A 40-year-old man with a history of hypertension comes to the office for a checkup. The patient has been under a lot of stress due to work issues and marital problems. He says, "My wife is always criticizing me, and we fight a lot. Last weekend, she was angry that I didn't make it to my daughter's basketball game. I wanted to go but was too tired because I had stayed out late with friends the night before. A man has to relax sometimes." The patient consumes 5 or 6 alcoholic drinks a night and more on weekends. He says that he never gets intoxicated as he is a "big guy with a high tolerance." Blood pressure is 170/90 mm Hg. Physical examination is normal. Laboratory evaluation indicates persistent mild elevation of liver function tests. The physician previously explained that the patient's hypertension is worsened by alcohol use and that the abnormal liver tests are likely due to alcohol use, but the patient remains unconcerned. Which of the following responses is most appropriate for initiating a discussion of the patient's alcohol use?

Question

A 40-year-old man with a history of hypertension comes to the office for a checkup.  The patient has been under a lot of stress due to work issues and marital problems.  He says, "My wife is always criticizing me, and we fight a lot.  Last weekend, she was angry that I didn't make it to my daughter's basketball game.  I wanted to go but was too tired because I had stayed out late with friends the night before.  A man has to relax sometimes."  The patient consumes 5 or 6 alcoholic drinks a night and more on weekends.  He says that he never gets intoxicated as he is a "big guy with a high tolerance."  Blood pressure is 170/90 mm Hg.  Physical examination is normal.  Laboratory evaluation indicates persistent mild elevation of liver function tests.  The physician previously explained that the patient's hypertension is worsened by alcohol use and that the abnormal liver tests are likely due to alcohol use, but the patient remains unconcerned.  Which of the following responses is most appropriate for initiating a discussion of the patient's alcohol use?

Quizplus · Accepted Answer

All patients should be screened for unhealthy alcohol use, and those identified should receive a brief counseling intervention geared to the patient's level of awareness of the problem and degree of motivation to change. This patient has been drinking excessively (≥4 drinks/day is considered problematic in men) with evidence of liver toxicity, worsening hypertension, and possible negative consequences to his marriage and family. In counseling this patient, the physician should take into account that the patient does not recognize his drinking as being problematic and is therefore probably not going to consider changing his behavior (stage of precontemplation). However, the patient does acknowledge that he would have liked to attend his daughter's basketball game; having him connect his alcohol use to negative effects on next-day functioning may increase his motivation to change (motivational interviewing). Once this patient is able to recognize that his use is causing problems, he will likely be more receptive to a trial of decreasing, or abstaining from, alcohol. motivational interviewing (Choices B and C) It is important to educate patients about the negative medical effects of alcohol. Even though this patient was educated about his hypertension and laboratory abnormalities, he continues to disregard the correlation between his health issues and his alcohol consumption. He is more likely to change his behavior if he can acknowledge the negative effects of his alcohol use on his relationships. (Choice D) Pointing out that the patient is in denial would likely be perceived as confrontational and judgmental. A collaborative approach is preferred. (Choices E and G) This patient has not accepted that he has problems with alcohol and is therefore unlikely to be receptive to recommendations to change his behavior or for treatment interventions. The first step is to develop his concern about his alcohol use. (Choice F) This patient describes a confrontational relationship with his wife. Initiating the discussion by pointing out his wife's perspective would likely be perceived as taking her side, causing the patient to become defensive and negatively affecting the physician-patient alliance. Educational objective: Effective brief interventions for alcohol abuse require an understanding of the patient's level of awareness of the problem and readiness to change. When the patient does not acknowledge the problem, the physician's role is to increase the patient's awareness that alcohol use may be interfering with personal goals. References: Motivational interviewing with primary care populations: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23934180) Can motivational interviewing in emergency care reduce alcohol consumption in young people? A systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/25563299)

A 40-Year-Old Man with a History of Hypertension Comes to the Office