Alcohol and Alcoholism Advance Access first published online on January 21, 2008
This version published online on February 18, 2008
Alcohol and Alcoholism, doi:10.1093/alcalc/agm180
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Hazardous Alcohol Use Among Hospital Doctors in Germany
Senior researcher of the German Research Foundation (DFG)
* Author to whom correspondence should be addresses: Federal Institute for Population Research Friedrich-Ebert-Allee 4 D-65185 Wiesbaden Germany. Fax: +45 (0)611 75 3960; E-mail: judith.rosta{at}destatis.de
Received 1 August 2007; first review notified 29 November 2007; ; accepted 12 December 2007
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ABSTRACT |
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Aims. To describe alcohol use, and the prevalence and predictors of hazardous drinking, among hospital doctors. Methods. Data were collected by anonymous mail survey in 2006, from a representative national sample of 1917 (58% response rate) hospital doctors in Germany. Alcohol use was measured using the AUDIT-C, scores of 5 or more for males and females indicating "hazardous drinking." Results. There were 9.5% abstainers, 70.7% moderate drinkers, and 19.8% hazardous drinkers. The majority of doctors (90.5%) used alcohol—mainly at a sensible level, e.g., 2–4 times a month (32%) or 2–3 times a week (29%), and 1–2 glasses on one occasion (83%). Binge drinking was common (53%), but for most occurred less than once in a month (39%). When hazardous drinking was controlled for certain confounders, being male (OR 4.7; 95% CI 3.4–6.5) and having a surgical specialty (OR 1.4; 1.1–1.8) were significantly correlated to hazardous drinking. Age had no influence on this model. By contrast, the age group 40 years and younger (OR 2.1; 1.4–3.0) was a significant predictor of abstinence. Conclusions. There is a higher rate of abstainers and a lower rate of binge drinkers among hospital doctors in Germany than in the general population. However, some hospital doctors drink hazardously, the risk being greater among males and among surgeons, which should be paid due attention in the interest of their health and their function as doctors.
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INTRODUCTION |
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Lifestyle-related diseases such as hazardous drinking are a cause for increasing concern in the area of public health. It is important that particular attention be paid to doctors’ drinking habits, because their lifestyle is idealized by the general public, in addition to their role as experts in lifestyle and health. (Aasland, 1994
). How much effort a doctor makes on activities to prevent hazardous drinking in patients depends on several factors—one of them being his own individual practice (Frank et al., 2000; Rosta, 2002). However, previous studies have shown that doctors have high levels of alcohol consumption—even higher than the general population (Brooke, 1996; Harrison and Chick, 1994; Romelsjo et al., 1992), and run an increased risk of alcohol-related diseases such as alcohol-related mortality, cancer, and suicide, and of accidents (BMA, 1993; Brooke et al., 1993; Drever et al., 1996). If we wish to improve the personal health of doctors and increase their preventive interventions in the context of their daily clinical work with patients, we therefore need information on how many doctors drink in a hazardous way. This study is the first to present representative data concerning alcohol use among hospital doctors in Germany.
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METHODS |
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Procedure and sample
Data on alcohol use were collected as a part of the national survey "Work Life, Lifestyle and Health among Hospital Doctors in Germany" carried out between September and October 2006 by means of a one-wave mail survey. Participation was voluntary and the data anonymized. To increase the response rate, a recommendation from the German hospital physicians’ union—the Marburger Bund (http://www.marburger-bund.de)—was enclosed with the accompanying letter and also publicized on the union's homepage. Moreover, the sponsor (the German Research Foundation, http://www.dfg.de) and the agency responsible for handling and analyzing the data (the Federal Institute for Population Research at the Federal Statistical Office, http://www.bib-demographie.de), were explicitly mentioned on the cover sheet of the questionnaires as these institutions are known for their independence.
The data sampling was commissioned by the German Hospital Institute (http://www.dki.de), which has many years of experience in the area of hospital surveys. The average random sample at hospital level comprised 964 hospitals with 100 or more beds. The number of doctors randomly selected per hospital varied with hospital size. The number of doctors in the subsamples from all participating hospitals (515 from 964) was 3295, with a response rate of 58% (n = 1917) (Rosta, 2007).
Questionnaire
The questionnaire consisted of 12 pages containing several items on working conditions (including job characteristics), health, lifestyle (including alcohol use), and demographic data, so as to facilitate the study of the relationships between working conditions and health outcomes.
Alcohol use and hazardous drinking were measured by the AUDIT-C screen (Busch et al., 1998). This inventory includes the first three items of the original instrument "Alcohol Use Disorders Identification Test" (AUDIT; Sauders et al., 1993) concerning frequency and amount of alcohol use and frequency of binge drinking (60 g of ethanol or more = 5 drinks or more on a drinking occasion). Each question was scored from 0–4, giving a possible summary score of 0–12.
A score of 5 points or more was used as an indicator of hazardous drinking (Rumpf et al., 2002; IHS, 2006, see Table 1). Hazardous drinking is defined as a pattern of alcohol consumption that increases the risk of harmful consequences for the user or others (Babor et al., 2001). However, selection of the cutoff point is influenced by national and cultural standards; and studies have varied on the cutoffs used, from 3 points or more to 6 points or more (Bradley et al., 2007; Busch et al., 1998; Dawson et al., 2005; Gual et al., 2002; HIS, 2006; Nordquest et al., 2004). In Germany, according to the US standards (Bradley et al., 2007), a cutoff of 4 points or more for male patients, and 3 points or more for female patients, is recommended by expert groups for use as a screening instrument in general practices (Diehl and Mann, 2005). These categories were not used for the present study, as they would screen "positive" a large proportion of subjects with "normal" German drinking habits; for example, male persons drinking 4–5 times per week, and female persons about 2–3 times per week (Hupkens et al., 1993). Owing to a paucity of data on Germany, it is not easy to provide an exact cutoff point recommendation for AUDIT-C (Rist et al., 2004). However, a score of 5 points or more for male and female persons was found to be a cutoff point among the population in northern Germany (Rumpf et al., 2002). A cutoff of 5 points or more using the AUDIT-C screen is also recommended by the Institute of Health & Society at the Newcastle University in the United Kingdom (IHS, 2006).
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Analysis
Categorical differences were tested using the Pearson
2 test, and simultaneous effects with logistic regressions. Most analyses were performed for females and males separately. For the purpose of logistic analysis, the variables were dichotomized. In accordance with previous findings that older doctors are more often frequent drinkers (Juntunen et al., 1988; Guldbrandsen and Aasland, 2000), age was categorized into two levels: 40 years or younger, and older than 40 years. Moreover, since evidence was found that doctors from surgical specialties had a higher rate of hazardous drinking (Rosta and Aasland, 2005), the specialties were categorized into surgical and nonsurgical specialties (see Table 3). The statistical Package for Social Science (SPSS) software, Windows Version 13, was used for data analysis.
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RESULTS |
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The majority of doctors were male (61%), younger than 45 years (79%), worked as interns or as board-certified doctors (71%) (i.e., neither chief physician nor head of department), worked full-time (89%) and had regular stand-by duty (71%) (Rosta, 2007
). Table 1 summarizes the alcohol consumption and the rate of hazardous drinking among hospital doctors. Most drank alcohol. Regular drinkers frequently drank 2–4 times a month or 2–3 times a week, and mostly 1–2 glasses on one occasion. Binge drinking (60 g ethanol or more on a drinking occasion) was common among half of these respondents, mainly less than once in a month. One out of five hospital doctors was a hazardous drinker. Compared to male doctors, female doctors were more likely to abstain from alcohol. Female doctors also reported less frequent consumption of alcohol (including binge drinking) and showed a significantly lower rate of hazardous drinking compared to male doctors.
As can be seen in Table 2, rates of hazardous drinking vary across medical specialties. Urology, anesthesiology, radiology, and surgery were specialties with over 20% of hazardous drinkers. Internal medicine, gynecology, and neurology ranked in the middle whereas pediatrics, psychiatry, and other specialties had rates of hazardous drinking under 10%. Table 3 shows that doctors from surgical specialties have a significantly higher rate of hazardous drinking, in general as well as when broken down separately into male and female doctors.
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Table 4 shows the logistic regression models on abstainers and hazardous drinkers. It was observed that being male and having a surgical specialty constituted significant predictors of hazardous drinking. Even with separate gender analyses, being a surgeon continued to be a significant predictor for both females and males. When abstainers were controlled for a number of confounders, the age group 40 years and younger correlated significantly with abstinence from alcohol (Table 4). After excluding from the sample subjects with non-German nationality, the age group 40 years and younger continued to be a significant predictor for abstinence among doctors with German nationality (n = 1774; B = 2.09; 95%CI = 1.4–3.12; P = 0.0001)
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DISCUSSION |
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The study shows alcohol consumption as an integral part of the life of hospital doctors in Germany, with one out of every five being classified as an AUDIT-C (HIS, 2006) case.
Before interpreting the results of this study, some remarks on the subject of German drinking patterns should be considered. Germany is a country with relatively high but stable levels of alcohol consumption (about 10 liters per person per year) compared to other European countries (Rehn et al., 2001). The proportion of abstainers is 5.5% (Kraus and Augustin, 2001), which is low compared to many other EU member states (Simpura and Karlsson, 2001). A majority of Germans drinks frequently—men drink about 4–5 times per week and women about 2–3 times per week (Hupkens et al., 1993)—and in excess of the national guidelines for safe drinking (Kraus and Augustin, 2001). Binge drinking is not supposed to be part of the German drinking culture, yet the percentage of bingers (measured on the criterion of binging at least once in the previous month) is 38% (Gmel et al., 2003). Owing to the different methods used in population surveys (sample characteristics, measuring methods, problem-related drinking, survey year), a direct comparison with our data is difficult. However, it is possible to point out some general tendencies in drinking habits such as binging and abstinence (see Table 5).
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In line with the results of the population surveys (Kraus and Augustin, 2001
), the majority of hospital doctors consumed alcohol on a frequent basis and at a moderate level. Hazardous drinking can be attributed to one-fifth of the doctors. The question of whether this rate is higher or lower than in the general population cannot be answered accurately. However, it is possible to compare the groups of binge drinkers (Table 5). This sort of comparison is an approach that has also been used as an indication of the risk of alcohol-related problems in survey research (Wechsler and Nelson, 2001; Weingardt et al., 1998). In contrast to the findings for the adult population, the outcome for doctors is positive. Essentially, there are fewer bingers (at least once a month) among doctors (13.5%) than in the general adult population (38%; Gmel et al., 2003).
Hospital doctors are not a homogeneous group when it comes to hazardous drinking. The finding that being of male gender tends to correlate significantly with more hazardous drinking, corresponds to earlier observations; for example, that female doctors, compared to their male colleagues in Norway, Finland, and USA, had a lower level of alcohol consumption (McAuliffe et al., 1991), a lower frequency of drinking (Aasland et al., 1987), and a lower prevalence of heavy or hazardous drinking (Aasland et al., 1987; Juntunen et al., 1988; Gulbrandsen and Aasland, 2000). The conception that, generally speaking, more men than women drink alcohol, and that men also tend to consume more alcoholic beverages than women, is also supported by the general population surveys conducted in European countries (Eurobarometer on Alcohol, 2007).
The affiliation to surgical specialties was also identified as a significant predictor of hazardous drinking. On the one hand, this finding is inconsistent with investigations carried out in USA (Frank et al., 1998; Hughes et al., 1999; Storr et al., 2000)—a result that might be traced back to the different method of classifying medical specialities. On the other hand, our results are in line with the Norwegian study (Rosta and Aasland, 2005) suggesting that both female and male surgeons are significantly different from doctors in other specialities with regard to alcohol use. Among the causal factors one may find listed are certain special personality traits such as sensation seeking (McAuliffe et al., 1984), the stressful nature and excessive workloads characteristic of surgery (Casswell, 1998) which had been associated with heavy drinking among medical staff in England (Plant et al., 1992) and Finland (Juntunen et al., 1988) in earlier studies. Here, it is also important to note the role of surgical culture as a traditionally male-dominated area (Rosta and Aasland, 2005), in other words: men generally drink more than women and predominantly male professions have a culture that weakens the influence of women's traditional values and attitudes concerning alcohol (Wilsnack and Wilsnack, 1991, 1992; Kraft et al., 1993; Davey et al., 2000). It is possible that these tendencies are also present in our study.
One notable finding is the high level of abstinence among doctors, especially among the younger age group. The present sample does not support the previous findings that younger age groups were found to be less likely to abstain from alcohol (Aasland et al., 1987; Gulbrandsen and Aasland, 2002). Moreover, higher numbers of abstainers were found among hospital doctors (9.5%) compared to the general population in Germany (5.5%; Kraus and Augustin, 2001) (see Table 5). Furthermore, the proportion of abstainers was even higher among doctors in Germany (female: 11.2%, male: 8.8%) than in Norway (female: 3.6–4.8%, male: 4.7–7.5%, Rosta and Aasland, 2005)—a country that has a history of a strong temperance movement, which is still somewhat active today. In Germany, as a "wet" country with a tradition of nonabstinence, where people with a higher educational level have a high tendency towards frequent alcohol drinking, these results are more than interesting.
One explanation for the high rate of abstinence among doctors might be the nature of the medical profession in Germany, with frequent and unforeseeable night shifts and working time overload (Rosta, 2007) where there are no, or only few, opportunities to drink alcohol. Another reason for not drinking might possibly lie in new trends. An example of this is the rising percentage of young people in Germany who do not consume any alcohol at all (Bzga, 2005). The relevant literature contains evidence that especially people of a higher educational level and, to some extent younger people, are prone to adopt new habits (Rogers and Stanfield, 1968) including those relating to alcohol consumption (Hupkens et al., 1993). Unfortunately, we have no comparable data on the consumption of alcohol by hospital doctors in Germany with which to examine drinking trends. However, the prognosis of researchers from the United Kingdom—Harrison and Chick—made 14 years ago, presumed that the increased emphasis placed on the dangers of alcohol by younger doctors would hopefully contribute to an increased risk-awareness concerning alcohol consumption, as was the case with the change in doctors’ smoking habits in many Western countries (Harrison and Chick, 1994). This might be the case here in our study, where there is a significant trend among the younger age groups of hospital doctors to be abstainers and no tendency to be hazardous drinkers.
Another interesting result refers to the factor "age" in relation to hazardous drinking. Contrary to earlier investigations from Finland and Norway (Juntunen et al., 1988; Aasland et al., 1988; Gulbrandsen and Aasland, 2002), the older age groups were not detected as hazardous drinkers in this study. Of course, one explanation for this could also be the healthy lifestyle trends of the last decades (Harrison and Chick, 1994). Doctors aged 40 or older belong to the group that could have been influenced in their youth by these trends—including the trend towards drinking less alcohol.
As with all studies, this one also has both limitations and strengths. The main strength of this study is that it was conducted on a fairly large nationwide sample of doctors in a variety of hospital sizes, geographic locations, and across all specialties. The response rate of 58%, while less than optimal, was much higher than that of other surveys of doctors, which had response rates ranging from 17% to 51% (Pittner et al., 1984; Stengel, 1991; Bestmann et al., 2004; Bornschein et al., 2006). Studies on physicians’ health from Norway (Gulbrandsen and Aasland, 2002) and Finland (Juntunen et al., 1988), however, showed higher response rates than those achieved here. The experience of recent years has shown that the willingness of the German population to participate in surveys is the lowest across EU-countries (Leifmann et al., 2002). Another concern is that a possible selection bias could be attributed to the content of the questions—working conditions, health, and life-style. Doctors with an unhealthy lifestyle—such as hazardous drinking—may be reluctant to participate because of their concern that they could be identified. On the other hand, doctors who are dissatisfied with working conditions might want to express their opinions. Another problem is that of working with data based on self-estimated alcohol use. Some studies have indicated that nonrespondents generally drink more or that alcohol misuse is more common in this group (Makela et al., 1999). Moreover, if we take the general underestimation of alcohol consumption into consideration, which is about 40–60% (Midanik, 1982) without much variation between nationalities (Lemmens et al., 1981), then the volume of alcohol consumption and the proportion of binge and hazardous drinkers could be even greater in this study. Further limitations included a lack of some intermediate variables, such as the absence of skills, individual traits, social conditions, and other workplace hazards, which could influence the outcomes of alcohol use (Brook, 1997; Gossop et al., 2001, McAuliffe et al., 1991, Rawnsley, 1984). Consequently, the importance of more detailed analysis has to be acknowledged, and it will be carried out at a future time.
There is some evidence that hospital doctors have healthier drinking habits—a higher proportion of abstainers and a lower proportion of bingers—than the general population. Yet, special attention to the medical profession in general, and to the surgeons and the males among them, in particular, is needed for the sake of their own health and on account of the possible consequences of their behavior, owing to their function in the health sector.
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FUNDING |
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This study was supported by the German Research Foundation (DFG). The funding agency had no role in the design and conduct of the study, the interpretation or analysis of the data, or the approval of the manuscript.
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ACKNOWLEDGEMENTS |
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I gratefully acknowledge the help of the hospital doctors that participated in this study.
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FOOTNOTES |
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An early version of this paper was presented at the 33rd Annual Alcohol Epidemiology Symposium of the Kettil Bruun Society, Budapest, Hungary, June 4–8, 2007.
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