Substance abuse and professional education: a tops-down or bottoms-up approach?

Substance misuse teaching in undergraduate medical education

BACKGROUND

Over 12,000 hospital admissions in the UK result from substance misuse, therefore issues surrounding this need to be addressed early on in a doctor's training to facilitate their interaction with this client group. Currently, undergraduate medical education includes teaching substance misuse issues, yet how this is formally integrated into the curriculum remains unclear.

METHODS

Semi-structured interviews with 17 key members of staff responsible for the whole or part of the undergraduate medical curriculum were conducted to identify the methods used to teach substance misuse. Using a previously devised toolkit, 19 curriculum co-ordinators then mapped the actual teaching sessions that addressed substance misuse learning objectives.

RESULTS

Substance misuse teaching was delivered primarily in psychiatry modules but learning objectives were also found in other areas such as primary care placements and problem-based learning. On average, 53 teaching sessions per medical school focused on bio-psycho-social models of addiction whereas only 23 sessions per medical school focused on professionalism, fitness to practice and students' own health in relation to substance misuse. Many sessions addressed specific learning objectives relating to the clinical features of substance dependence whereas few focused on iatrogenic addiction.

CONCLUSIONS

Substance misuse teaching is now inter-disciplinary and the frequent focus on clinical, psychological and social effects of substance misuse emphasises the bio-psycho-social approach underlying clinical practice. Some areas however are not frequently taught in the formal curriculum and these need to be addressed in future changes to medical education.

Undergraduate medical education in substance use in Ireland: a review of the literature and discussion paper

BACKGROUND

Medical complications of substance use are a considerable cause of morbidity and the role of the physician in the care of such problems has consistently been demonstrated. Appropriate knowledge and skills are necessary to carry out this role.

AIMS

To review the literature on training undergraduate medical students in identifying and managing substance misuse and to discuss the implications of this literature for Irish medical education.

METHODS

A search of the literature was performed using keywords; "substance-related disorders", "undergraduate" and "curriculum". All abstracts were reviewed and the full text of relevant abstracts was studied and references reviewed for further articles.

RESULTS

Despite an increase in prevalence of the problem of drug and alcohol use in Ireland and the UK, this has not been reflected in undergraduate medical curricula. In the UK, minimal time is devoted to formal teaching of medical undergraduates in the area of substance misuse and many doctors do not have the appropriate knowledge, skills, attitudes and confidence to treat patients with such problems. In Ireland, no data has reported formal undergraduate teaching hours in the area of drug and alcohol misuse. Internationally, substance abuse curricula have been developed and implemented in medical schools in the United States and Australia.

CONCLUSION

While substance misuse is increasing in prevalence, this is not reflected in the composition of medical curricula, especially in Ireland. International best practice whereby undergraduate curricula that adequately address substance misuse and related issues are systematically developed and implemented, is recommended for adoption by Irish medical schools.

Training primary health care workers about drugs: a national survey of UK trainers' perceptions towards training

Reports have consistently shown that non-specialist drug workers (whose working role is not specifically concentrated on dealing with drug-related issues) are reluctant to work with drug users. A number of explanations have been offered to account for this unwillingness including attitudinal factors, occupational constraints and a lack of motivation to learn about drug-related issues. Previously, it has been shown that training affects commitment to working with substance misusers, although failure to attract particular professional groups (e.g. general practitioners) into training courses has also been reported. No previous research has examined the views of trainers about training primary health care and health-related workers. This study of a (non-probability) sample of UK drug trainers (n = 145) assessed training activity for different health care workers, and trainers' differential perceptions of training needs and methods. GPs were the group least likely to become trained about drug issues. Training in attitudes towards drug using individuals was perceived to be more important than either skills or knowledge training for GPs, practice nurses, other nurses and probation officers. Experiential training methods were perceived to be more important than a didactic approach for training all health groups except GPs for whom lecture type instruction was believed to be equally appropriate. Seventy-nine percent of subjects reported providing training across drugs in alcohol or drugs, alcohol and tobacco. Most trainers who stated that certain professions required independent training believed that GPs should be trained separately from other groups.

Medical education in substance use disorders

This paper outlines recent developments in drug and alcohol medical education, and highlights improved prospects for prevention and appropriate management of substance use disorders. The paper also presents a model of effective drug and alcohol medical education designed to induce both clinical competence and effective practice behaviour. Of particular note is the trend towards greater emphasis on skills development, especially clinical interaction skills. This emphasis is underpinned by an increasingly behavioural orientation, whereby concern is focused on fostering clinical competence in specific skills, e.g. identification, history taking and interventions. Practical examples of the application of such approaches are noted. In addition, relevance of concepts, such as self-efficacy and role legitimacy, to the area of drug and alcohol medical education is highlighted. Together with recent data on early intervention, and the widespread recognition and support for medical practitioners' involvement in drug and alcohol problems, future prospects are viewed as very encouraging.

A controlled trial of educational strategies to teach medical students brief intervention skills for alcohol problems

OBJECTIVES

Comparatively little is known about the most effective educational strategies to train medical students to successfully intervene in their patients' alcohol problems. The relative effectiveness of two educational programs to teach medical students brief intervention skills for managing alcohol problems was examined.

METHODS

Teaching took place over 3 hr and was either the traditional didactic teaching program on the principles and practice of brief and early intervention or an interactive program involving a shortened lecture, clinical practice, and small group feedback on clinical performance. Students were assessed on a 10-min videotaped encounter with a simulated patient before and after teaching according to how they addressed alcohol-related issues and on their general interactional skills.

RESULTS

Performance on alcohol-related issues and interactional skills were significantly improved after teaching, although still poor in terms of clinical performance. A between-groups comparison on pre/ postteaching difference scores indicated interactive training was no more effective than traditional didactic lectures in developing the knowledge and skills needed for a brief alcohol intervention.

CONCLUSION

The need for more detailed teaching sessions on sensitive areas such as alcohol use in indicated.

Research in general practice for smokers and excessive drinkers in Australia and the UK. III. Dissemination of interventions

This article reviews the main methods of dissemination of interventions to doctors for the benefit of patients who are smokers and excessive drinkers. Firstly, the modes of delivery of interventions are discussed such as: postal delivery, face-to-face strategies such as an educational facilitator, courier, training workshops, reinforcement contact after training, and teaching in medical school. Secondly, we examine GPs' delivery of interventions working in association with others such as with: the health visitor, health facilitator, practice nurse, and specialist clinic. Thirdly, we discuss the debate about the public health impact of GP interventions for smokers, which is about rates of recruitment of patients to programs and about the most effective interventions that will continue to be used by GPs. Fourthly, doctors underutilize their opportunities to identify and intervene with smokers and excessive drinkers and we explore many of the barriers to intervention. Finally, there are several new initiatives in general practice that require research including: matching GPs to specific treatments, comparing the uptake and continued use of different levels of interventions, evaluating the most effective ways of delivering interventions to GPs, and the training of doctors in the intervention methods.

A theory-driven approach to the evaluation of professional training in alcohol abuse

This paper begins by observing that, to date, evaluations of brief training courses in alcohol abuse for non-specialist professionals indicate that they have little influence on attitudes and behaviour. The reasons why this is so have not been studied in detail, and such training courses continue to be widely used despite their minimal effects. It is argued that the failure of this field of inquiry to develop beyond this point is due to the fact that, with only a very few exceptions, it has not been informed by theoretical concerns. The research in this area is discussed in terms of the types of models tested and the research designs typically used in evaluations. This is followed by a detailed description of the 'theory driven approach' to evaluation. It is proposed that the use of such an approach by those concerned with the development and evaluation of training in alcohol abuse for non-specialists would increase the likelihood of identifying the real effects of such programmes and the processes that mediate their successful implementation. This would result in a more purposeful use of educators' and evaluators' energies and skills.

Drug and alcohol medical education: evaluation of a national programme

In recognition of inadequacies in drug and alcohol medical education, funds were allocated to all Australian medical schools in 1988 to appoint co-ordinators to develop and implement drug and alcohol curricula. This programme was broadly modelled on the Career Teacher Programme successfully implemented in North America in the 1970s and early 1980s. During 1989 all but one of Australia's 10 medical schools made drug and alcohol co-ordinator appointments. Appointees came from diverse backgrounds including general practice, psychiatry, internal medicine, psychology and social work. The present study is a process evaluation and forms the first examination of the programme. Overall, findings indicated the programme to have achieved a 158% increase in drug and alcohol teaching hours, a 383% increase in the number of electives and a 109% increase in student places for electives. These effects occurred even though the average duration of co-ordinators' appointments was only 15 months. Implications of these recent developments are discussed in terms of teaching strategies, clinical experience and the inclusion of key educational issues such as early intervention. Recommendations are made for a continuation of the programme and for future outcome evaluation.

Evaluation of an alcohol education package for non-specialist health care and social workers

A quasi-experimental non-equivalent control group design was used to assess the influence of a two-day experiential alcohol education package for non-specialist health care and social workers. Four pairs of teams took part in the study: general practice; accident and emergency; medicine for the elderly; and social work. The dual foci of the evaluation were agents' knowledge and attitudes, and these were assessed using a modified version of the Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ). For both variables, the one-month follow-up scores of the education teams were significantly higher than those of the comparisons, although the effect was stronger in the case of therapeutic attitudes than knowledge. There were also significant differences in improvement in attitude scores, with significant effects being observed in the general practice, medicine for the elderly and social work teams but not the accident and emergency. At 6 months, the level of fall-off in improvement varied and this, along with the pattern of change evident in the five components which comprise the AAPPQ attitude scale, was examined and discussed in relation to previous research in this field of inquiry.