For practical reasons six of the 39 general practitioners in the original pragmatic study were not invited to a focus group or an individual interview. Of the other 33 doctors, 24 were interviewed—19 in the two focus groups (four in one group and 15 in the other) and five individually. These 24 doctors were representative of the whole sample in terms of age (mean 48 (SD 5) years), sex (28% women), number of years in practice (mean 13 (SD 7)), proportion in rural practice (25% in rural practices), and number of patients screened during the study period (mean 177). The background variables of the sample did not differ significantly from the average Danish general practitioner.
The analysis identified doctors' experiences relating to the relevance of drinking problems identified by screening, the programme's acceptability to the patient and doctor, and the doctors' sense of the programme's effectiveness. The analysis also identified some conclusions on whether the screening and brief intervention could be recommended.
Should screening target young binge drinkers?
The identification by the screening of a large group of young hazardous drinkers surprised most of the doctors. Many doctors felt that the prevention of alcohol problems in young people should chiefly take place earlier and elsewhere in the community and in their families. The doctors felt that systematic interventions for young drinkers were not a natural part of their job, and they questioned the rationale of screening in young drinkers, because they often grow out of hazardous drinking: “Most of them [young patients]—it's something they get over and get through after all. They quit and come to heel, don't they?” (group 2). Some doctors did think it was important to deal with drinking among young people, but they found it difficult to do so.
Truthfulness of the patients' responses
Most doctors were convinced that some patients did not respond honestly to the AUDIT questionnaire. Many heavy drinkers declined screening or gave poor excuses for not being able to participate, or they gave obviously false answers to the screening questions. Several doctors from smaller communities conveyed descriptions from patients or staff of how word of the screening got around and how some patients avoided visiting the centre during that period: “Some patients give false answers. They get a low score and are not in for counselling, so we don't waste our energy on them. That's a good thing about the questionnaire” (group 1).
Effects on the doctor-patient relationship
Almost all the doctors experienced negative reactions from some patients, ranging from uneasiness or embarrassment and lying about their drinking behaviour to finding another doctor. However, most doctors considered their relationships with their patients robust enough for them to give systematic advice on sensible drinking. The doctors said that the few negative reactions were counterbalanced by a positive reaction in most patients, who felt that the screening was implemented out of concern for their health and wellbeing: “Most of them react positively to having a doctor who cares to deal with more than just the usual humdrum” (group 2).
However, most patients in the intervention group who revisited their general practitioner had not been followed up on their drinking. Some doctors felt that they had been intruding into the private life of their patient and needed to leave the subject for a while. Others could not give reasons for their not following up on excessive drinking among their patients.
Difficulties of counselling patients on drinking
All doctors agreed that counselling on health is an important part of their work and that it should continue to be so. They saw advice on alcohol as an important part of such counselling, despite the fact that counselling is not easy and that counselling on alcohol easily implies an unwanted moral dimension: “There is nothing new in it, is there? We are health counsellors, it's the main part of our everyday work, this is what we spend most of our time doing” (doctor 5).
Most doctors found that the screening conflicted with establishing rapport (especially among middle aged and elderly patients), because it set an agenda in advance. They were generally surprised at how difficult it was to generate rapport and to ensure compliance with interventions to address risky drinking behaviour or to reduce harm and to arrange follow up consultations. Explanations given by the doctors included that screening was a clinically insensitive way of finding alcohol problems, that they lacked the right communication skills for the task, and, in some cases, that their own attitudes were inappropriate.
Some doctors said that they felt they had been just part of a campaign and did not always feel comfortable with their role in it, which was almost that of a judge or examiner: “It's the view of the patient you need to tackle, and their motivation and thoughts, and I had some difficulties sitting there with a questionnaire that supplies you with a score. It's like taking an examination, you go to the teacher and you're supposed to be judged” (group 1).
Some doctors said that a few patients may have been encouraged to take steps to modify their drinking behaviour, but in general the doctors were deeply sceptical about the effect of the intervention on patients' drinking behaviour. The patients' lack of interest in the follow up consultations seemed to confirm this scepticism. The doctors said that if any response was evoked it was among a few middle aged and elderly patients who were already highly motivated to modify their drinking behaviour.
Practical and skills constraints
Two important barriers to the effectiveness of the programme seemed to be lack of time and lack of training. Screening and assessment became a major addition to the workload in many practices. Ten minutes of intervention several times a day was experienced as stressful by the doctors, and the stress influenced the quality of the intervention. Several doctors believed that 10 to 15 minutes was too little time anyway, as alcohol problems were often part of much more complex problems.
Many doctors questioned their own attitudes and skills. They felt that were they to improve their counselling skills they might become more effective as health counsellors, although this would take time and training: “Maybe this just tells us that we need to spend more time training in communication and things like that when we're having such a hard time talking to patients about such things” (doctor 4).
Both focus groups and four of the five doctors who were interviewed individually concluded that they could not recommend screening for excessive alcohol use, nor would they screen their patients in the future. One doctor said he would think about ways of using the screening questionnaire in his practice.
Three arguments prevailed. Firstly, the screening and brief intervention programme was seen as awkward to implement in the normal flow of a consultation. It disturbed the agenda, and patients seemed to be distracted from the subject that made them seek health care in the first place. Secondly, doctors could not work in their usual patient centred way because of the agenda setting imposed by the screening. Thirdly, the extra workload was too high, taking resources from other functions of general practice and in general disrupting the pattern of working together in the practice: “To me, just asking everybody about their drinking habits is in part comparable to if I had to do a rectal examination on all patients that came to see me” (group 2).