One in 4 transplant hepatologists in the United States screens positive for unhealthy alcohol use

INTRODUCTION Alcohol use disorder (AUD) affects 10.2% of Americans,1 and rising rates of both AUD and alcohol-associated liver disease have provoked increased awareness among health care teams to offer evidence-based treatment options, including pharmacotherapy and psychotherapy, to affected patients. “Unhealthy alcohol use,” a term that encompasses a broad range of high-risk drinking behaviors,2 is unfortunately common (15.3%) among physicians,3 and linkages to a formal diagnosis of AUD as well as treatment should similarly be offered when it is suspected. Transplant hepatologists are susceptible to burnout4 and may be at high risk for unhealthy alcohol use. We aimed to highlight the prevalence of, and factors associated with, suspected unhealthy alcohol use among transplant hepatologists in the United States to better inform workplace health promotion. METHODS This is a secondary analysis of a 69-item survey designed to assess rates and predictors of burnout among practicing transplant hepatologists in the United States. Potential respondents were identified via the American Association for the Study of Liver Diseases member directory. Variables captured include domains of burnout (emotional exhaustion, depersonalization, and personal accomplishment), demographics (age, gender, years of practice, academic rank, marital status, geographic region, number of dependents, whether hepatologists receives assistance with dependents), practice characteristics, and psychological factors (whether medical errors were recently committed, positive affect, negative affect, and resilience). Other details regarding survey development and administration have been previously reported.4 Three questions comprising the Alcohol Use Disorders Identification Test (AUDIT-C) were used to assess alcohol drinking patterns. Given the heterogeneity in how unhealthy alcohol use is defined using AUDIT-C cutoffs, we applied 2 different definitions: definition 1: AUDIT-C of 3 or higher for women and 4 or higher for men, commonly used in the broad population,5 and definition 2: AUDIT-C of 4 or higher for women and 5 or higher for men, used in physician-based studies.6 A working group of transplant hepatologists (Jihane N. Benhammou, Jasleen Singh, Akshay Shetty, Hirsh D. Trivedi, Beshoy Yanny, Kamron Pourmand, and Arpan A. Patel) iteratively generated the final list of covariates deemed relevant to predicting unhealthy alcohol use. Age and academic rank were excluded due to multicollinearity with other variables and missing data, respectively. Analyses were conducted in R 4.3 (R Core Team, 2023). Multiple Imputation by Chained Equations from the MICE library was used to replace missing AUDIT-C scores for multivariate analysis. Imputed data were then entered into a linear regression to test predictors of a higher AUDIT-C score, which was treated as a continuous variable. We conducted additional exploratory analyses to examine the possibility of limited interactions. RESULTS A total of 185 responses (response rate = 25% of 738 practicing transplant hepatologists) were analyzed. Most were male (61%), 10 or fewer years out of practice (57%), married (82%), and from the Northeast (34%). Of the 179 with AUDIT-C scores, 47 (26.3%) hepatologists screened positive for unhealthy alcohol use using definition 1, while 20 (11.2%) screened positive using definition 2 (Figure 1). Most reported drinking at least 2 or more times a month (68%), fewer than 3 drinks on drinking days (95%), and without binge drinking (88%). Multivariate regression analysis revealed that male gender (standardized β-coefficient [βstd]: 1.51, 95% CI: 1.08–2.12), higher feelings of personal accomplishment (βstd: 1.29, 95% CI: 1.04–1.60), and being single, as opposed to divorced (βstd: 3.62, 95% CI: 1.58–8.27), were independently associated with higher AUDIT-C scores. Being divorced, as opposed to married (βstd: 0.37, 95% CI: 0.20–0.71), and bringing home additional hours of work (βstd: 0.55, 95% CI: 0.31–0.98) were independently associated with lower AUDIT-C scores (Supplemental Table, https://links.lww.com/HC9/C148). Testing of interactions between gender, marital status, and hours worked at home and their association with AUDIT-C scores yielded no significant changes in result patterns.FIGURE 1: Proportion of transplant hepatologists who screened positive for unhealthy alcohol use (N=179 responses). Abbreviation: AUDIT-C, Alcohol Use Disorders Identification Test.DISCUSSION We found that rates of unhealthy alcohol use among transplant hepatologists are lower than those reported among physicians (11.2% vs. 15.3%)7 but higher compared to the general population (26.3% vs. 25.5%).8 Bringing home additional hours of work was the only practice-related factor found to be associated with lower AUDIT-C scores in our analysis, while male gender was associated with more unhealthy alcohol use, patterns that align with US physician data.6,7 Paradoxically, increased feelings of personal accomplishment, rather than increased emotional exhaustion and depersonalization, were associated with higher AUDIT-C scores, counter to what was expected. While we believe our survey captured a relatively comprehensive set of variables related to practice settings and personal characteristics, it is possible that unmeasured confounders, such as stressors associated with working in a high-intensity transplant practice or managing complex patients, may have explained this association. To better understand this phenomenon, future qualitative inquiry may be indicated. Limitations to our study include a response rate of 25% and potential response bias in answering questions about alcohol use truthfully due to concerns about stigma, which may have underestimated the true prevalence of unhealthy alcohol use in our sample. At present, our findings suggest that modifying practice-related factors may not meaningfully alter patterns of alcohol use, but transplant teams should still have a heightened awareness that 1 in 4 transplant hepatologists may benefit from linkage to care that formally diagnoses and ultimately offers evidence-based treatments for AUD. Although we are not able to report whether transplant hepatologists with suspected unhealthy alcohol use in our sample received such care, our findings underscore the immense need for such services to be available. In the United States, state physician health programs often receive referrals from hospital systems or concerned colleagues, establish treatment and monitoring plans, and may liaise with the state medical board to determine probation or sanctions. The majority of physicians who undergo treatment through these programs remain licensed and continue working at long-term follow-up.9 We encourage transplant centers and leadership to normalize such linkage to care, as stigma and fear of professional consequences likely limit self-referrals, and to ensure that their physician workforce has access to the very same high-quality, confidential counseling and AUD treatments that are recommended to their patients.