Alcohol use in the medical profession

Medical professionalism is an area of importance for all health care practitioners [1]. Alcohol use in the medical profession has been frequently reported for decades [2–6]. Not only is this behavior of intoxication inflicting a damaging impression on medical professionalism, but most notably it is a major threat to patient safety [7]. Most health care professionals maintain the same habits as the general populace, which includes an occasional drink while relaxing after work and heavier drinking associated with social functions [8–10]. Drinking in excess to the point of inebriation, however, is not generally associated with professional medical behavior. While this general statement is true, there are still instances where medical professionals were reported taking alcohol at work or being inebriated upon reporting for duty [4, 6, 11–13]. Both of these activities are concerning as alcohol use impairs judgment and impacts the ability of medical professionals to provide accurate and competent health care.

The majority of current research consists of quantitative studies on alcohol abuse in medical professionals [4, 6, 8–13]. These studies concentrate on the prevalence and impact of alcohol abuse in medical professionals or identification of alcohol impaired medical professionals [4, 6, 8–13]. The studies have reported that medical professionals may examine patients and make medical decisions while inebriated and that the medical professional in question may not feel that inebriation impacts their ability to make accurate and correct medical judgments [4, 6, 8–13].

Drinking behaviours and provocation among medical students

Articles concerning alcohol use among university students consistently relate their drinking behaviours to gender, religion, culture and social norms such as peer influences [14–17]. A majority of studies report how students may be pressured into drinking excessive alcohol by their peers [1, 14–17]. One qualitative study describes medical students engaging in acts of forced drinking that could cause distress to their peers [1]. This study conceptualizes a drinking behaviour as “alcohol-related provocation”, which refers to any action that can make others feel coerced or compelled to consume alcohol or drink more alcohol than intended [1].

Drinking culture

Western drinking practices may take place frequently both in everyday social occasions or in private households for various purposes at all scales of alcohol consumption [18]. In Taiwan, like in many other Chinese societies, alcohol consumption is typically associated with drinking occasions during celebrations for holidays such as the Lunar New Year, or is specifically recognized as an important facilitator for business and work settings [19–21]. It is a tradition for Japanese employees to attend “Bonenkai” events which are drinking parties commonly held by workplaces at the end of each year to give thanks to others [22]. Similar to this custom, the “Weiya” events known as annual workplace banquets are also observed in Chinese societies (including Taiwan) [23]. Most hospitals in Taiwan also organise annual banquets (Weiya drinking parties) which are unquestionably a part of this specific workplace drinking culture. Another unique drinking etiquette identified with workplace banquets in Chinese societies is “quanjiu”, which describes the custom of urging others to drink [24]. This drinking habit could be considered a type of alcohol provocation behaviour [20, 24]. In Taiwanese hospitals where alcohol consumption is inevitable at social functions such as department gatherings or year-end parties, medical professionals are often required to attend these social events and the occurrence of alcohol provocation can be commonplace. While studies have provided insights into alcohol use and alcohol provocation among medical students, no studies have addressed experiences of alcohol provocation among medical professionals in the Asian context.

The present study

The purpose of this study is to interview medical professionals to gain a better understanding of how alcohol provocation occurs and the impact of alcohol provocation on medical professionals. The use of a qualitative method allows for a more open format to identify hypotheses and common themes that can enhance our understanding of alcohol provocation in medical professionals from multiple perspectives and cultural backgrounds. It is anticipated that understanding of alcohol provocation would allow the development of effective interventions targeted at reducing the risk of alcohol abuse in medical professionals, and hence lowering the likelihood of compromising medical professionalism and patient safety.

Setting

This qualitative study involving focus groups was undertaken between December 2015 and January 2016 in a large teaching hospital in Taiwan. In accordance with the standards for reporting qualitative research and ensuring rigor in this study, the framework of this methodology involves the following steps: sampling of participants, data collection and data analysis [25, 26]. This study was approved by the Chang Gung Medical Foundation Institutional Review Board on July 7, 2014 (Ref.: 103-7771B).

Sampling of participants

The participants comprised residents and physicians recruited from the local hospital using targeted emails, memos, and flyers. All participants were selected using purposive sampling technique [27]. The study recruited a total of 61 participants comprising 32 physicians (mean age of 43 years; 27 males) and 29 residents (mean age of 27 years; 18 males). The most common specialty found among the group of physicians was neurosurgery (n = 16) while the rest were general surgery (n = 1), colon and rectal surgery (n = 1), cardiac surgery (n = 1), thoracic surgery (n = 1), physical medicine and rehabilitation (n = 1), orthopedics (n = 1), thoracic medicine (n = 1), nephrology (n = 2), emergency medicine (n = 2), internal medicine (n = 1), pediatrics (n = 1), neonatal–perinatal medicine (n = 1), dermatology (n = 1) and radiology (n = 1). In the group of residents, there were 19 participants in their first year of post graduate rotational training, 8 neurosurgical trainees and 2 general surgical trainees. No participants withdrew from either group. All participants were informed about the purpose and voluntary nature of the study. Written consent forms were obtained from all individual participants included in the study.

Data collection

All recruited participants (n = 61) volunteered to take part in focus groups. A questionnaire regarding prevalence of alcohol consumption was given to each participant prior to their interview. Alcohol consumption or alcohol inebriation were assessed respectively by asking the participants “Have you consumed any alcohol in the last year?” and “Have you gotten drunk in the last year?” Those who answered yes to each question were further asked respectively about the frequency of their alcohol consumption or inebriation. Participants were also asked to self-report if they have ever taken alcohol or been drunk while on duty. These questions were reviewed by the current research team before administration. The number of participants included in each focus group ranged from 4 to 6. Residents and physicians were sometimes interviewed in separate focus groups due to circumstances where residents might have to comment on their superiors. A total of 12 focus groups followed a topic guide developed by all members in the research team (S1 File). Interview questions were reviewed and approved by the Institutional Review Board (Ref.: 103-7771B). The duration for every interview held in a private meeting room was between 50 and 70 minutes. Interviews were audio-recorded and conducted in Mandarin (participants’ native language) by a researcher (MMC, a member of our research team) trained in qualitative studies. The interviewer guided the process with the goal of encouraging group discussions in an open-ended manner and ensured that leading questions were kept to a minimum to prevent interviewer bias. Narratives of personal experiences were also encouraged to ground the data in actual experiences rather than merely opinions. Notes were taken during the interviews by CHL, another researcher from our team. Both researchers, MMC and CHL are not members of the departments from which the participants were recruited.

Data analysis

The audio recordings were transcribed verbatim (see S2 File) and to ensure anonymity during data analysis, participants were assigned a unique identifier. All transcripts and notes were analyzed thematically to identify, analyze and report patterns within the data [28]. The software ATLAS.ti was utilized for data management and coding. All transcripts and results were translated into English by a paid translator after thematic analysis. Two researchers from our team, CYL and CHL, who familiarized themselves with the transcripts through repetitive reading completed the first coding round of four initial transcripts. A third researcher from our team, HYL coded the interview data of four focus groups independently. A coding scheme was developed by CYL and CHL and reviewed by HYL. A second coding round was then performed and all interview transcripts were coded separately by CYL and CHL. Both versions of coding results were compared to reveal differences in coding. CYL, CHL and HYL discussed discrepancies to resolve them and reach an agreement on the labeling and definitions of codes. There was no need for further data collection once no new ideas or themes emerged from the data. All researchers reached consensus on the final analytical framework of common themes across all interviews. The quantitative data collected from questionnaires were analyzed using Statistical Product and Service Solutions (SPSS 24) software.

Ethics approval

Written informed consent was obtained from all individual participants included in the study. This study was carried out in accordance with relevant guidelines and regulations, and approved by the Chang Gung Medical Foundation Institutional Review Board on July 7, 2014 (Ref.: 103-7771B).

Theme 1. Social drinking in the Taiwanese medical profession

Most participants provided their experience with work-related gatherings where alcohol consumption was always involved. By toasting drinks to meet with others, drinking alcohol at these events was believed a way of showing respect and adherence to social etiquette.

We have this tradition where the younger doctors have to line up to make a toast to the elders for showing respect and gratitude for taking care of them throughout the year. We only do it for the sake of this tradition. (P9-3)

[Drinking or toasting is] a social behavior or to maintain a close relationship, to put it in a nice way. Formally speaking, it’s also a type of etiquette. (P3-2)

It’s also to show your manners. It wouldn’t look nice to take out the juice. Drinking wine and proposing a toast [at the dinner event]is not only being polite but also showing your manners. (R12-1)

Some participants stated that the regular year-end drinking party is a typical drinking culture originating from Japan, which shares similar characteristics of workplace social drinking with Taiwan. The year-end party or department gatherings were frequently mentioned by both physicians and residents throughout the transcripts as regular drinking occasions organized by the hospital. Specifically for most residents, other workplace drinking occasions also include welcome parties for freshmen or mentor support gatherings.

The year-end party which everyone goes to is meant for “forgetting about [anything unpleasant happened during] the year” and a tradition from Japan. Juniors make a [drinking] toast to the seniors at the year-end party. (P5-5)

It’s more like a Japanese [drinking] culture, you have to make a toast if eating with elders and teachers, and when there is alcohol provided on the table. (P4-3)

…we have this mentor support gatherings (an organized drinking event where a mentoring physician meets their students) but the worst case I had witnessed was at the welcome parties, some were forced drinking and got so drunk till they passed out. (R12-4)

The tradition of expressing gratitude by toasting drinks to teachers was considered by some participants to be beneficial for their medical career. Some participants felt this drinking behavior was likely to be associated with specialties where an apprenticeship is valued.

I think attending these gatherings always helps your career in some way by getting to know more people to enhance your interpersonal relationships [with other doctors or teachers]… It’s hard to avoid [making toasts to teachers] if you are from the surgery (department). (R6-2)

You felt like you had to drink because you were from the surgery department. Experienced specialists who taught me things about operations, I wanted to make a toast to show my gratitude to them and other seniors. (P4-5)

There is this apprenticeship system [commonly seen] at the surgery division. The relationship between a mentor and an apprentice. And they [the teachers and apprentices] become closer to each other without feeling a wall [barrier] between them when they get together to drink after work. (R6-1)

On the other hand, it was regarded as pressure for some participants to be present at these drinking events. There were concerns raised about their career if failing to follow this drinking tradition in the workplace.

I think there is pressure when some supervisor is present or for some particular occasion where it makes you that you have to [drink and make a toast]. (P8-2)

Some people might think it’s not polite [to skip] making a toast to your teachers. Would this have an effect on your job? There might be. I think there is. The custom of this society leads to this particular etiquette. (P3-4)

Theme 2. Workplace hierarchy and changes in drinking culture

The difference in hierarchy in the workplace means the presence of various ranking of positions, status and power, leading to inequality among employees. On many drinking occasions, physicians who were more inclined to display superiority would often lead the residents to propose a toast not only to their teachers but also to many others. Young doctors or those with a junior rank might be manipulated by any authority figure to take alcohol unwillingly or in excess. Participants pointed out a regular scene from workplace drinking events where an unequal amount of alcohol consumption occurs. In this case, a junior might have to drink in response to several drinking toasts made by teachers or colleagues while the teachers would only have to take one glass of drink in response to all of them. There is obvious unfair treatment due to rank distinction observed at drinking events where doctors of junior rank were more likely to become inebriated. Most of the participants expressed a feeling of compulsory drinking or requirement to “out-drink” due to workplace hierarchy:

People drink alcohol and make toasts to one another and it is a must! I remember myself at a younger age preparing [alcoholic] drinks for making toasts to teachers. Unfairness in [the amount of] drinking alcohol happened frequently. The situation where you had to drink a whole glass or more while your teacher only took a sip was pretty common. (P9-2)

…A teacher [supervisor or superior] would come to me with a bottle of wine asking how many glasses [of drinks] I would drink in response to his drinking toast. He would say it’s a must to out-drink your teachers. Some people drank until they threw up…. Once at one gathering for the surgery department, the superintendent came to make a toast to you, you had to drink 5 glasses while he only had to finish one glass. (P2-4)

Several physicians reported the term “quanjiu”, which describes the behavior of urging others to take alcohol or making others drink excessively. The situation where doctors forcing others to drink or being pressured into drinking at gatherings fits into the concept of “alcohol provocation”. Some participants who might have had no intention to drink could have been forced to drink in excess under the influence of provocation from superiors.

It depends on what your chief physician is like. Our former chief physician enjoyed drinking quite a lot and he forced us to drink until we all, even the female (colleagues) got drunk. (P9-1)

Students made drinking toasts to the teachers while teachers “quanjiu” to the students (made the students drink)… It was a mess as everyone was making a toast and urging others to drink. We would choose to hide in the back unless if someone comes to your table and says “Come on, let’s drink more tonight and get drunk a bit more”, we would pretend to drink but spit it out later. (R6-1)

Similar provocation occurred when colleagues or bystanders also played a role in urging others who were then obliged to drink, as described by one of the physicians:

As I recall, it is usually those bystanders (who may not necessarily be superiors) or colleagues who happen to urge you to drink 3 glasses of alcohol instead of one glass as originally demanded by the teacher. …Those bystanders (staff from other departments), colleagues or superiors are those held responsible for making this kinda demand. (P4-3)

Drinking provocation found in the Taiwanese medical profession, either from superiors or peers, was once believed to be passed on as a tradition through generations. It is now viewed as an optional convention which is seldom followed or practiced by the residents or physicians of current generations.

… All the doctors had been through the same kind of ordeal (provocation) before when they were juniors. Once they turned to be senior doctors, they would expect the young fresh doctors to greet them with drinking toasts… The fact of being his [the junior’s] teacher is the biggest reason good enough to make the juniors drink… [It’s like] I was being mistreated in the same way before and now it is finally my turn to be in the reverse position [of making others drink]. (P2-5)

There would be differences as times have changed. The time when I was a resident [but comparing to] the present day where the spirit of democracy encourages people to value personal rights and protect interests of others. Not many residents [nowadays] will be willing to drink,…. I might get kicked out [if I didn’t follow to drink] in the past time. It’s changed now. You could hardly see anyone being forced to drink [at any current drinking event] nowadays, no such thing would occur, whether it [drinking] be between peers or [among a group of] junior and senior doctors. (P11-3)

Theme 3. Influence on the medical profession

At workplace drinking events where alcohol provocation was common, some participants were often unaware of how much alcohol they could tolerate until they were made to drink excessively to the point of losing consciousness. In addition to the anticipated adverse effects of drinking on health, participants who experienced any form of alcohol provocation suffered severe consequences including hospitalization, absence from work, or compromised work performance.

There is always impact from [alcohol] provocation. It leads to binge drinking. [What’s worse]is the next day you have to show up at work and feeling all dizzy and sleepy as a result from excessive drinking, as well as the headache [you get] from hangover. My work performance was slightly affected but luckily no serious accident occurred. (P3-2)

..it is always to make the first year residents to drink till they drop at the welcome parties. The affected freshmen residents always ended up in the emergency room. (R6-5)

I managed to show up at work for most of the time after the year-end drinking parties I attended (the day before). Occasionally, I really did fail to show up (because of forced binge drinking on the previous day, then [my] supervisor or colleagues would have to take over my work at the emergency room. (P5-1)

Participants expressed a feeling of disapproval of persistent persuasion from colleagues, even if they tried to resist alcohol provocation, and how this leads to a negative impact on the relationship with colleagues as some may regarded it as an act of bullying.

I personally disapprove of such behavior where you are being pressured consistently into drinking despite the effort of a polite decline is made. Eventually, you end up in having a bad impression on the person doing so. In my opinion, it is not a decent behavior to some extent. (P8-3)

Don’t overdo it [provocation], try to control yourself. What you behave at the drinking event may influence on how your colleagues see you. It has some effect on your professional image or the relationship you have with your colleagues. (P10-1)

The bad thing about it [alcohol provocation], some people reckon it is more fun to deliberately force those who gets drunk easily to drink. It’s perceived an act of bullying (from colleagues) by those people who can’t really drink. (P5-3)