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Independents' Day

Wife wants you to conspire against 'alcoholic' husband

Case history

Dennis, 70, has psoriasis with mild arthropathy. Symptoms are well controlled on methotrexate, diclofenac and topical emollients, and he normally consults your partner. Today, in your partner's absence, he has come to see you with his wife Dora. You know Dora well, as she has multiple medical problems and tends towards hypochondriasis. For several months she has been talking about the stress caused by her husband's drinking.

At the last consultation, Dennis was noted to be hypertensive and had blood tests which showed massively elevated liver enzymes. Your partner has noted he is a non-smoker and drinks two pints of beer on Saturday evenings only.

Dora comes in first. 'You're seeing Dennis today too and I don't want you to mention anything I've said about you-know-what to him,' she says. 'He's worried about the blood tests and he's asked me to come in with him, if that's all right.'

Dr Claire Bailey

'This is tricky: balancing confidentiality and my duty of care as a doctor'

Dora has put me in a difficult situation! My responsibility lies with the patient and in this case that would be Dennis, who is worried and come to get his blood results. If possible, before Dennis has entered the room I would explain to Dora I understand her concerns regarding 'you-know-what' but I need to ask Dennis about his general health including alcohol intake when I see him. I would make no reference to Dora in the conversation.

I am in a tricky position as I must balance a confidentiality issue with Dora and my duty of care as a doctor to Dennis. I would not object to seeing them together if Dennis had given his permission.

When giving Dennis his blood results I would explain they indicated a problem with his liver which we would need to look into further. This involves taking a general history, tailored to other possible liver pathology and including a social history with specific reference to his estimated alcohol consumption. I think it would be negligent not to ask about alcohol in view of the results given. It may be an easy starting point to use the social history previously documented in his notes and ask if there has been any change.

Methotrexate itself can cause derangement of liver function tests and cirrhosis so must be stopped immediately. I would arrange for Dennis to have repeat LFTs in two weeks to make sure this derangement was resolving. At the same time I would also request a GGT to assess his alcohol intake if it was not included before. It would be prudent to contact the consultant concerned in Dennis's shared care at an early stage for advice on recommencement of methotrexate in future.

My questioning would be very open, allowing Dennis to volunteer the information without pressure. Encouraging Dennis to make an association between his alcohol consumption and his other clinical problems such as his hypertension and the medication he is taking is vital.

I would probably stop the consultation there as there has been a lot of information and discussion so far. It is important to arrange a follow-up consultation in a couple of days not only to readdress this issue but also to consider management of his hypertension which needs to be controlled promptly.

Finally, it may be a great asset having Dora present as Dennis may need her help to sort this out in the future.

Dr Neil Brownlee

'If Dennis admits to a high alcohol intake I would CAGE him'

The first issue here is confidentiality. I must not inadvertently mention Dora's previous consultations for stress. I do have every right to ask about his drinking and whether it is causing family problems. If the liver function tests show a classic rise in GGT

I would ask Dennis if he had been realistic about his alcohol intake during the last consultation. A raised MCV would also be an indicator.

Dora may be exaggerating his drinking and it would be dangerous to miss hepatotoxicity from methotrexate. I would look at his past LFTs. A long history of heavy drinking should be reflected in a chronic elevation of the GGT. Nevertheless, I would stop the methotrexate and contact the dermatology department for advice.

If Dennis admits to a high alcohol intake I would use the following CAGE questionnaire:

 · Have you ever felt you should Cut down?

 · Have people Annoyed you by criticising your drinking?

 · Have you ever felt bad or Guilty about drinking?

 · Have you ever had to have a drink in the

morning to steady your nerves (an Eye-opener).

This not only assesses dependence but may bring to light Dora's alleged domestic stress without breaking her confidentiality.

I would then explore reasons for his drinking. He may be depressed about his illness. He may have an arthropathy-induced chronic pain syndrome. We often assume the patient's pain is well controlled but he may be suffering in silence. Perhaps Dora's hypochondriasis has driven him to the bottle.

I would talk about safe levels of intake and point him in the direction of Alcoholics Anonymous (0845-7697555) and Drinkline, the alcohol helpline (0345-320202). Lastly, I would offer referral to the community alcohol team.

His hypertension is also an issue. I would monitor this via our practice nurse. Treatment can probably wait until his altered LFTs have been fully investigated.

Dr Stefan Cembrowicz

'Hidden alcoholism can catch you out years into practice'

Hidden alcoholism is one of the things you tell the registrar about on day one and yet which can still catch you out after 20 years in practice. Patients you have established a comfortable modus vivendi with, perhaps for years and years, suddenly appear in a completely different light and it may take one of your partners to spot the obvious tell-tale signs. These include repeated time off sick for non-specific reasons, those persistent repeat script requests for Prozac when they really don't want to bother the doctor, notes from the local A&E mentioning unexplained injuries, and as in this case the unexpected rise in liver enzymes.

You are being put into a double bind by his wife. You may well prefer to avoid confronting her but he is your patient now and you cannot conspire with her against him. You have to do what is in his best interests.

Before Dennis comes in, can she explain why she now wishes to avoid addressing the subject of his alcohol use ­ which she has complained to you about so frequently? She may simply want to avoid a row or may deny or not appreciate the connection between his liver tests and his alcohol use. Perhaps she also has a quiet drink on a rather frequent basis?

Dennis does need to know if he has alcoholic liver damage. What does he think the problem could be with his liver? You can start the batting in this way without disclosing anything Dora has told you in confidence, and some lifestyle questions for you as a doctor new to him may lead gently ­ via smoking, diet and exercise ­ into alcohol use, and avenues of help and support for problem drinkers.

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