Alcohol use among physicians in a medical school in Nepal

Objective: The objective of the study was to know about the use of alcohol among physicians and factors that were related to it. Methods: This was a cross sectional study conducted among the physicians in a medical school of eastern Nepal. A semi structured questionnaire was used to collect information. Results: There were 55 subjects in the study. Half of them were between 35-45 years age group and one fourth among them were female. There were more than 88% physicians consuming alcohol for more than 10 years. One third used to preferred whisky as their favorites drink. Use of alcohol among them was due to peer pressure and to become a social human being. Most of them drink alcohol occasionally with an average amount 30-60ml in a sitting and usually in the evening. Most of the time, they use alcohol either in parties or at home. Conclusion: Alcohol use in Nepal is very much prevalent. The use of alcohol is socially accepted in many communities. Uses of alcohol by physicians have direct effect on their health as well as the health of many people because they are role model for many people. They are also in direct contact with the patients. Steps to council the physicians may reduce the consumption of alcohol. Key words: Alcohol, Nepal, Physicians, Dependence, Abuse.     

Detecting and managing elder abuse: challenges in primary care

OBJECTIVE: To determine family physicians' perceptions of barriers and strategies in the effective detection and appropriate management of abused elderly people. DESIGN: Questionnaire survey; the protocol included an advance notification letter and 3 follow-up mailings. SETTING: Regional Municipality of Hamilton-Wentworth, Ont. PARTICIPANTS: All active nonspecialist physicians who reported seeing elderly patients in their practices were eligible for inclusion. Fifty health service organization (HSO) physicians were randomly selected from among those listed with the HSO Mental Health Program, and 200 fee-for-service physicians were randomly selected from the Canadian Medical Directory. Of the 189 eligible physicians 122 returned completed questionnaires, a response rate of 65%. OUTCOME MEASURES: Physicians' ratings of the importance of potential barriers in assisting older people experiencing abuse and of the usefulness of strategies for dealing with elder abuse. RESULTS: Physicians identified the following barriers as fairly or very important: denial of abuse, resistance to intervention, not knowing where to call for help, lack of protocols to assess and respond to abuse, lack of guidelines about confidentiality, fear of reprisal, and lack of knowledge of the prevalence and definition of elder abuse. Strategies deemed to be helpful included a single agency to call, a directory of services, a list of resource people, an educational package, guidelines for detection and management, reimbursement for time spent on legal matters, continuing education, revision of fee structure and a central library of resources on elder abuse. CONCLUSION: Although the physicians perceived numerous barriers to their detection and management of elder abuse, they identified many strategies that could be implemented at a local level. Preparation of an algorithm to help physicians is the next phase of this work.     

The physician's role.

Physicians can play an important role in society's response to alcohol problems. In diagnosis, alcohol problems among patients are frequently overlooked. Physicians should routinely ask patients about alcohol intake. In light of evidence on the effectiveness of brief interventions, especially with heavy-drinking but nondependent patients, physicians' treatment efforts should be focused in this direction. Patients who are alcohol dependent might best be treated by nonphysicians. Research contributions of physicians should be concentrated on topics for which physician input is needed: longitudinal studies of health consequences, factors contributing to mortality and health service costs, biochemical markers of alcohol use and basic pharmacology. Strong evidence links population alcohol consumption levels to overall harm. Therefore, prevention efforts should be aimed at the population as well as at people who may be at risk. Physicians can contribute to these efforts by influencing public policy and by setting healthy examples in their own alcohol use.     

Physicians' evaluations of patients' decisions to refuse oncological treatment

OBJECTIVE: To gain insight into the standards of rationality that physicians use when evaluating patients' treatment refusals. DESIGN OF THE STUDY: Qualitative design with in depth interviews. PARTICIPANTS: The study sample included 30 patients with cancer and 16 physicians (oncologists and general practitioners). All patients had refused a recommended oncological treatment. RESULTS: Patients base their treatment refusals mainly on personal values and/or experience. Physicians mainly emphasise the medical perspective when evaluating patients' treatment refusals. From a medical perspective, a patient's treatment refusal based on personal values and experience is generally evaluated as irrational and difficult to accept, especially when it concerns a curative treatment. Physicians have a different attitude towards non-curative treatments and have less difficulty accepting a patient's refusal of these treatments. Thus, an important factor in the physician's evaluation of a treatment refusal is whether the treatment refused is curative or non-curative. CONCLUSION: Physicians mainly use goal oriented and patients mainly value oriented rationality, but in the case of non-curative treatment refusal, physicians give more emphasis to value oriented rationality. A consensus between the value oriented approaches of patient and physician may then emerge, leading to the patient's decision being understood and accepted by the physician. The physician's acceptance is crucial to his or her attitude towards the patient. It contributes to the patient's feeling free to decide, and being understood and respected, and thus to a better physician-patient relationship.     

Effectiveness of physician-based interventions with problem drinkers: a review.

OBJECTIVE: To review the results of randomized controlled trials on the effectiveness of brief physician interventions with problem drinkers. DATA SOURCES: The MEDLINE and EMBASE databases were searched for articles published from 1966 and 1972 respectively, with the terms "problem/controlled/responsible/moderate/risk/drink"; "advice/drink"; "physician, nurse, general practitioner"; and "random." Forty-three articles were identified in the EMBASE search and 112 articles in the MEDLINE search. STUDY SELECTION: All trials examining the effectiveness of interventions by physicians in reducing alcohol consumption among problem drinkers attending a health-care facility were reviewed. Trials involving subjects attending an alcohol treatment clinic and those involving interventions delivered solely by nonphysicians were excluded. Eleven trials met the final selection criteria. DATA EXTRACTION: For each article, two of the authors independently assigned a score from 0 to 2 on a number of criteria for validity and generalizability. DATA SYNTHESIS: The four trials with the highest validity scores showed that men in the intervention groups reduced their weekly alcohol consumption by five to seven standard drinks more than the men in the control groups. Results for women were inconsistent. No convincing evidence of declines in alcohol-related morbidity among men or women was found. CONCLUSIONS: The trials support the use of brief interventions by physicians for patients with drinking problems. Although further studies are needed to determine their effect on morbidity and mortality, the public health impact of such interventions is potentially enormous. Further research is needed to determine which patients are best suited for brief interventions, the optimal intensity of treatment and which components of brief interventions are most effective. Research is also needed to establish which strategies are effective in inducing physicians to use brief interventions.     

定性访谈在中医药干预癌症研究中的应用

定性访谈作为定性研究的重要方法,因其突出的人文倾向适用于回答中医药临床诊疗中不可量化的问题.在中医药干预癌症的研究中,通过与医生、患者和家属分别进行一对一个体深度访谈,定性访谈能够用于探索中医药复杂干预,了解医生、患者和家属主观态度、信念、期望等要素,获得来自个体主观的信息,并从中分析特异性和共性,是一种值得探索的研究...     

Attitudes of primary care physicians toward corporal punishment.

OBJECTIVE--The purpose of this study was to determine whether or not family physicians and pediatricians support the use of corporal punishment. The frequency with which these physicians offer anticipatory guidance on discipline was also studied. DESIGN--Self-report survey, mailed to study participants. PARTICIPANTS--The sample for this study was 800 family physicians and 400 pediatricians, randomly selected from the Ohio State Medical Board's roster of family physicians and pediatricians. Physicians with a subspecialty were excluded. Participants who did not return their surveys received a second, and if necessary, a third mailing of the survey. After three mailings, a total of 619 physicians (61%) completed a survey. MAIN OUTCOME MEASURE--Participants were considered to support corporal punishment if they would tell a parent in their medical practice that spanking would be an appropriate response to any one of a series of childhood misbehaviors presented in the survey. RESULTS--Of family physicians, 70% (95% confidence interval [CI], 66% to 75%) support use of corporal punishment. Of pediatricians, 59% (95% CI, 52% to 66%) support corporal punishment. Of pediatricians, 90% (95% CI, 86% to 94%) indicated that they include discipline issues either always or most of the time when providing anticipatory guidance to parents. Significantly fewer family physicians (52%; 95% CI, 47% to 57%) indicated that they discuss discipline either always or most of the time when providing anticipatory guidance (P less than .01). CONCLUSIONS--Most family physicians and pediatricians support the use of corporal punishment in spite of evidence that it is neither effective nor necessary, and can be harmful. Pediatricians offer anticipatory guidance on discipline more often than family physicians.     

Evaluation of do not resuscitate orders (DNR) in a Swiss community hospital

OBJECTIVE: To evaluate the effect of an intervention on the understanding and use of DNR orders by physicians; to assess the impact of understanding the importance of involving competent patients in DNR decisions. DESIGN: Prospective clinical interventional study. SETTING: Internal medicine department (70 beds) of the hospital of La Chaux-de-Fonds, Switzerland. PARTICIPANTS: Nine junior physicians in postgraduate training. INTERVENTION: Information on the ethics of DNR and implementation of new DNR orders. Measurements and main results: Accurate understanding, interpretation, and use of DNR orders, especially with respect to the patients' involvement in the decision were measured. Junior doctors writing DNR orders had an extremely poor understanding of what DNR orders mean. The correct understanding of the definition of a DNR order increased from 31 to 93% (p<0.01) after the intervention and the patients' involvement went from 17% to 48% (p<0.01). Physicians estimated that 75% of their DNR patients were mentally competent at the time of the decision. CONCLUSION: An intervention aimed at explaining the ethical principles and the definition of DNR orders improves understanding of them, and their implementation, as well as patient participation. Specific efforts are needed to increase the involvement of mentally competent patients in the decision.     

Family physicians' attitudes toward advance directives.

OBJECTIVE: To examine the attitudes toward, the experience with and the knowledge of advance directives of family physicians in Ontario. DESIGN: Cross-sectional survey. PARTICIPANTS: A questionnaire was mailed to 1000 family physicians, representing a random sample of one-third of the active members of the Ontario College of Family Physicians; 643 (64%) responded. RESULTS: In all, 86% of the physicians favoured the use of advance directives, but only 19% had ever discussed them with more than 10 patients. Most of the physicians agreed with statements supporting the use of advance directives and disagreed with statements opposing their use. Of the respondents 80% reported that they had never used a directive in managing an incompetent patient. Of the physicians who responded that they had such experience, over half said that they had not always followed the directions contained in the directive. The proportions of physicians who responded that certain patient groups should be offered the opportunity to complete an advance directive were 96% for terminally ill patients, 95% for chronically ill patients, 85% for people with human immunodeficiency virus infection, 77% for people over 65 years of age, 43% for all adults, 40% for people admitted to hospital on an elective basis and 33% for people admitted on an emergency basis. The proportions of physicians who felt that the following strategies would encourage them to offer advance directives to their patients were 92% for public education, 90% for professional education, 89% for legislation protecting physicians against liability when following a directive, 80% for legislation supporting the use of directives, 79% for hospital policy supporting the use of directives, 73% for reimbursement for time spent discussing directives with patients and 64% for hospital policy requiring that all patients be routinely offered the opportunity to complete a directive at the time of admission. CONCLUSIONS: Family physicians favour advance directives but use them infrequently. Most physicians support offering them to terminally or chronically ill patients but not to all patients at the time of admission to hospital. Although governments emphasize legislation, most physicians believe that public and professional education programs would be at least as likely as legislation to encourage them to offer advance directives to their patients.     

Sanctions against sexual abuse of patients by doctors: sex differences in attitudes among young family physicians.

OBJECTIVE: To explore attitudes of new-to-practice certified family physicians in Ontario concerning sanctions against sexual abuse of patients by physicians and to assess the importance of concern about accusations of sexual abuse in influencing clinical decisions. DESIGN: Qualitative study and cross-sectional survey. SETTING: Ontario. PARTICIPANTS: Focus groups: 34 physicians who completed family medicine residency training between 1984 and 1989 participated in seven focus groups between June and October 1992. Survey: all certificants of the College of Family Physicians of Canada who received certification between 1989 and 1991 and were currently practising in Ontario. Of the 564 eligible physicians 395 (184 men and 211 women) responded, for an overall response rate of 70.0%. The response rates among the male and female physicians were 70.5% and 69.6% respectively. OUTCOME MEASURES: Physicians' attitudes toward restricting physical examinations done by physicians to same-sex patients, mandatory reporting of sexual impropriety and loss of licence in cases of sexual violation and the perceived importance of concern about accusations of sexual abuse as an influence on clinical decisions. RESULTS: During the focus groups male physicians in particular expressed concerns about the effect on their practice patterns of the current climate regarding sexual abuse of patients. Female physicians were less concerned about possible accusations of sexual abuse but expressed concerns regarding possible sexualization of the clinical encounter by male patients. In the survey equal proportions of men (163 [93.7%]) and women (191 [92.3%]) disagreed with restricting examinations to same-sex patients. The women were more likely than the men to agree that all suspected cases of sexual impropriety committed by other physicians should be reported (121 [58.7%] v. 86 [50.0%]), whereas the men were more likely to disagree (48 [27.9%] v. 32 [15.5%]) (p = 0.008). The women were also more likely than the men to agree that physicians should lose their licence permanently if they were found guilty of sexual violation (125 [62.2%] v. 73 [43.5%]), whereas the men were more likely to disagree (61 [36.3%] v. 37 [18.4%]) (p < 0.001). Almost half of the men (80 [46.5%]) but only 28 women (14.1%) reported that concerns about accusations of sexual abuse were of importance in their clinical decisions (p < 0.001). CONCLUSIONS: Young female family physicians practising in Ontario are much more likely than their male counterparts to endorse permanent loss of licence for physicians who sexually abuse patients and are significantly less concerned about accusations against themselves. Neither sex endorses only same-sex examinations by physicians. Educational approaches to protect patients while ensuring that appropriate care continues to be delivered are essential.     

Royal College debates whether MDs should promote moderate consumption of alcohol

Emerging news about the potential beneficial effects of moderate alcohol consumption raises some interesting challenges for physicians, who often come face to face with problems created by alcohol. Physicians on the affirmative side won a debate on the pros and cons of moderate drinking that was held during this fall's Royal College meeting. Pam Harrison explains how they did it.     

Female family physicians in obstetrics: achieving personal balance.

OBJECTIVE: To describe the experiences of female family physicians who practise obstetrics in balancing professional obligations with personal and family needs, given the unique challenges that such practice poses for these physicians. DESIGN: Qualitative study. SETTING: Ontario. PARTICIPANTS: A purposefully selected sample of nine female family physicians who met the criteria of being married, having children and currently practising obstetrics. OUTCOME MEASURES: Experiences of female family physicians and their strategies in their personal, family and professional lives that enable them to continue practising obstetrics. RESULTS: All participants continued to practise obstetrics because of the pleasure they derived from it, despite the challenges of balancing the unpredictable demands of obstetrics with their personal and family needs. To continue in obstetrics, they needed to make changes in their lives, either through a gradual, evolutionary process or in response to a critical event. Alterations to work and family arrangements permitted them to meet the challenges and led to increased satisfaction. Changes included making supportive call-group arrangements, limiting work hours and the number of births attended and securing help with household duties. CONCLUSIONS: An in-depth examination, through the use of qualitative methods, showed the reasons why some female family physicians continue to practise obstetrics despite the stressful aspects of doing so. This knowledge may be useful for women who are residents or experienced clinicians and who are considering including obstetrics in their practice.     

Do physicians assess lifestyle health risks during general medical examinations? A survey of general practitioners and obstetrician-gynecologists in Quebec

BACKGROUND: In Canada several guidelines have been published for the screening of lifestyle health risks during general medical examinations. The authors sought to examine the extent to which such screening practices have been integrated into medical practice, to measure physicians' perceived level of difficulty in assessing these risks and to document physicians' evaluation of their formal medical training in lifestyle risk assessment. METHODS: An anonymous mail survey was conducted in 1995 in Quebec with a stratified random sample of 1086 general practitioners (GPs) and with all 241 obstetrician-gynecologists (Ob-Gyns). The authors evaluated the proportion of physicians who reported routine assessment (with 90% or more of their patients) of substance use, family violence and sexual history during general medical examinations of adult and adolescent patients; the proportion of those who find inquiring about these issues difficult; and the proportion of those who evaluated their medical training in lifestyle risk assessment as adequate or excellent. RESULTS: The overall response rate was 72.6%. Among adult patients, 82.2% of the GPs reported routinely assessing tobacco use, 67.2% alcohol consumption, 34.2% illicit drug use and 3.2% family violence; the corresponding proportions for assessment among adolescent patients were 77.1%, 61.8%, 52.9% and 5.6%. Comparatively fewer Ob-Gyns reported routinely assessing these issues (56.1%, 28.6%, 20.4% and 1.3% respectively among adults and 62.7%, 35.2%, 26.8% and 2.8% respectively among adolescents). In the area of sexual history, condom use was routinely assessed by more Ob-Gyns than GPs (47.0% v. 28.2%); however, the proportion of Ob-Gyns and GPs was equally low for assessing number of partners (24.8% and 23.1%), sexual orientation (18.8% and 16.9%) and STD risk (26.2% and 21.2%). The vast majority of GPs and Ob-Gyns reported finding it difficult to assess family violence (86.5% and 93.0%) and sexual abuse (92.7% and 92.4% respectively). Over 80% of the physicians felt that they had had adequate or excellent medical training in assessing risk behaviours for heart disease and STD risk. The proportion who felt this way about their training in screening for illicit drug use, family violence and sexual abuse ranged between 12.7% and 31.6%. INTERPRETATION: Although morbidity and mortality associated with smoking, alcohol consumption, illicit drug use, unsafe sexual practices, family violence and sexual abuse have been well documented, routine screening for these risk factors during general medical examinations has yet to be integrated into medical practice.     

Primary care physicians and AIDS. Attitudinal and structural barriers to care

OBJECTIVE--To explore the extent to which primary care physicians are providing health care for people with human immunodeficiency virus (HIV) infection and to document barriers to HIV care giving. DESIGN--National random-sample mailed survey. PARTICIPANTS--Population-based random sample of 2004 US general internists, family physicians, and general practitioners in 1990. Response rate was 59%. MAIN OUTCOME MEASURES--HIV treatment experience, willingness to treat HIV-infected patients, negative attitudes toward homosexuals and intravenous drug users, fear of contagion of the acquired immunodeficiency syndrome (AIDS), perceived lack of information about AIDS, and time demands of HIV care. RESULTS--Most physicians (75%) had treated one or more patients with HIV infection. A majority (68%) believed that they had a responsibility to treat people with HIV infection, yet half (50%) indicated that they would not, if given a choice. Over 80% of respondents believed that they lacked information about AIDS and that caring for people with AIDS is time consuming. Further, 35% of respondents agreed that they "would feel nervous among a group of homosexuals" and 55% expressed discomfort about having intravenous drug users in their practice. Physicians who had treated 10 or more HIV-infected patients expressed less negativity toward members of these stigmatized groups who are likely to be HIV infected. CONCLUSIONS--These data suggest that many primary care physicians are responding professionally to the AIDS epidemic but that attitudinal barriers may be hindering some physicians from providing treatment to HIV-infected patients.     

Medical decisions concerning the end of life: a discussion with Japanese physicians.

OBJECTIVES: Life-sustaining treatment at the end of life gives rise to many ethical problems in Japan. Recent surveys of Japanese physicians suggested that they tend to treat terminally ill patients aggressively. We studied why Japanese physicians were reluctant to withhold or withdraw life-support from terminally ill patients and what affected their decisions. DESIGN AND PARTICIPANTS: A qualitative study design was employed, using a focus group interview with seven physicians, to gain an in-depth understanding of attitudes and rationales in Japan regarding medical care at the end of life. RESULTS: Analysis revealed that physicians and patients' family members usually make decisions about life-sustaining treatment, while the patients' wishes are unavailable or not taken into account. Both physicians and family members tend to consider withholding or withdrawing life-sustaining treatment as abandonment or even killing. The strongest reason to start cardiopulmonary resuscitation- and to continue it until patients' family members arrive-seems to be the family members' desire to be at the bedside at the time of death. All physicians participating in our study regarded advance directives that provide information as to patients' wishes about life-sustaining treatment desirable. All expressed concern, however, that it would be difficult to forego or discontinue life-support based on a patient's advance directive, particularly when the patient's family opposed the directive. CONCLUSION: Our group interview suggested several possible barriers to death with dignity and the appropriate use of advance directives in Japan. Further qualitative and quantitative research in this regard is needed.     

Risk language preferred by mothers in considering a hypothetical new vaccine for their children.

OBJECTIVES: To determine the type of risk language preferred by mothers considering the use of hypothetical new vaccine for their children and to compare their choice with what their physicians perceived they would prefer. DESIGN: Mail survey. SETTING: Thirteen family practices in southwestern Ontario. PARTICIPANTS: Women with at least one child between the ages of 6 months and 5 years and their physicians. MAIN OUTCOME MEASURES: Preferred risk language and physicians' predictions about patient preference. RESULTS: Of the 226 women sent the questionnaire 208 (92%) responded. Of the 192 who indicated their risk language preference 118 (61%) chose a numeric statement. Of the 11 physicians who answered the question 8 (73%) predicted that their parents would prefer non-numeric statements. Although the women in the study were more likely to be married, were better educated and had higher family incomes than women of the same age in the Ontario population, risk language preference was not found to be related to any of those demographic characteristics. CONCLUSION: Physicians must be prepared to outline the risks associated with vaccination in both quantitative and qualitative terms.     

Effects of perceived patient demand on prescribing anti-infective drugs

BACKGROUND: Although patient demand is frequently cited by physicians as a reason for inappropriate prescribing, the phenomenon has not been adequately studied. The objectives of this study were to determine the prevalence of perceived patient demand in physician-patient encounters; to identify characteristics of the patient, physician and prescribing situation that are associated with perceived demand; and to determine the influence of perceived demand on physicians' prescribing behaviour. METHODS: An observational study using 2 survey approaches was conducted in February and March 1996. Over a 2-day period 20 family physicians in the Toronto area completed a brief questionnaire for each patient encounter related to suspected infectious disease. Physicians were later asked in an interview to select and describe 1 or 2 incidents from these encounters during which perceived patient demand influenced their prescribing (critical incident technique). RESULTS: Perceived patient demand was reported in 124 (48%) of the 260 physician-patient encounters; however, in almost 80% of these encounters physicians did not think that the demand had much influence on their decision to prescribe an anti-infective. When clinical need was uncertain, 28 (82%) of 34 patients seeking an anti-infective were prescribed one, and physicians reported that they were influenced either "moderately" or "quite a bit" by perceived patient demand in over 50% of these cases. Of the 35 critical prescribing incidents identified during the interviews, anti-infectives were prescribed in 17 (49%); the reasons for prescribing in these situations were categorized. INTERPRETATION: This study provides preliminary data on the prevalence and influence of perceived patient demand in prescribing anti-infectives. Patient demand had more influence on prescribing when physicians were uncertain of the need for an anti-infective.     

A randomized-controlled trial of computerized alerts to reduce unapproved medication abbreviation use

Abbreviation use is a preventable cause of medication errors. The objective of this study was to test whether computerized alerts designed to reduce medication abbreviations and embedded within an electronic progress note program could reduce these abbreviations in the non-computer-assisted handwritten notes of physicians. Fifty-nine physicians were randomized to one of three groups: a forced correction alert group; an auto-correction alert group; or a group that received no alerts. Over time, physicians in all groups significantly reduced their use of these abbreviations in their handwritten notes. Physicians exposed to the forced correction alert showed the greatest reductions in use when compared to controls (p=0.02) and the auto-correction alert group (p=0.0005). Knowledge of unapproved abbreviations was measured before and after the intervention and did not improve (p=0.81). This work demonstrates the effects that alert systems can have on physician behavior in a non-computerized environment and in the absence of knowledge.     

Physician awareness of fetal alcohol syndrome: a survey of pediatricians and general practitioners.

OBJECTIVE: To determine the knowledge, clinical experience and perceived needs for resource materials of Saskatchewan physicians in regard to fetal alcohol syndrome (FAS) and alcohol-related birth defects. DESIGN: Mailed survey. SETTING: Saskatchewan. PARTICIPANTS: All 48 pediatricians and half (394) of the family physicians (FPs) and general practitioners (GPs) practising in Saskatchewan received a questionnaire. The numbers of physicians who completed it were 24 and 249 respectively. RESULTS: The pediatricians were more likely than the other physicians to be aware of FAS and to have diagnosed at least one case of FAS. Among the FPs and GPs, the year of graduation from medical school was a significant factor in their knowledge of FAS and their diagnostic practices. Those who graduated before 1974, the year FAS was first described in the medical literature, were less likely than the more recent graduates to be aware of FAS and to ask their patients about alcohol use during pregnancy but were more likely to feel comfortable discussing alcohol-related issues in families. All of the groups reported a need for more information about FAS and for resources on alcohol-related issues in general. CONCLUSIONS: Saskatchewan physicians are aware of FAS but have expressed a need for more information about FAS, particularly for parents, as well as physician training materials and information about where to refer patients with FAS and parents with alcohol-related problems.