000094 10.3205/000094 urn:nbn:de:0183-0000949 Research Article Alterseffekt in Alkoholkonsumgewohnheiten bei norwegischen und deutschen Krankenhausärzten – eine Studie basierend auf landesweiten Erhebungen Rosta Rosta Judith J PhD

The Research Institute of the Norwegian Medical Association, PO Box 1152 Sentrum, 0107 Oslo, Norway, Phone: +47 – 23 10 90 62, Fax: +47 – 23 10 90 60The Research Institute of the Norwegian Medical Association, Oslo, Norway

judith.rosta@legeforeningen.no author Aasland Aasland Olaf G. OG Prof. MD, MHA

The Research Institute of the Norwegian Medical Association, Oslo, Norway Department of Health Management and Health Economics, University of Oslo, Norway

olaf.aasland@legeforeningen.no author German Medical Science GMS Publishing House

Düsseldorf

610 alcohol drinking patterns hospital doctors Norway Germany Alkoholkonsum Krankenhaus Ärzte Norwegen Deutschland 20091117 20100106 20100222 engl 1612-3174 8 GMS German Medical Science GMS Ger Med Sci 05 Ziel: Die Studie beschreibt und diskutiert die Alkoholkonsumgewohnheiten der jungen Generation der Krankenhausärzte in Norwegen und Deutschland – die Abstinenz, den häufigen Alkoholkonsum, das Rauschtrinken und den riskanten Alkoholkonsum.Methoden: Die Datengewinnung erfolgte auf Grundlage schriftlicher Erhebungen in Norwegen (2000) und Deutschland (2006). Die Auswertung baute auf einer repräsentativen Auswahl von 1898 deutschen und 602 norwegischen Krankenhausärzten im Alter von 27 bis 65 Jahren (N=2500). Alkoholkonsumgewohnheiten wurden mit den ersten drei Fragen von AUDIT in Norwegen und AUDIT-C in Deutschland erfasst, ein Punktwert von ≥5 (auf der Skala von 0 bis 12) war die Definition für riskanten Alkoholkonsum. Die Definition des Rauschtrinkens war ein Konsum von ≥5 Gläsern Alkohol mindestens einmal pro Woche. Die Definition des häufigen Alkoholkonsums war ein Konsum von Alkohol mindestens zweimal pro Woche. Die Definition der Abstinenz war kein Alkoholkonsum. Die Alkoholkonsumgewohnheiten wurden nach Geschlecht und Altersgruppen (27–44 Jahre und 45–65 Jahre) beschrieben. Ergebnisse: Im Vergleich zur Altergruppe der 45–65-jährigen tendierte die jüngere Altersgruppe (27–44 Jahre) zur höheren Abstinenzrate und zur niedrigen Rate von häufigem Alkoholkonsum, Rauschtrinken und riskantem Alkoholkonsum. Schlussfolgerung: Die jüngere Generation der Krankenhausärzte in Norwegen und Deutschland zeigte Tendenzen zu einem gesünderen Konsumverhalten. Änderungen im Arbeitsleben und in der persönlichen Einstellung gegenüber dem Alkoholkonsum dürften die vorliegenden Ergebnisse erklären. Aims: To describe and discuss the alcohol drinking patterns of the younger generation of hospital doctors in Norway and Germany – respectively the abstainers, frequent drinkers, episodic heavy drinkers and hazardous drinkers.Methods: Data were collected in nationwide postal surveys among doctors in Norway (2000) and Germany (2006). A representative sample of 1898 German and 602 Norwegian hospital doctors aged 27–65 years were included in the analyses (N=2500). Alcohol drinking patterns were measured using the first three items of AUDIT in Norway and the AUDIT-C in Germany, scores of ≥5 (ranking from 0 to 12) indicating hazardous drinking. Episodic heavy drinking was defined by the intake of ≥60g of ethanol, on one occasion, at least once a week. Frequent drinkers were who drank alcoholic beverages at least twice a week. Abstainers were persons who drank no alcohol. The analyses were performed separately for age groups (27–44 years versus 45–65 years) and genders.Results: Compared to the age groups 45 to 65 years in the Norwegian and German samples, the younger age groups (27–44 years) tend to have higher rates of abstainers, higher rates of infrequent drinking of moderate amount of alcoholic drinks, lower rates of episodic heavy drinking and lower rates of hazardous drinking. Conclusion: The younger generation of hospital doctors in Norway and Germany showed tendencies to healthier drinking habits. Changes in professional life, and in the attitude towards alcohol consumption, may go some way towards explaining these findings. IntroductionPrevious investigations among doctors have identified the older age group as one of the important factors for harmful alcohol consumption , , , , , . Why the young age group of doctors tends to have less risk for harmful drinking, is still an unexplored field. Answers to this question would be interesting, as it is shown that within the general population (at least in many European countries) harmful drinking among younger adults is on the rise , . Since data across different drinking cultures suggest similar age patterns in doctors' alcohol consumption , , , , , , there may be common conditions for lower risk among younger doctors compared to older doctors that could be further analyzed in an intercultural context. A comparison of previous studies is limited by methodological differences. Yet, it is possible to perform reliable analyses between Norway and Germany. Comparable measurement methods and items on drinking patterns were used in nation-wide surveys among doctors in Norway in 2000, and in Germany in 2006. There are some differences in the cultural importance of drinking in these two countries – i.e. lower annual sales of pure alcohol per inhabits aged 15+ years (12.9 liter vs. 5.8 liter) , higher rate of abstainers (11–15% vs. 4.3–5.9%) , and lower rate of heavy drinkers (3.0–5.2% vs. 11.2–11.3%) in Norway than in Germany. These make analyses of the alcohol drinking patterns of the younger and older generation of doctors interesting. Because the German sample includes hospital doctors only, the present study will be limited to this category. Yet, there is clearly a need for research that aims at the entire population of hospital doctors. Recent studies focus on medical students, GPs, certain specialties or healthcare professionals in general , , , , , , , , , – with little attention given to hospital doctors . Hospital doctors constitute the largest group among doctors work force. They have a key role both in treating and prevention diseases – including alcohol-related diseases . And how much effort a doctor spends on prevention against harmful drinking depends also on own individual alcohol consumption . The aim of the study is to describe and discuss the alcohol drinking patterns of the younger generation of hospital doctors in Norway and Germany – divided into abstainers, frequent drinkers, episodic heavy drinkers and hazardous drinkers. MethodsProcedure, setting and sampleIn both countries the questions on alcohol habits were parts of more comprehensive questionnaires on doctors' health and work condition. In Norway the questionnaire was disseminated in 2000, with one reminder, from The Research Institute of The Norwegian Medical Association to 1616 Norwegian doctors. In Germany, the questionnaire was sent from the German Hospital Institute in 2006 with no reminder to 3295 hospital doctors. The response rates were 86% (1385/1616) in Norway and 58.2% (1917/3295) in Germany. Only hospital doctors between 27 and 65 years of age were included in this study. Thus, the combined sample comprised 2500 hospital doctors: 602 Norwegian and 1898 German. The gender distribution and the mean age were comparable between the two countries (Table 1 ).QuestionnaireAlcohol drinking patterns were identified using a slightly modified version of the Alcohol Use Disorders Identification Test (AUDIT) in Norway and the Alcohol Use Disorders Identification Test, version C (AUDIT-C) in Germany. According to a current review, the AUDIT-C is comparable to the original AUDIT in terms of sensitivity and specificity . In addition, the AUDIT and the AUDIT-C were found to function well in different national and cultural settings. Both inventories included comparable questions on frequency and amount of alcohol consumption and frequency of drinking 60g of ethanol, or more, on a single occasion (Table 2 ). The scores on the Norwegian items were re-coded from 1–7 to 0–4. The maximum sum score is 12. The choice of a cut-off point for hazardous drinking is influenced by national and cultural standards; and may vary from ≥3 to ≥6 , , , , , . A score of ≥5 points for females and males was found to be appropriate cut-off point in the population of northern Germany . A cut-off of ≥5 points is also recommended by Institute of Health and Society at the Newcastle University in the United Kingdom . Thus, ≥5 points was used as an indicator of hazardous drinking in the present study. Episodic heavy drinking was defined as drinking ≥60g of ethanol on one occasion at least once a week. Frequent drinkers were those who drank alcoholic beverages at least twice a week. Abstainers were those who had not used any alcohol during the last year. AnalysesDifferences between countries, females and males, and age groups (27–44 years vs. 45–65 years) were tested in 2 by 2 tables using Fishers' Exact Test. ResultsTable 3 describes the age-related differences in alcohol drinking patterns of female and male Norwegian and German hospital doctors. With one exception the younger age group (27 to 44 years) had higher rates of abstainers, higher rates of infrequent drinking of moderate amount of alcoholic drinks, lower rates of episodic heavy drinking and lower rates of hazardous drinking, compared to the age group 45 to 65 years. The exception was Norwegian female doctors, where both age groups had the same rates of abstainers. Moreover, the younger age group of Norwegian female doctors had a higher quantity of alcohol intake by infrequent drinking than the older. But the majority of female doctors in both countries, 60 to 80 percent, reported a moderate and infrequent drinking pattern (1–2 drinks less than twice a week). The age-related differences in alcohol drinking patterns are clear, although not all differences were statistically significant. Independent of age group, gender and nationality, the majority of hospital doctors in Norway and Germany consumed alcoholic beverages, and they drank mostly at a non-hazardous level. Specifically the female doctors among them were found to have lower numbers of episodic heavy drinkers and hazardous drinkers. According to nationality, abstinence was more prevalent among German doctors. German doctors tended to frequently drink 1–2 drinks per occasion, and Norwegian doctors to infrequently drink 3–4 drinks per occasion. The percentage of episodic heavy or hazardous drinking was higher in the Norwegian than the German sample, except for the sub-group of male doctors aged 27–44 years, where the differences were minimal. DiscussionThe study describes the drinking patterns among hospital doctors in Norway and Germany. Consistent with other research , , , , , , hazardous drinking was less prevalent among the younger age groups. The present investigation adds knowledge on possible predictors of non hazardous drinking among doctors. Most young female and male hospital doctors (27–44 vs. 45–65 years) tend to report higher rates of abstinence, higher rates of infrequent drinking and lower rates of episodic heavy drinking. These tendencies were observed both in the German and Norwegian samples. The healthier drinking patterns of the young hospital doctors in Germany and Norway may reflect a number of common factors. Culture plays an important role in defining normative drinking patterns , , which was also verified among doctors . It was concretely shown that the work place culture, including job conditions and gender mix within medical specialties , may accept or encourage doctors' drinking. Thus, one reason for healthier drinking among young doctors lies in differences in workplace culture. Indeed, several regulations of financial structure, organization and management system of German and Norwegian hospitals have been implemented during the last decade, as well as in many other European countries. This process has also influenced the work conditions of hospital doctors , . Increasing workload, time pressure and work hours – particularly among young doctors – have been widely discussed both in Germany , and Norway . In this context, a reduced opportunity for frequent alcohol consumption and episodic heavy drinking is likely. Also, long work hours automatically reduces time spent on social activities , and spending less time with friends is a predictor of less frequent alcohol consumption in a study on health-related behavior among young people .One could argue that work time overload and unbalanced work-home interface may also lead to stress among doctors , , , and that alcohol may be used to reduce stress , , . However, drinking norms may also reflect the gender composition at the workplace . Previous studies from Germany and Norway have shown, for example, that doctors working in a specialty with the lower percentage of male doctors (non-surgical specialties vs. surgical specialties) were significantly less likely to drink heavily. Thus, it is possible that the growing presence of women in the medical profession in Norway as well as in Germany also accounts for the lower prevalence of heavy drinking in our sample. Another plausible explanation for the healthier drinking patterns among young hospital doctors in Norway and Germany might be a general shift in attitudes regarding alcohol consumption. A new life-style trend among doctors in Scotland , and a changed attitude in medical circles towards alcohol – from positive to negative – in Canada have been observed throughout the last decades. Data from England and Wales show a remarkable decrease in alcohol-related mortality for male doctors from the 1960s to 2005. Similarly, male doctors in California were among the occupations with low mortality rates from liver cirrhosis. Previous analyses in Norway and Germany have shown that the level of alcohol consumption is not higher among doctors than among comparable groups in the adult population. In another Norwegian study, young doctors were found to be more aware of the dangers of alcohol use as a public health problem , and they were also less likely to be hazardous drinkers in the Young Doctors Cohort in 2003 than in 1993 , . The study yielded a noteworthy result. A higher number of abstainers was found in the younger age groups in both countries – except in the case of female Norwegian doctors, where the number of abstainers was similar in both age groups. If we consider higher educational level and lower age in the Norwegian and German adult populations as factors associated with non-abstinence , , these results become more than interesting. It is also remarkable that the prevalence of abstinence among doctors in Germany is between 6 and 10 percent, while the adult German population has fewer abstainers than the Norwegian (5.5% vs. 13%) , , . Although one might be led to assume that the higher proportion of younger doctors refraining from drinking alcohol might correlate with the steady influx of foreign doctors with a tradition of abstinence, this does not seem to be the case. Eighty-five percent of foreign doctors in Norway originally came from Nordic or other European countries , and the majority of immigrant doctors in Germany come from Austria or the eastern European countries . It has not been possible, however, to determine the percentage of doctors with a cultural background with a tradition of abstinence. Strengths and limitationsThe study’s main strength is the representative dataset, the results of which should be generalizable for the entire population of hospital doctors in Germany and Norway. The high validity of the questionnaires, comparable items on drinking patterns and similarities in measurement methods should also be pointed out. One limitation is the lower response rate among German doctors which might reflect a lower willingness to participate in surveys compared with other Europeans . Nevertheless, it should be noted that, despite the fact that no reminder was sent in Germany, the response rate of 58.2% was better than in previous surveys of German doctors . We know from other studies that non-respondents generally drink more or that alcohol misuse is more common in this group , if we were to take the general underestimation of alcohol consumption into consideration – about 40–60% without much variation between nationalities – the proportion of episodic heavy drinkers and hazardous drinkers could be even greater in this study. A further limitation is the different time-frames of the surveys, with a six year gap (2000 and 2006). The self-rating scales could also have an effect on the results. However, both measurement instruments of alcohol drinking patterns – AUDIT and AUDIT-C – are thoroughly validated and widely used in different national and cultural settings , , , . The possible age-related differences in socially desirable responding should be also noted. It might be that younger doctors had answered the questions more in socially desirable direction – i.e. they were more likely to underreport alcohol consumption and deny having engaged in episodic heavy drinking. Many younger hospital doctors have time-limited contract at the beginning of their career, and it could be a reason to present themselves in a more favorable light. Another concern is that we described the alcohol drinking patterns for age groups and genders. Since alcohol consumption varies with personality, marital status, the presence of children and medical specialty, it would be important to include these as covariates in future investigations – something which was not possible in the present study. In addition, the understanding the nature of the young doctors' working culture and the factors related to drinking patterns might be improved by closely studying the alcohol drinking of comparable socio-economic groups. Because the long term effects of stressful working conditions within the medical profession (e.g. high intensity of work, heavy professional responsibility, exhaustion in relation to long hours and sleep deprivation on-call) can result in several health issues including harmful alcohol consumption in the elderly group , , , , , , , it may especially be interesting to see whether the seemingly increasing tendency to moderation in alcohol habits will continue. ConclusionsThe younger generation of doctors in Norway and Germany, the group aged 27 to 44 years compared with 45 to 65 years, shows healthier drinking patterns. A certain "feminisation" of the profession, increasing workload, long work days, a shift in attitudes towards drinking from positive to negative, and new lifestyle trends might to some degree account for these observations. Although there is some evidence that, in the future, doctors will have even less drinking problems than today, special attention still needs to be paid on the medical profession, and in particular middle aged male doctors. NotesConflicts of interestNone declared.AcknowledgementThe authors wish to thank all hospital doctors who have supported this study by participating. The Norwegian Survey among Doctors, data analyses and writing of this article were founded by the Research Institute of the Norwegian Medical Association. The data collection among German doctors was supported by the German Research Foundation (DFG). None of the funders had any role in the design of this study, data collection, data analysis and interpretation, written the article or the decision to submit the article for publication. Juntunen J Asp S Olkinuora M Aärimaa M Strid L Kauttu K Doctors' drinking habits and consumption of alcohol 1988 BMJ 951-4 Juntunen J, Asp S, Olkinuora M, Aärimaa M, Strid L, Kauttu K. Doctors' drinking habits and consumption of alcohol. BMJ. 1988;297(6654):951-4. DOI: 10.1136/bmj.297.6654.951 http://dx.doi.org/10.1136/bmj.297.6654.951 McAuliffe WE Wechsler H Rohman M Soboroff SH Fishman P Toth D Friedman R Psychoactive drug use by young and future physicians 1984 J Health Soc Behav 34-54 McAuliffe WE, Wechsler H, Rohman M, Soboroff SH, Fishman P, Toth D, Friedman R. Psychoactive drug use by young and future physicians. J Health Soc Behav. 1984;25(1):34-54. DOI: 10.2307/2136703 http://dx.doi.org/10.2307/2136703 McAuliffe WE Rohman M Breer P Wyshak G Santangelo S Magnuson E Alcohol use and abuse in random samples of physicians and medical students 1991 Am J Public Health 177-82 McAuliffe WE, Rohman M, Breer P, Wyshak G, Santangelo S, Magnuson E. Alcohol use and abuse in random samples of physicians and medical students. Am J Public Health. 1991;81(2):177-82. DOI: 10.2105/AJPH.81.2.177 http://dx.doi.org/10.2105/AJPH.81.2.177 Harrison D Chick J Trends in alcoholism among male doctors in Scotland 1994 Addiction 1613-7 Harrison D, Chick J. Trends in alcoholism among male doctors in Scotland. Addiction. 1994;89(12):1613-7. DOI: 10.1111/j.1360-0443.1994.tb03762.x http://dx.doi.org/10.1111/j.1360-0443.1994.tb03762.x Rosta J Aasland OG Female surgeons' alcohol use: a study of a national sample of norwegian doctors 2005 Alcohol Alcohol 436-40 Rosta J, Aasland OG. Female surgeons' alcohol use: a study of a national sample of norwegian doctors. Alcohol Alcohol. 2005;40(5):436-40. DOI: 10.1093/alcalc/agh186 http://dx.doi.org/10.1093/alcalc/agh186 Sebo P Bouvier Gallacchi M Goehring C Künzi B Bovier PA Use of tobacco and alcohol by Swiss primary care physicians: a cross-sectional survey 2007 BMC Public Health 5 Sebo P, Bouvier Gallacchi M, Goehring C, Künzi B, Bovier PA. Use of tobacco and alcohol by Swiss primary care physicians: a cross-sectional survey. BMC Public Health. 2007;7:5. DOI: 10.1186/1471-2458-7-5 http://dx.doi.org/10.1186/1471-2458-7-5 Leifman H Osterberg E Ramstedt M 2002 Alcohol in Postwar Europe, ECAS II: A discussion of indicators on alcohol consumption and alcohol-related harm Leifman H, Osterberg E, Ramstedt M. Alcohol in Postwar Europe, ECAS II: A discussion of indicators on alcohol consumption and alcohol-related harm. Stockholm: Edita Ljunglöfs; 2002. Rehm J Taylor B Patra J Volume of alcohol consumption, patterns of drinking and burden of disease in the European region 2002 2006 Addiction 1086-95 Rehm J, Taylor B, Patra J. Volume of alcohol consumption, patterns of drinking and burden of disease in the European region 2002. Addiction. 2006;101(8):1086-95. DOI: 10.1111/j.1360-0443.2006.01491.x http://dx.doi.org/10.1111/j.1360-0443.2006.01491.x World Health Organization 2004 Global Status Report on Alcohol 2004 World Health Organization. Global Status Report on Alcohol 2004. Geneva: World Health Organization, Department of Mental Health and Substance Abuse; 2004. Kraus L Augustin R Repräsentativerhebung zum Gebrauch psychoaktiver Substanzen bei Erwachsenen in Deutschland 2000 [Population Survey on the Consumption of Psychoactive Substances in the German Adult Population 2000] 2001 Sucht 35-43 Kraus L, Augustin R. Repräsentativerhebung zum Gebrauch psychoaktiver Substanzen bei Erwachsenen in Deutschland 2000 [Population Survey on the Consumption of Psychoactive Substances in the German Adult Population 2000]. Sucht. 2001;47(Sonderheft 1):35-43. Horverak Ø Bye EK 2007 Det norske drikkemønstret. En studie basert på intervjudata fra 1973-2004 [The Norwegian Drinking Pattern. Study based on interview data from 1973-2004] Horverak Ø, Bye EK. Det norske drikkemønstret. En studie basert på intervjudata fra 1973-2004 [The Norwegian Drinking Pattern. Study based on interview data from 1973-2004]. Oslo: Statens institutt for rusmiddelforskning; 2007. Gulbrandsen P Aasland OG Endringer i norske legers alkoholvaner 1985-2000 [Changes in drinking habits among Norwegian doctors 1985-2000] 2002 Tidsskr Nor Laegeforen 2791-4 Gulbrandsen P, Aasland OG. Endringer i norske legers alkoholvaner 1985-2000 [Changes in drinking habits among Norwegian doctors 1985-2000]. Tidsskr Nor Laegeforen. 2002;122(29):2791-4. Kenna GA Lewis DC Risk factors for alcohol and other drug use by healthcare professionals 2008 Subst Abuse Treat Prev Policy 3 Kenna GA, Lewis DC. Risk factors for alcohol and other drug use by healthcare professionals. Subst Abuse Treat Prev Policy. 2008;3:3. DOI: 10.1186/1747-597X-3-3 http://dx.doi.org/10.1186/1747-597X-3-3 Borschos B Kühlhorn E Rydberg U [Alcohol and drug use among medical students 1995: more than every tenth male student had hazardous alcohol drinking habits] 1999 Lakartidningen 3253-8 Borschos B, Kühlhorn E, Rydberg U. [Alcohol and drug use among medical students 1995: more than every tenth male student had hazardous alcohol drinking habits]. Lakartidningen. 1999;96(28-29):3253-8. Kjøbli J Tyssen R Vaglum P Aasland O Grønvold NT Ekeberg O Personality traits and drinking to cope as predictors of hazardous drinking among medical students 2004 J Stud Alcohol 582-5 Kjøbli J, Tyssen R, Vaglum P, Aasland O, Grønvold NT, Ekeberg O. Personality traits and drinking to cope as predictors of hazardous drinking among medical students. J Stud Alcohol. 2004;65(5):582-5. Frank E Elon L Naimi T Brewer R Alcohol consumption and alcohol counselling behaviour among US medical students: cohort study 2008 BMJ a2155 Frank E, Elon L, Naimi T, Brewer R. Alcohol consumption and alcohol counselling behaviour among US medical students: cohort study. BMJ. 2008;337:a2155. DOI: 10.1136/bmj.a2155 http://dx.doi.org/10.1136/bmj.a2155 Bíró E Balajti I Adány R Kósa K [Survey of the state of health and health behavior among medical students in Hungary] 2008 Orv Hetil 2165-71 Bíró E, Balajti I, Adány R, Kósa K. [Survey of the state of health and health behavior among medical students in Hungary]. Orv Hetil. 2008;149(46):2165-71. Abuissa H Lavie C Spertus J O'Keefe J Jr Personal health habits of American cardiologists 2006 Am J Cardiol 1093-6 Abuissa H, Lavie C, Spertus J, O'Keefe J Jr. Personal health habits of American cardiologists. Am J Cardiol. 2006;97(7):1093-6. DOI: 10.1016/j.amjcard.2005.10.057 http://dx.doi.org/10.1016/j.amjcard.2005.10.057 Hitchins J Do General Practitioners misuse alcohol? A crosssectional study of alcohol usage amongst GPs in Kent, UK 2008 2008 BMA-AMA-CMA International Conference on Doctors Health 76 Hitchins J. Do General Practitioners misuse alcohol? A crosssectional study of alcohol usage amongst GPs in Kent, UK. In: British Medical Association. 2008 BMA-AMA-CMA International Conference on Doctors Health. Doctors Health Matters - Finding the Balance. Abstracts. London: British Medical Association; 2008. p. 76. Rosta J Hazardous alcohol use among hospital doctors in Germany 2008 Alcohol Alcohol 198-203 Rosta J. Hazardous alcohol use among hospital doctors in Germany. Alcohol Alcohol. 2008;43(2):198-203. DOI: 10.1093/alcalc/agm180 http://dx.doi.org/10.1093/alcalc/agm180 Tobias JS Hospital doctor's role in the Health of the Nation 1995 BMJ 889 Tobias JS. Hospital doctor's role in the Health of the Nation. BMJ. 1995;310(6984):889. Cherpitel CJ Ye Y Drug use and problem drinking associated with primary care and emergency room utilization in the US general population: data from the 2005 national alcohol survey 2008 Drug Alcohol Depend 226-30 Cherpitel CJ, Ye Y. Drug use and problem drinking associated with primary care and emergency room utilization in the US general population: data from the 2005 national alcohol survey. Drug Alcohol Depend. 2008;97(3):226-30. DOI: 10.1016/j.drugalcdep.2008.03.033 http://dx.doi.org/10.1016/j.drugalcdep.2008.03.033 Saunders JB Aasland OG Babor TF de la Fuente JR Grant M Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption--II 1993 Addiction 791-804 Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption--II. Addiction. 1993;88(6):791-804. DOI: 10.1111/j.1360-0443.1993.tb02093.x http://dx.doi.org/10.1111/j.1360-0443.1993.tb02093.x Bush K Kivlahan DR McDonell MB Fihn SD Bradley KA The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test 1998 Arch Intern Med 1789-95 Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med. 1998;158(16):1789-95. DOI: 10.1001/archinte.158.16.1789 http://dx.doi.org/10.1001/archinte.158.16.1789 Reinert DF Allen JP The alcohol use disorders identification test: an update of research findings 2007 Alcohol Clin Exp Res 185-99 Reinert DF, Allen JP. The alcohol use disorders identification test: an update of research findings. Alcohol Clin Exp Res. 2007;31(2):185-99. DOI: 10.1111/j.1530-0277.2006.00295.x http://dx.doi.org/10.1111/j.1530-0277.2006.00295.x Frank D DeBenedetti AF Volk RJ Williams EC Kivlahan DR Bradley KA Effectiveness of the AUDIT-C as a screening test for alcohol misuse in three race/ethnic groups 2008 J Gen Intern Med 781-7 Frank D, DeBenedetti AF, Volk RJ, Williams EC, Kivlahan DR, Bradley KA. Effectiveness of the AUDIT-C as a screening test for alcohol misuse in three race/ethnic groups. J Gen Intern Med. 2008;23(6):781-7. DOI: 10.1007/s11606-008-0594-0 http://dx.doi.org/10.1007/s11606-008-0594-0 Dawson DA Grant BF Stinson FS Zhou Y Effectiveness of the derived Alcohol Use Disorders Identification Test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population 2005 Alcohol Clin Exp Res 844-54 Dawson DA, Grant BF, Stinson FS, Zhou Y. Effectiveness of the derived Alcohol Use Disorders Identification Test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population. Alcohol Clin Exp Res. 2005;29(5):844-54. DOI: 10.1097/01.ALC.0000164374.32229.A2 http://dx.doi.org/10.1097/01.ALC.0000164374.32229.A2 Gual A Segura L Contel M Heather N Colom J Audit-3 and audit-4: effectiveness of two short forms of the alcohol use disorders identification test 2002 Alcohol Alcohol 591-6 Gual A, Segura L, Contel M, Heather N, Colom J. Audit-3 and audit-4: effectiveness of two short forms of the alcohol use disorders identification test. Alcohol Alcohol. 2002;37(6):591-6. DOI: 10.1093/alcalc/37.6.591 http://dx.doi.org/10.1093/alcalc/37.6.591 Institute of Health and Society of Newcastle University 2006 Screening tools for alcohol related risk Produced by Design Services Institute of Health and Society of Newcastle University. Screening tools for alcohol related risk Produced by Design Services. Newcastle: Design Services, Gateshead Council, 2006. Nordqvist C Johansson K Bendtsen P Routine screening for risky alcohol consumption at an emergency department using the AUDIT-C questionnaire 2004 Drug Alcohol Depend 71-5 Nordqvist C, Johansson K, Bendtsen P. Routine screening for risky alcohol consumption at an emergency department using the AUDIT-C questionnaire. Drug Alcohol Depend. 2004;74(1):71-5. DOI: 10.1016/j.drugalcdep.2003.11.010 http://dx.doi.org/10.1016/j.drugalcdep.2003.11.010 Bradley KA DeBenedetti AF Volk RJ Williams EC Frank D Kivlahan DR AUDIT-C as a brief screen for alcohol misuse in primary care 2007 Alcohol Clin Exp Res 1208-17 Bradley KA, DeBenedetti AF, Volk RJ, Williams EC, Frank D, Kivlahan DR. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol Clin Exp Res. 2007;31(7):1208-17. DOI: 10.1111/j.1530-0277.2007.00403.x http://dx.doi.org/10.1111/j.1530-0277.2007.00403.x Rumpf HJ Hapke U Meyer C John U Screening for alcohol use disorders and at-risk drinking in the general population: psychometric performance of three questionnaires 2002 Alcohol Alcohol 261-8 Rumpf HJ, Hapke U, Meyer C, John U. Screening for alcohol use disorders and at-risk drinking in the general population: psychometric performance of three questionnaires. Alcohol Alcohol. 2002;37(3):261-8. DOI: 10.1093/alcalc/37.3.261 http://dx.doi.org/10.1093/alcalc/37.3.261 Room R Intoxication and bad behaviour: understanding cultural differences in the link 2001 Soc Sci Med 189-98 Room R. Intoxication and bad behaviour: understanding cultural differences in the link. Soc Sci Med. 2001;53(2):189-98. DOI: 10.1016/S0277-9536(00)00330-0 http://dx.doi.org/10.1016/S0277-9536(00)00330-0 Gmel G Rehm J Frick U Trinkmuster, Pro-Kopf-Konsum von Alkohol und koronare Mortalität [Per capita volume of alcohol consumption, patterns of drinking and coronary heart disease mortality 2003 Sucht 95-104 Gmel G, Rehm J, Frick U. Trinkmuster, Pro-Kopf-Konsum von Alkohol und koronare Mortalität [Per capita volume of alcohol consumption, patterns of drinking and coronary heart disease mortality. Sucht. 2003;49(2):95-104. Aasland OG Wiers-Jenssen J Norske medisinstudenter i utlandet-karriereplaner, personlighet, røykning og alkoholbruk [Norwegian medical students abroad--career plans, personality, smoking and alcohol use] 2001 Tidsskr Nor Laegeforen 1677-82 Aasland OG, Wiers-Jenssen J. Norske medisinstudenter i utlandet-karriereplaner, personlighet, røykning og alkoholbruk [Norwegian medical students abroad--career plans, personality, smoking and alcohol use]. Tidsskr Nor Laegeforen. 2001;121(14):1677-82. Brooke D Why do some doctors become addicted? 1996 Addiction 317-9 Brooke D. Why do some doctors become addicted? Addiction. 1996;91(3):317-9. DOI: 10.1111/j.1360-0443.1996.tb02281.x http://dx.doi.org/10.1111/j.1360-0443.1996.tb02281.x Aasland OG Rosta J Nylenna M Health care reforms and job satisfaction among doctors in Norway Scand J Public Health Aasland OG, Rosta J, Nylenna M. Health care reforms and job satisfaction among doctors in Norway. Scand J Public Health. Forthcoming. Rosta J Nylenna M Aasland OG Job satisfaction among hospital doctors in Norway and Germany. A comparative study on national samples 2009 Scand J Public Health 503-8 Rosta J, Nylenna M, Aasland OG. Job satisfaction among hospital doctors in Norway and Germany. A comparative study on national samples. Scand J Public Health. 2009;37(5):503-8. DOI: 10.1177/1403494809106504 http://dx.doi.org/10.1177/1403494809106504 Marburger Bund 2006-2008 Ärzte-Streik 2006-2008 [Doctors-strike 2006-2008] Marburger Bund. Ärzte-Streik 2006-2008 [Doctors-strike 2006-2008]. [updated 2008 Sept 15; cited 2008 Sept 20]. Available from: http://www.marburgerbund.de/marburgerbund/bundesverband/unsere_themen/tarifpolitik/vka/tarifrunde2008/index.php. http://www.marburgerbund.de/marburgerbund/bundesverband/unsere_themen/tarifpolitik/vka/tarifrunde2008/index.php Rosta J Hospital Doctors' Working Hours in Germany 2007 Dtsch Arztebl Rosta J. Hospital Doctors' Working Hours in Germany. Dtsch Arztebl. 2007;104(36):A-2417. Available from: http://www.aerzteblatt.de/int/article.asp?id=58149. http://www.aerzteblatt.de/int/article.asp?id=58149 Befring A Misvisende pastander om legelønn [Misleading claims about doctors' salary] 2006 Tidsskr Nor Laegeforen 1374-5 Befring A. Misvisende pastander om legelønn [Misleading claims about doctors' salary]. Tidsskr Nor Laegeforen. 2006;126(10):1374-5. Burke RJ 2006 Research Companion to Working Time and Work Addiction Burke RJ, editor. Research Companion to Working Time and Work Addiction. Cheltenham: Edward Elgar Publishing; 2006. World Health Organization 2000 Health and Health Behaviour Among Young People (EUR/ICP/IVST 060305A) World Health Organization. Health and Health Behaviour Among Young People (EUR/ICP/IVST 060305A). Copenhagen: World Health Organization; 2000. Richardsen AM Burke RJ Occupational stress and job satisfaction among physicians: sex differences 1991 Soc Sci Med 1179-87 Richardsen AM, Burke RJ. Occupational stress and job satisfaction among physicians: sex differences. Soc Sci Med. 1991;33(10):1179-87. DOI: 10.1016/0277-9536(91)90234-4 http://dx.doi.org/10.1016/0277-9536(91)90234-4 Falkum E Gjerberg E Hofoss D Aasland OG [Time stress among Norwegian physicians] 1997 Tidsskr Nor Laegeforen 954-9 Falkum E, Gjerberg E, Hofoss D, Aasland OG. [Time stress among Norwegian physicians]. Tidsskr Nor Laegeforen. 1997;117(7):954-9. Røvik JO Tyssen R Hem E Gude T Ekeberg O Moum T Vaglum P Job stress in young physicians with an emphasis on the work-home interface: a nine-year, nationwide and longitudinal study of its course and predictors 2007 Ind Health 662-71 Røvik JO, Tyssen R, Hem E, Gude T, Ekeberg O, Moum T, Vaglum P. Job stress in young physicians with an emphasis on the work-home interface: a nine-year, nationwide and longitudinal study of its course and predictors. Ind Health. 2007;45(5):662-71. DOI: 10.2486/indhealth.45.662 http://dx.doi.org/10.2486/indhealth.45.662 British Medical Association 1992 Stress and the Medical Profession British Medical Association. Stress and the Medical Profession. London: British Medical Association; 1992. Tyssen R Vaglum P Aasland OG Grønvold NT Ekeberg O Use of alcohol to cope with tension, and its relation to gender, years in medical school and hazardous drinking: a study of two nation-wide Norwegian samples of medical students 1998 Addiction 1341-9 Tyssen R, Vaglum P, Aasland OG, Grønvold NT, Ekeberg O. Use of alcohol to cope with tension, and its relation to gender, years in medical school and hazardous drinking: a study of two nation-wide Norwegian samples of medical students. Addiction. 1998;93(9):1341-9. DOI: 10.1046/j.1360-0443.1998.93913415.x http://dx.doi.org/10.1046/j.1360-0443.1998.93913415.x Shore ER Drinking patterns and problems among women in paid employment 1992 Alcohol and Health and Research World 160-4 Shore ER. Drinking patterns and problems among women in paid employment. Alcohol and Health and Research World. 1992;16(2):160-4. Den norske legeforening Legestatistikk (Statitics about doctors) Den norske legeforening. Legestatistikk (Statitics about doctors). [updated 2009 Sept 28; cited 2009 Oct 12]. Available from: http://www.legeforeningen.no/id/18.0. http://www.legeforeningen.no/id/18.0 Bundesärztekammer 2008 Ärztestatistik 2008 (Statistics about doctors 2008) Bundesärztekammer. Ärztestatistik 2008 (Statistics about doctors 2008). [updated 2009 Apr 22; cited 2009 Oct 12] Available from: http://www.bundesaerztekammer.de/page.asp?his=0.3.7128.7130. http://www.bundesaerztekammer.de/page.asp?his=0.3.7128.7130 Albuquerque J Alcohol and doctors: from Beauty to Beast 2008 2008 BMA-AMA-CMA International Conference on Doctors Health 77-8 Albuquerque J. Alcohol and doctors: from Beauty to Beast. In: British Medical Association. 2008 BMA-AMA-CMA International Conference on Doctors Health. Doctors Health Matters - Finding the Balance. Abstracts. London: British Medical Association; 2008. p.77-8. Romeri E Baker A Griffiths C Alcohol-related deaths by occupation, England and Wales, 2001-05 2007 Health Stat Q 6-12 Romeri E, Baker A, Griffiths C. Alcohol-related deaths by occupation, England and Wales, 2001-05. Health Stat Q. 2007;(35):6-12. Leigh JP Jiang WY Liver cirrhosis deaths within occupations and industries in the California occupational mortality study 2006 Addiction 767-79 Leigh JP, Jiang WY. Liver cirrhosis deaths within occupations and industries in the California occupational mortality study. Addiction. 2006;88(6): 767-79. DOI: 10.1111/j.1360-0443.1993.tb02091.x http://dx.doi.org/10.1111/j.1360-0443.1993.tb02091.x Aasland OG Amundsen A Bruusgaard D Jervell J Mørland J Norske legers alkoholvaner (Drinking habits among Norwegian physicians) 1988 Nord Med 85-9 Aasland OG, Amundsen A, Bruusgaard D, Jervell J, Mørland J. Norske legers alkoholvaner (Drinking habits among Norwegian physicians). Nord Med. 1988;103(3):85-9. Grotmol KS Vaglum P Ekeberg Ø Gude T Aasland OG Tyssen R Alcohol expectancy and hazardous drinking: a 6-year longitudinal and nationwide study of medical doctors 2010 Eur Addict Res 17-22 Grotmol KS, Vaglum P, Ekeberg Ø, Gude T, Aasland OG, Tyssen R. Alcohol expectancy and hazardous drinking: a 6-year longitudinal and nationwide study of medical doctors. Eur Addict Res. 2010;16(1):17-22. DOI: 10.1159/000253860 http://dx.doi.org/10.1159/000253860 Henkel D Zemlin U Dornbusch P Sozialschicht und Konsum von Alkohol und Tabak im Bundesgesundheitssurvey 1998 [Social class and consumption of alcohol and tobacco in the health survey] 2003 Sucht 306-11 Henkel D, Zemlin U, Dornbusch P. Sozialschicht und Konsum von Alkohol und Tabak im Bundesgesundheitssurvey 1998 [Social class and consumption of alcohol and tobacco in the health survey]. Sucht. 2003;49(5):306-11. Strand BH Steiro A Alkoholbruk, inntekt og utdanning i Norge 1993-2000 [Alcohol consumption in Norway by level of income and education, 1993-2000] 2003 Tidsskr Nor Laegeforen 2849-53 Strand BH, Steiro A. Alkoholbruk, inntekt og utdanning i Norge 1993-2000 [Alcohol consumption in Norway by level of income and education, 1993-2000]. Tidsskr Nor Laegeforen. 2003;123(20):2849-53. Kopetsch T The migration of doctors to and from Germany 2008 J Public Health 33-39 Kopetsch T. The migration of doctors to and from Germany. J Public Health. 2008;17:33-39. DOI: 10.1007/s10389-008-0208-7 http://dx.doi.org/10.1007/s10389-008-0208-7 Makela P Fonager K Hibell B Nordlund S Sabroe S Simpura J 1999 Drinking Habits in the Nordic Countries Makela P, Fonager K, Hibell B, Nordlund S, Sabroe S, Simpura J. Drinking Habits in the Nordic Countries. Oslo: National Institute for Alcohol and Drug Research; 1999. Midanik L The validity of self-reported alcohol consumption and alcohol problems: a literature review 1982 Br J Addict 357-82 Midanik L. The validity of self-reported alcohol consumption and alcohol problems: a literature review. Br J Addict. 1982;77(4):357-82. DOI: 10.1111/j.1360-0443.1982.tb02469.x http://dx.doi.org/10.1111/j.1360-0443.1982.tb02469.x Lemmens P 1991 Measurments and Distributions of Alcohol Consumption [Doctoral Thesis] Lemmens P. Measurments and Distributions of Alcohol Consumption [doctoral thesis]. Maastricht: University of Limburg; 1991. Riley GJ Understanding the stresses and strains of being a doctor 2004 Med J Aust 350-3 Riley GJ. Understanding the stresses and strains of being a doctor. Med J Aust. 2004;181(7):350-3. 11

Table 1: Study population

22

Table 2: Items and scores

33

Table 3: Alcohol drinking patterns of female and male Norwegian and German Hospital doctors aged 27–44 and 45–65 years, percent

3 0 0 0