Thursday, December 20, 2012


In the ER, as an intern:

Me: "How much alcohol do you drink?

Patient: "I drink beer at night."

Me: "How many beers?"

Patient: "You know, a couple."

Me: "Well, how many? Like 2 or 3? 3 or 4?"

Patient: "Um, I'm not sure..."

Me: "If you had to take a guess though... how many beers a night?"

Patient: "Maybe 5 or 6."

Me: "Okay. Have you ever wanted to cut down?"

Patient: "You know, these questions are a violation of privacy."

Me: "Excuse me?"

Patient: "I mean, you're asking me 2 or 3, 3 or 4 beers... I feel like this is rehashing prohibition."

Me: "Prohibition?"

Patient: "Well, I guess you don't know much about American history. Prohibition was... look, I don't mean to lecture you. It just feels like... you know, there are some questions that are private that you're not supposed to ask."

Me: "I don't want you to feel like I'm singling you out. I have to ask everyone about their alcohol use. It's on the form and I have to fill something in. I don't want you to feel like I'm attacking you."

Pt: "No, I'm sorry... I just... I feel like some things ought to be private, you know?"

Me: "Yes, of course."

I wrote on his history: Patient became very defensive when asked about alcohol use.


  1. "I think this is private. Hey, can you bring me a beer?"

  2. I imagine that means patient was drinking WAY more than he was willing to let on.... Ah, the wonders of internship.

  3. I think he's scoring positive for G (guilt) in the CAGE assessment...

    1. lol that's the first thing that came to mind while reading this...

  4. And then when he starts screaming about the snakes on the wall and the bugs in his bed, shoots his temp to >104 and starts seizing, remember - this is a private matter. Tricia

  5. Back in 1975 I helped admit a severe alcoholic in his thirties with upper and lower GI bleed asking for beer with his enabling family surrounding him. Found him later that day on the bathroom floor with blood everywhere. He was dead within two days.

  6. When I ask about alcohol intake and the patient says s/he has "a couple beers a night," I ask in the most uninterested way possible as I robotically type into the computer, "So, like a six-pack?" Sometimes they act shocked and give me an actual number less than 6. Other times they say, "Yeah, about that," which prompts me to ask if some nights it might be more like 8 or 9, or more.

    If they admit to "a few beers a night," I start with, "So, like 10 or 12? More?" If they tell me they like whisky and I ask how many drinks, I may ask if they'd say they drink about a fifth/day. A surprising number of people tell me, "Yeah, about that much."

    For heavy or binge drinkers I do initiate a straightforward discussion of how alcohol is directly toxic to their brain, nerves, heart, and liver. I can usually relate their alcohol intake to their current problems as they're often coming to see me for neurological issues that greatly diminish their quality of life.

    People seem more willing to quickly give a concrete answer when I intentionally overestimate what they've just implied they drink. I hate wasting time getting people to answer basic questions that don't even begin to address the reason they came to see me in the first place.

    1. Before I went to med school, I met a guy who drank an entire case of beer every Friday and Saturday night (and then got started on care #2). I had no idea a person could drink that much and still be alive. Haha. Little did I know.

    2. I do the same...casually offer up some inflated number of drinks so they're more likely to give me a truthful answer.

    3. We've been taught to either intentionally say double what we guesstimate, or double the patient's answer.
      I've thought about it myself, and I totally underestimate my consumption so I don't get a stupid lecture from the doc/resident/student. Trust me, I already know about the effects I alcohol. But I also know about the "double up" rule, so I tell the doc a quarter of what I actually drink, so the doc can double that in his/her head and I avoid the lecture...

  7. Just loved this post. . . as it sounds like you were probably talking to my alcoholic spouse. "couple of beers" = 18 pack.

    I ran into his doctor in the hall and just casually mentioned something and his doc was astonished that he drank. . .?!?!? I just responded "you didn't know he is a flaming alcholic? . . Hmmm Might want to have that in his problem list!"

    I am with PGYx with asking patients and getting it documented in the chart. I always find it interesting when getting a history of social behaviors that smoking pot is not considered "do you smoke?" So now I had a new category. "SMOKER,DRINKER, MIDNIGHT TOKER?"