The last time I went in for a routine physical, I decided to be honest with my doctor about my drinking habits.
I’ve read the guidelines; I know the Centers for Disease Control and Prevention says women should consume no more than seven alcoholic drinks per week. Nonetheless, my weekly number often falls a few drinks higher, especially if I’m on vacation or attending lots of social events.
When I admitted this to my doctor, I was ready for a raised eyebrow and a reminder to keep my revelry in check. Instead, her reaction was explosive: “Why do you drink so much?!?” She quickly announced she was ordering a test of my liver function (it came back fine) and told me that anything more than the occasional glass of champagne was harmful and unnecessary.
Her response freaked me out. When I told a friend about my experience, she sympathized with my frustration over my doc’s judgmental tone. Then she said, matter-of-factly, “You know that doctors always double the number of drinks you tell them, right?”
The idea that doctors automatically double a patient’s self-reported alcohol intake made headlines in 2018.
No, I did not know that. But it made sense — patients probably downplay how much they drink all the time. Plus, during the pandemic, alcohol sales have spiked and many adults have reported their drinking is up. And I’m sure some people underestimate their weekly total without meaning to. It’s easy to forget that a generous pour equals more than one glass of wine, or to omit half-finished cocktails from your drink count.
Did some unspoken doubling rule explain why my doctor reacted so strongly to my confession? Did she think I was actually imbibing upwards of 20 or 30 drinks a week?
“That seems like a bad rap we get,” says Dr. Allison L. Ruff, a general medicine physician. Ruff says the only people who cite the drink-doubling rule are patients.
“I’ve heard patients tell me all these things like, ‘Oh, you’ll double what I say,’ ” she says. “I don’t think doctors really do that. Patients are surprised to hear that, but I really do take what people say at face value, especially with alcohol intake.”
A common myth
The idea that doctors automatically double a patient’s self-reported alcohol intake made headlines in 2018 when British media reported on a survey of fewer than 200 general practitioners. Many said they used an “alcohol multiplier” to assess patients’ drinking habits, assuming that patients only admit to about half of their actual consumption.
Ruff, who also teaches the “Introduction to Doctoring” course at the University of Michigan medical school, says this might be the case for some old-school doctors. But in her experience, and in her role educating medical students, “I promise nowhere in the course does it say ‘Double the amount of drinks someone tells you,’” she says.
Dr. Giuseppe Aragona, a general practitioner based in the UK, says he personally doesn’t double his patients’ numbers.
“’When people self-report, I think you can usually believe them, unless there are telltale signs that [indicate] otherwise,” he says. “If you have evidence, then press them on this.”
Downplaying your “bad habits” or exaggerating your virtuous ones isn’t going to do you any favors — in fact, it ultimately makes your doctor’s job more difficult.
Curious for more insight, but not equipped to execute a formal study of my own, I texted a few friends in their late 20s and early 30s who are medical residents across the US. Two out of three were emphatic: They always take patients’ self-reported number of drinks at face value, unless a patient’s test results indicate liver damage or other signs of excessive drinking.
But one friend did tell me she’d been told to round up the number of drinks that patients report, and she assumed this practice was widespread. So it’s possible that this happens sometimes, even with younger providers.
Tempted to underreport? Don’t.
Regardless, it’s important to have honest conversations with your provider about your habits, whether you’re talking about your diet choices or discussing how much you drink, smoke or use drugs.
Downplaying your “bad habits” or exaggerating your virtuous ones isn’t going to do you any favors — in fact, it ultimately makes your doctor’s job more difficult. Ruff points out that these behaviors contribute to other medical conditions: “If you tell me you’re only drinking two drinks a week because you think I’m going to inflate that, and then your liver tests come back a little bit elevated, I might start looking for other causes, when in actuality it’s because you had a beer last night.”
Withholding information or fudging the truth also makes it harder for your doctor to create an effective treatment plan. One example is a patient that’s trying to quit smoking.
“If you’re underestimating how much you’re smoking, then I’m going to give you the nicotine replacement for that amount,” Ruff says. “Then you’re going to come back to me and it’s not going to work.”
“Intervention” doesn’t have to be scary
What should it look like when your doctor wants to have a conversation about habits that create cause for concern?
For conversations about drinking, there’s “a fairly particular framework around how that conversation happens rooted in the framework around motivational interviewing,” says Randy Brown, associate professor at the University of Wisconsin School of Medicine and Public Health. “The idea is to get a sense of where the patient is in terms of their own desires around behavior changes, providing concrete feedback around why the provider is concerned about it, and then negotiating a set of goals around what might happen.”
Those goals may or may not include going cold turkey.
“Historically, a lot of the treatment around the US was pretty firmly rooted in 12-step approaches that are abstinence-focused,” says Brown, who also directs the Center for Addictive Disorders at UW Hospital and Clinics. “Not everyone is going to feel comfortable with the idea of being told that abstinence is the answer and they need to start doing that right now.”
Your doctor should meet you where you are, Brown says. That doesn’t mean sugarcoating the situation or validating your decisions, but it does mean evaluating your drinking habits in context, not just zeroing in on the number of drinks you report.
“Where it is important for patients to be reflective is not necessarily a pure focus on the quantity [of drinks],” he says, “but whether or not they have some idea that a pattern of use may be contributing to a hazard in their lives.”
When I talked to my doctor about how much I was drinking, I didn’t get the feeling she was looking at my full health picture or curious about my alcohol use in context. I felt chastised and ashamed, and I haven’t been back to see her since. Does that mean it’s time to find a new primary care provider?
You shouldn’t feel like you need to lie about your own [drinking] habits just to appease [your doctor].
“I think that’s totally valid,” Brown says. What it doesn’t mean, though, is that I should go with the first doctor who tells me it’s fine to throw back more than seven drinks a week. It also doesn’t mean I’ll be able to avoid uncomfortable conversations completely.
As telehealth becomes more widespread, conversations about drinking and taboo subjects can also become trickier.
“It’s so much easier to have these difficult conversations in person,” Ruff says. “Because there’s less small talk virtually, I find it harder to assess some of the social behaviors that are much easier to assess in person.” Ruff says most of her virtual visits address a specific concern rather than a general health check, which doesn’t create an opening to discuss drinking habits, for example.
“That may change as the pandemic goes on,” she says. “Folks might do more general wellness via virtual visits once it becomes more and more clear that this is the way of the future.”
Considerations when switching providers
Traditionally, “for your primary care doctor, the idea is this person is going to be with you for years, if not decades,” Ruff says. “It’s reasonable to find someone who fits with you.” In her own practice, Ruff says her colleagues all have “different flavors”: Some are paternalistic and stern, others are more casual and laid back.
Brown notes that patients should feel empowered to steer conversations about drinking and other touchy topics in the exam room. If you know your doctor’s style is to condemn any level of alcohol use, you shouldn’t feel like you need to lie about your own habits just to appease them.
“Ideally the patient would be able to say, ‘I’m drinking beyond what I know is recommended. I’d appreciate us not taking up a lot of our visit talking about it; if it is an issue, I will talk to you about it,’” he says.
However, even if you’re not experiencing any immediate consequences from your habit, it’s still your doctor’s job to inform you about the risks.
“Even lower levels of [alcohol] consumption can increase risk for breast cancer and may have some impact on cognition later in life,” Brown says. Alcohol can also interfere with management of hypertension, diabetes, depression and mental health issues.
Unfortunately, there’s no hack for finding the doctor that fits you best. Landing on the right one might take trial and error. But both Ruff and Brown agree that your doctor’s role is ultimately to help you lead a healthier life, and sometimes difficult discussions are part of the equation.
If you’re switching providers, you might be tempted to avoid sensitive topics altogether if you had an unpleasant experience in the past. But Brown suggests getting ahead of the issue and addressing it with your new provider at the first appointment.
The conversation can be simple, he says: Consider saying something like, “I’m switching providers because there is this issue, and the relationship between [us] was a bit challenging. I’d like to hear more about your approach.”
As for whether your doctor is secretly rounding up your number of drinks, cigarettes or sexual partners? It’s unlikely, unless your test results contradict your story. But even if you question your doctor’s assumptions, your best bet is to be forthcoming.
“As much as my patients expect me to be honest about what I think is going on with them, I really do expect that my patients value our relationship enough to be honest with me,” Ruff says.
This makes your doctor’s job easier, and frankly, it makes yours easier too: no mental math, no fudging the truth, no stories to keep straight — just unfiltered conversations that help your doctor see the full picture of your health.