6
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Relapse
By 1988, five doctors had relapsed on one occasion for an average of 3 weeks during an average recovery of 5 years. None of these doctors relapsed again. The response to the questionnaire in March 2001 revealed that 15 of 57 respondents had relapsed on a total of 45 occasions, followed in each instance by re-recovery. Eight doctors relapsed only once. The mean number of relapses per doctor was 3, with a range of 1–10, and an average duration of 28 weeks with a range of <1 to 312 weeks. One doctor currently drinking heavily and one in controlled drinking have also relapsed. The three doctors who are now drinking normally have, by definition, also relapsed, but are not included in the above figures.
Mortality and cancer
Mortality is shown in 2Table 7. In addition to those who have died of cancer, there are three who have survived cancer. One has survived pharyngeal cancer for 5 years bringing the total incidence of oral/oesophagopharyngeal cancer to 9%. One doctor has survived colonic cancer for 6 years and one ureteric cancer for 5 years.
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Employment
Of the 54 surviving doctors in recovery (51 abstinent and three drinking normally), 29 claim to be employed as doctors. The oldest six are only working part-time. They have an average age of 59 years with a range of 38–79. Twenty-one are in general practice and eight in hospital practice, a ratio of 2.6:1. The remaining 25 doctors have retired and have an average age of 68 years with a range of 49–89.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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A 21-year follow-up of 100 alcoholic doctors found a unique recovery rate of at least 73% over an average interval of 17.3 years within a range of 12–38 years. There are no comparable long-term surveys of alcoholic doctors. The newly established specialist in-patient care facility for health professionals at the Maudsley Hospital, London has reported its initial 1 year findings (Gossop et al., 2001
). Of the 46 referrals, 16 failed to make a contact and 22 failed to complete a 28 day course of treatment. Twenty-one of the 46 were doctors, but there is no analysis by profession. Other reports exclude from outcome evaluation those who fail to enter or complete programmes of treatment. In a report from New York University, a cohort of 550 doctors who had recently received treatment were approached to complete a research questionnaire (Galanter et al., 1990). Only 116 agreed and 16 were disqualified, leaving 100, which permitted the authors to claim an apparent 100% successful treatment. A report of the Missouri Health Programme for impaired physicians (Bohigan et al., 1996) claims a 94% recovery rate over 4 years, though they were only able to determine the outcome for 146 of 194 physicians. The real recovery rate is, therefore, at best, 70%. It is more useful to evaluate recovery rates for the whole cohort, as has been done in the present report.
The 3% of doctors who are drinking normally corresponds with observation in a general population (Chick et al., 1988). The term natural recovery is now used to describe those who recover from alcoholism without help (Burman, 1997). In an analysis of factors affecting recovery among 93 alcoholics who recovered naturally and 42 who used self-help groups, it was found that there were more commonalities than differences in their respective successful recoveries (Bischof et al., 2000). Though uncommon, natural recovery appears to be a reality. The three doctors in this survey simply relapsed and discovered that they could drink normally.
In the current survey, abstinence had a high correlation with recovery, as might be expected within a group which has abstinence as its primary goal. Another published report of the relationship between recovery and attending a peer group of doctors states that ‘their devotion to group is reflected by the fact that when no longer mandated, many continue voluntarily’, ‘Many report profound relief at discovering that they are not alone and are able to use the group to address their deeply felt sense of shame’ and ‘come to learn that they can say whatever is on their mind without being criticised, ridiculed, or punished’ (Fayne and Silvan, 1999). These sentiments accurately reflect the function of the NWDDG, which is to overcome shame, guilt, professional pride and obsessive anonymity to achieve recovery.
Alcoholics Anonymous is a worldwide, respected self-help support for recovering alcoholics (Godlaski et al., 1997). A triennial report by AA indicated that by 3 months after first contact, 50% no longer attend meetings and by 12 months 90% have dropped out (Alcoholics Anonymous, 1990). In a recent article, it was stated that little is known about the effectiveness of attending AA (Fiorentine, 1999). The present report shows that attending self-help groups, including AA, is critical to the initial recovery of doctors, but its importance wanes with the passage of time. AA is seen by new doctor members of the NWDDG as a serious threat to their anonymity, which membership of a less threatening professional group is able to avoid. It is the practice of the NWDDG to take new members to meetings of AA some distance from their home town until they have the confidence to attend a group near their home. It is a credit to AA that 15 of 51 doctors with long-term recovery continue to attend.
Relapse happens. A review of 10 short-term (0.75–6 years) Impaired Physician Programmes in the USA (Nelson et al., 1996) showed an average relapse rate of 36.6%, with a range of 14–57%. The encouraging finding in the present report is the high rate of re-recovery from relapse of 45 out of 49 (92%). It is also evident that relapse is better realized in recovery intervals longer than 5 years.
The prospective high level reporting of mortality by relatives was facilitated by having an associated Families Group and monthly reminders of meetings. An alternative method, using death certificates, has been described in a 20-year retrospective analysis of the records of 99 male members of the general population, 88 of whom were traced through the National Health Service Register (Doll et al., 1994). In that study, 11 men lost to follow-up were assumed to be alive, unlike the present study which makes no such assumption. Only seven had death certificates indicating ‘chronic alcoholism’ or ‘alcohol poisoning’, compared with 24 deaths due to alcoholism in the present study. Though the two populations are not entirely comparable, the difference is substantial. There is no evidence to suggest that relatives may over-report mortality due to alcoholism.
Oral and oesophagopharyngeal malignancies have a relationship with alcoholism independently of smoking habits (Chao et al., 2000). Recent research has revealed an association between a genetic cause of cancer of the oesophagus and alcoholism (Yokayama et al., 1999). Two genes are apparently involved and each additional gene multiplies the risk incidence.
In conclusion, all the evidence in the present survey shows that alcoholic doctors do sustain their established recovery for long periods and are able to continue to contribute to medical care.
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ACKNOWLEDGEMENTS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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I owe thanks to the following: Professor Martin Roland of Manchester University for help with statistical analysis and comments on the draft article; psychiatrists Spencer Madden of Chester, Jonathan Chick of Edinburgh, Colin Drummond of St George's Hospital Medical School, Tim Garvey and Chris Daly of Manchester for helpful comments on the draft article; and Mr Alan Howes of the General Medical Council and officers of the National Health Service Records Office for help in finding lost doctors. I am also grateful to Richard Whittome of the Royal College of General Practitioners and to Stephania at Cochrane for help with literature search and photocopies of references. Special gratitude is extended to all the doctors who completed the questionnaires and tolerated my insistent enquiries. Without their recovery and willing help this report would not have been possible.
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REFERENCES |
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Alcoholics Anonymous (1990) Comments on AA's Triennial Survey. Alcoholics Anonymous World Services, New York.
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Bohigan, G. M., Croughan, J. L., Sanders, K. et al. (1996) Substance abuse and dependence in physicians: The Missouri Physician Health Program. Southern Medical Journal 89, 1078–1080.[Web of Science][Medline]
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