Do medical students have drinking problems?

A study from the Mayo Clinic says one-third of US medical students drink too much alcohol and something must be done about it.

In 2012, the authors sent a survey with questions about alcohol abuse, burnout, depression, fatigue, suicidal ideation, and quality of life to 12,500 medical students of whom 4402 (35.2%) responded.

Of those responding, 1411 (32.4%) “met diagnostic criteria for alcohol abuse/dependence.”

According to the Mayo Clinic’s press release, “Nationally, that translates to about one-third of those responding, compared to only 16 percent of peers not in medical school, and double the rate of alcohol abuse or dependence of surgeons, US physicians or the general public based on earlier research by this team.”

The paper also found that burn out, depression, high educational debt, being unmarried, and being younger were associated with dependence on or abuse of alcohol.

The authors called for a multifaceted approach “addressing burnout, medical education costs, and alcohol use.”

Here are some problems with this study.

Moderate maternal alcohol use lowers children’s IQ (not)

A new study shows that children of mothers who drank as little as 1 to 6 units of alcohol per week had children whose IQs at age 8 were statistically significantly lower than those of children who mothers abstained.

This finding was widely reported by news media yesterday. Google “IQ alcohol” and you will find many articles which uncritically describe the findings of the study. As is the case in many such articles, quotes from the press release accompanying the paper’s publication appear to have been liberally used.

The major problem with this study is one that I’ve written about before. Results that are statistically significant may not necessarily be clinically significant.

The difference in IQ between the two groups of children was 1.8 points. Do you really think that an IQ difference of 1.8 is going to be a life-altering finding for a child? I don’t.

IQ tests are often unreliable and if taken more than once can yield different results. A difference of 1.8 points is well within the margin of error of such tests. One source I found states that the margin of error of the IQ test used in this study is a minimum of 5 points. The children in this study were 8 years old when they took the test.

The study, done by a group in Bristol, England, was published on PLoS One and the full text is available here. Caution is advised if you plan to read it. There are many other problems to consider.

Data collected for this paper were pulled from another study which was done from 1992 to 2000 about the genetics of alcohol metabolism. The primary focus of the original study was not the hypothesis of the IQ study.

A unit of alcohol was defined as 8 grams by the authors. Since I was not familiar with what 8 grams of alcohol really meant, I looked it up. A “standard drink” was said to contain anywhere from 8 (in the UK) to 14 grams (in the US) of alcohol.

Here’s a quote from the paper’s “Methods” section, “At approximately 18 and 32 weeks of pregnancy women were also asked on how days during the past month they had drank [sic] 2 pints of beer (or the equivalent amount of alcohol), any women who reported doing this on at least one occasion was classified as a binge drinker in our analysis of the association between genotype and binge drinking.”

Really? Two pints of beer on one occasion makes a woman a binge drinker? Depending on the type of beer, a pint contains 2 to 3 units or 16 to 24 grams of alcohol.

To help you understand the paper better, here is a table:

I asked my wife what she thought of this study and she said, “I think the women who drank were probably more fun to be with.”

Surgeon performance degraded by drinking to excess the night before. What excuses do reporters have?

A big media splash accompanied the publication of a paper in the April 2011 issue of the Archives of Surgery about surgeon performance on a simulator after a night of alcohol ingestion. Briefly, the paper showed that drinking to excess can negatively affect performance of tasks involving simulated laparoscopic cholecystectomy the next day even if alcohol levels are zero. What is not clear is whether making small errors on a simulator means that patients would be a) similarly vulnerable in a real operation and b) harmed by these errors. There is a big difference between playing with a simulator in a laboratory and operating on a living, breathing patient.

What is clear is that the reporting of this story leaves a lot to be desired. I looked at a number of articles and found numerous mistakes leading me to wonder if alcohol consumption affects reporters negatively too.

“Hung-over surgeons more error-prone” was how Reuters chose to headline the story. As the authors of the paper point out “There is no consensus definition of hangover and most studies identify various constellations of symptoms, including headache, diarrhea, anorexia, fatigue, and nausea.” There was no mention in the paper that subjects of the research had any of these symptoms.

“Time to give surgeons breathalizers [sic]?” was the headline on CNET News. The only problem is that the study was about the effects of alcohol on performance the day after drinking. Only one subject even had a detectable level of alcohol on a breath test the next day. And “breathalyzers” is misspelled. This story did point out the error in the Reuters headline regarding the absence of true hangovers.

CNN.com wrote “A second dinner-and-drinks experiment -- this one involving a group of surgery trainees and a control group that did not drink…” A similar error was made by Time.com which said, “In a two-part study involving 16 medical students and eight experienced surgeons…” The subjects in this group were students at Queens University, Belfast, not surgery trainees or medical students.
 

A website called AccessRx wrote “A recent study has shown that surgeons are more likely to make mistakes during a surgery if they are hung-over, even if there is no detectable alcohol in their system.” And they also say that the non-surgeon subjects were medical students. Many articles on this subject feature dramatic photos of seemingly distressed doctors in surgical garb. The one at AccessRx was at least amusing [below].

[He forgot his mask. Is that glass sterile?]

This is my favorite. From MyFoxBoston.com [printed in its entirety]:

“(FOX 25 / MyFoxBoston.com) - This might not come as a surprise, but a new study says that surgeons who drink a lot the night before surgery are more likely to make mistakes the next day. Irish researchers set up two simulated surgeries. In the first, 16 college students were told to either drink or not drink the evening before. In the second, eight experts drank all they wanted. The study showed that there were more errors among the drinkers.”

The folks at AccessRx called for action stating emphatically, “Should some sort of regulation be put in place to restrict surgeons from drinking the night before a surgery?” 

Similarly, I call for alcohol testing of reporters before they file their stories.

Alcohol Is the Most Harmful Drug? Nonsense!

An article published yesterday by the prestigious journal The Lancet claims that alcohol is the most harmful drug of all, including crack cocaine and heroin. The story was reported uncritically by the science news media such as Reuters Health, MedPageToday and Science Daily as well as the lay media [CBS News, New York Daily News, and many others]. At least one outlet, The Atlantic Wire, was skeptical, pointing out that the study’s lead author, Professor David J. Nutt [yes, Nutt] had an axe to grind. It seems he was fired as the UK’s adviser on drugs for insisting that alcohol was a worse problem than marijuana. They also added comments from other skeptics.

So far, no one has addressed the “science” of the paper, the full text of which is available free on line. I’ll have a go at it. Dr. Nutt and colleagues established their own rating system for harm. It has not been validated by others. It rates 16 “harm criteria” on a scale from 1 to 100. The paper’s methods section does not indicate how the “harm criteria” were chosen or how the ratings were assigned. It certainly seems rather arbitrary to say the least. The third paragraph of the description of how the scores were weighted is incomprehensible to me. Here it is in its entirety:

“During the decision conference participants assessed weights within each cluster of criteria. The criterion within a cluster judged to be associated with the largest swing weight was assigned an arbitrary score of 100. Then, each swing on the remaining criteria in the cluster was judged by the group compared with the 100 score, in terms of a ratio. For example, in the cluster of four criteria under the category physical harm to users, the swing weight for drug-related mortality was judged to be the largest difference of the four, so it was given a weight of 100. The group judged the next largest swing in harm to be in drug-specific mortality, which was 80% as great as for drug-related mortality, so it was given a weight of 80. Thus, the computer multiplied the scores for all the drugs on the drug-related mortality scale by 0.8, with the result that the weighted harm of heroin on this scale became 80 as compared with heroin's score of 100 on drug-specific mortality. Next, the 100-weighted swings in each cluster were compared with each other, with the most harmful drug on the most harmful criterion to users compared with the most harmful drug on the most harmful criterion to others. The result of assessing these weights was that the units of harm on all scales were equated. A final normalisation [sic] preserved the ratios of all weights, but ensured that the weights on the criteria summed to 1.0. The weighting process enabled harm scores to be combined within any grouping simply by adding their weighted scores. Dodgson and colleagues provide further guidance on swing weighting. Scores and weights were input to the Hiview computer program, which calculated the weighted scores, provided displays of the results, and enabled sensitivity analyses to be done.”

The figures are equally bizarre especially figure 3. The paper does not allow for variations in amount of drug used. For example, is one alcoholic drink per day a problem?

Certainly alcohol abuse can be a quite harmful but what about the recent research showing that 1 to 2 drinks per day improves health? The way this story was reported might actually be detrimental by causing social drinkers to stop thereby possibly harming themselves.

Honestly, I am surprised that The Lancet would publish a paper such as this. It’s not April 1, so I don’t think it’s a joke. Did they just want to be controversial or get publicity? If so, I guess it worked. And what about the media? Should they just report these press releases without question? Widespread uncritical dissemination of junk science like this gives it unwarranted credibility.

Moderate Alcohol Intake Is Good for You

According to a recent article in the journal Alcoholism: Clinical and Experimental Research, people with moderate alcohol intake had the lowest mortality rate of all groups compared to light drinkers, heavy drinkers and abstainers. The study involved 1824 Californians between the ages of 55 and 65 at baseline. Light drinking was defined as drinking an average of up to one drink per day. Moderate was defined as drinking an average of one to less than three [or two, if you are math challenged] drinks per day. Heavy was defined as drinking three or more drinks per day. Abstainers were people who had previously used alcohol but had become abstainers sometime before the start of the study. This was a very well-designed observational study with an end point of all-cause mortality after 20 years.

When age and gender were controlled [statistical techniques were used to remove variations among groups] the results showed that compared to moderate drinkers, abstainers had more than twice the risk of dying, heavy drinkers had 70% more risk and light drinkers had 23% more risk. This risk was cumulative over the 20 years that the subjects were followed. Even when all other covariates were controlled, moderate drinking was associated with the lowest mortality rate and abstention with the highest mortality rate.

The authors caution that there are limitations to this study including the following: it was observational and not a true experiment; the drinking data were self-reported [that is, the subjects themselves stated how much they drank]; lifelong abstainers were excluded [the study included only abstainers who had stopped drinking alcohol]; all drinking groups may have experienced episodic heavier drinking, which was not accounted for.

In a Science Daily report, the lead author stressed the word “moderation” and also pointed out that the study should not be interpreted as endorsing the concept that lifelong abstainers should start drinking to live longer.

With science on our side, let’s have cocktails! [See related post on How to Make a Great Vodka Martini.]

How to Make a Great Vodka Martini

UPDATED June 6, 2011

1. Any vodka will do. Trust me, Smirnoff's is as good as Ketel One or Grey Goose. Here is the “proof” [pun intended].
2. No flavored vodka. EVER!
3. Do not use vodka from the freezer. It's important for the vodka to melt the ice a little.
4. Add at least 3-5 drops of dry vermouth. It's got to have vermouth. Otherwise it's straight vodka, which is fine with me, but then it's not a Martini.
5a. James Bond was right. Shaken, not stirred. Let it sit for 30 seconds or so to allow the ice to melt a little. This takes the edge off the vodka.
5b. Shake as hard as you can so that some of the ice flakes off and is poured into the glass.
6. A Martini must be served "straight up" in a real Martini glass, which must be chilled. No plastic glasses please. If someone tries to give you a plastic glass, order something else.
7. One or more large green olives; no pits please; stuffing is optional. Pimento is the standard stuffing. I prefer garlic- or jalapeño-stuffed olives.
8. Extra juice from the olive jar (so-called "dirty Martini") is acceptable for some but not for me.

I'll have one when I'm off duty. Cheers!