‘When I was a GP trainee, a patient confided in me that she was drinking three litres of wine a day, and that she hadn’t told anyone about that before. She also revealed that she’d been abused as a child. This had led to depression and she’d taken overdoses. It’s very difficult to know what to do when people are in such difficult situations and I hadn’t a clue where to start.

'I went to the senior GP at the practice, who said that nothing was going to improve while she was still drinking. But I didn’t know how to help her stop drinking, and it was quite an overwhelming situation for her – and for me. It wasn’t that I was lacking empathy and desire to help this lady, but I had absolutely no idea how to go about it.’

Rachel Phillips is a GP in Portobello, a small seaside town on the outskirts of Edinburgh. She has been qualified quite a few years now and has much more experience than she did as a trainee. Yet dealing with the effect alcohol has on her patients is still a huge challenge for her, as it is for general practice as a whole.

That’s why she was keen to take on a role with SHAAP (Scottish Health Action on Alcohol Problems) that would see her develop resources for GPs in handling the many alcohol-related issues that land in their consulting rooms. This involved creating educational resources aimed squarely at GPs, which sought to destigmatise alcohol problems but also increase doctors’ confidence to handle them.

Dr Phillips, who was speaking just ahead of publication of the Scottish Government's new strategy on drugs and alcohol, says she was clear from the beginning of the project she wanted the educational resources to speak to GPs such as her – and that she was determined the tone would be helpful rather than hectoring.

‘Most of us are in this job with really good intentions, and we’re not trying to stigmatise, and we’re pretty exhausted,’ she says. ‘We’re doing our best to keep up empathy in quite a relentless job. So, I was thinking, “who is going to attend a lecture on needing to reduce stigma when they’re busy all the time?” I certainly wouldn’t. I’m pretty tired and low on empathy and doing my best and if I felt like I was being lectured on reducing my stigma it would be off-putting.

‘Most of us are trying to be kind in all our consultations and it’s not for lack of desire – it’s the pressures of the job, which you’re not going be able to solve in a video lecture.’

Working with SHAAP and the Royal College of GPs Scotland, she came up with the idea of a podcast series. ‘After a long day at work you’re not going to come home and put the computer on to watch a video but you might listen to a podcast while you’re walking the dogs or doing the dishes. It’s something you can fit into your life and if it is interesting interviews with people who are actually working on the subject and have some expertise that we could learn from, that would be more appealing.’

There are six episodes so far, with a seventh due to drop imminently (available on Spotify and through the SHAAP website) covering topics including the policy landscape around alcohol, the relationship between trauma and addiction, alcohol-related brain damage and recovery.

One is an interview with Maree Todd MSP, minister for drugs and alcohol policy and sport. ‘She was amazing,’ says Dr Phillips. ‘She spoke very openly about her own experiences of growing up in an alcoholic household, highlighting the effects on the whole family. She spoke about her parents’ recovery journeys and how both of them got sober from her teens onwards, and the hugely positive effect that had on her life trajectory.’

Speaking to Dr Phillips, one of the most striking things is the lessons that she herself took from making the podcasts and meeting the experts. ‘For example, it hadn’t really occurred to me that alcohol-related brain damage can be reversed for a good proportion of folk,’ she says. ‘There was a real message of hope coming through.’

Although she is referring here to hope for patients, there was also a sense that the information in the podcasts brings hope to GPs who might be despairing and uncertain about how they can help patients with alcohol problems. And one of the main lessons is that, actually, a GP’s role in a patient’s recovery is limited, and that it’s important to accept that.

‘One of the people I interviewed is an addictions specialist nurse and she was very practical about giving tips on how to improve our conversations with patients. She was very good at sticking to the patient’s agenda. I hadn’t realised quite how entrenched my well-intended but very clear “doctor” agenda is, which is that I’m really hoping for full sobriety [in the patient] and that’s what we’re aiming for. She points out that unless a goal comes from a patient, that’s not going to work, and that recovery can come in all shapes and sizes.’

Giving GPs a better idea of the neuroscience behind addiction can also help them to cope when patients attempt to put pressure on, for example, to be prescribed diazepam to support recovery.

‘Sometimes you’re told “if you don’t do that, I’m going to stop drinking anyway and if I have a fatal seizure it’s down to you”. You can feel you’re really letting someone down by not covering them for safe withdrawal.

'But once it’s been explained to you why that’s not safe, and that withdrawal needs to be managed by the appropriate team, and that the actual withdrawal is only a small part of the picture – if you’ve not built up your social capital and network, then it probably won’t work anyway, and you’ll relapse, and the more you go through withdrawal and relapse the worse it is for your brain – you can see there are good reasons behind having clear boundaries that GPs don’t prescribe diazepam for patients to safely withdraw at home because it can be dangerous and they could end up dying from that too. Then it becomes much easier to do your job.’

Throughout our conversation, Dr Phillips is keen to emphasise the project has been an educational experience for her as much as anyone else. ‘I’m a bit wary of somehow representing myself as an expert when it’s the opposite – I’m someone who struggles with this and so this has been helpful to me and hopefully it will help others too.’

So, is she now confident she can manage a consultation where a patient discloses high alcohol intake? ‘That’s exactly what people do,’ she says ruefully. ‘They say, “I’ve been drinking three litres a day for some years now and it’s got to stop now, and what are you going to do, doctor?”. That’s exactly why those consultations are so challenging because you’ve got to find a nice way of saying, “I’m not going to do some magic today that’s going to solve this”.

She advises GPs to have a good knowledge of local drop-in services for people with alcohol problems and to ‘signpost with intention’ to these, while warning patients that even if they do go straight there, it’s likely they will have to wait some weeks for a first appointment.

‘Nothing is going to happen fast, and it also wouldn’t be safe for the person to suddenly stop drinking. So, sometimes the main advice I will give is to keep drinking, which seems an odd thing to do, but over time they have to build the relationships and support to safely detox and have a better chance of not relapsing.’

And it’s not only about the extreme and evident cases. ‘One in five of the patients we see every day are likely coming to harm from alcohol and it’s not at all obvious – for example, 10 per cent of breast cancers are linked to alcohol. So, one of our main roles is to raise the subject of alcohol in the first place – when patients present with chronic diarrhoea, poor sleep, reflux or symptoms of anxiety. Simply asking could be our main contribution.’

The quality of these conversations is also important, for example being curious and open about asking why they are drinking and how they feel about it, rather than simply counting units and giving advice. ‘These conversations can make a difference to the stigma that people perceive from healthcare workers, and the self-shame they already feel.’

Accepting that, as a GP, you are not going to be the solution is vital, she adds. ‘I gave a presentation recently and a GP trainee said “hang on a minute, we’re not allowed to prescribe the drugs for safe withdrawal, we’re not the people to support you through the process because you’ve got Turning Point or an NGO for that, you’re saying it’s mutual aid [peer support] that helps more than fancy medications – what’s our role as GPs?” She was feeling quite frustrated and futile.

'But I suppose the answer is that if someone comes to you to talk about your alcohol use, how you respond makes a big difference to how they embark on the journey. They need somebody to be kind, but also not overwhelmed. Somebody who can be matter of fact and give safe advice.

'We’ve got a very good SHAAP publication which I can send to patients which shows how they can slowly cut down, for example. And we’re going to be the ones to explain some of the neuroscience to our patients in understandable ways that helps them realise this isn’t their fault or a personality defect, but it’s a disease: alcohol has come to dominate their dopamine reward system. We can signpost with conviction – we can speak to them authentically about what, from our experience, can help people in their situation.

‘We also hold the hope for them, because we’ve been exposed to stories of recovery. That’s a different kind of consultation, and if we change our conversations, not only is it better for patients, but it helps us realise that just because we’re GPs, it’s not all up to us.’