Drug and alcohol medical education: evaluation of a national programme

Barriers and facilitators to implementing addiction medicine fellowships: a qualitative study with fellows, medical students, residents and preceptors

Background

Although progress in science has driven advances in addiction medicine, this subject has not been adequately taught to medical trainees and physicians. As a result, there has been poor integration of evidence-based practices in addiction medicine into physician training which has impeded addiction treatment and care. Recently, a number of training initiatives have emerged internationally, including the addiction medicine fellowships in Vancouver, Canada. This study was undertaken to examine barriers and facilitators of implementing addiction medicine fellowships.

Methods

We interviewed trainees and faculty from clinical and research training programmes in addiction medicine at St Paul’s Hospital in Vancouver, Canada (N = 26) about barriers and facilitators to implementation of physician training in addiction medicine. We included medical students, residents, fellows and supervising physicians from a variety of specialities. We analysed interview transcripts thematically by using NVivo software.

Results

We identified six domains relating to training implementation: (1) organisational, (2) structural, (3) teacher, (4) learner, (5) patient and (6) community related variables either hindered or fostered addiction medicine education, depending on context. Human resources, variety of rotations, peer support and mentoring fostered implementation of addiction training. Money, time and space limitations hindered implementation. Participant accounts underscored how faculty and staff facilitated the implementation of both the clinical and the research training.

Conclusions

Implementation of addiction medicine fellowships appears feasible, although a number of barriers exist. Research into factors within the local/practice environment that shape delivery of education to ensure consistent and quality education scale-up is a priority.

Two birds with one stone: experiences of combining clinical and research training in addiction medicine

BACKGROUND

Despite a large evidence-base upon which to base clinical practice, most health systems have not combined the training of healthcare providers in addiction medicine and research. As such, addiction care is often lacking, or not based on evidence or best practices. We undertook a qualitative study to assess the experiences of physicians who completed a clinician-scientist training programme in addiction medicine within a hospital setting.

METHODS

We interviewed physicians from the St. Paul's Hospital Goldcorp Addiction Medicine Fellowship and learners from the hospital's academic Addiction Medicine Consult Team in Vancouver, Canada (N = 26). They included psychiatrists, internal medicine and family medicine physicians, faculty, mentors, medical students and residents. All received both addiction medicine and research training. Drawing on Kirkpatrick's model of evaluating training programmes, we analysed the interviews thematically using qualitative data analysis software (Nvivo 10).

RESULTS

We identified five themes relating to learning experience that were influential: (i) attitude, (ii) knowledge, (iii) skill, (iv) behaviour and (v) patient outcome. The presence of a supportive learning environment, flexibility in time lines, highly structured rotations, and clear guidance regarding development of research products facilitated clinician-scientist training. Competing priorities, including clinical and family responsibilities, hindered training.

CONCLUSIONS

Combined training in addiction medicine and research is feasible and acceptable for current doctors and physicians in training. However, there are important barriers to overcome and improved understanding of the experience of addiction physicians in the clinician-scientist track is required to improve curricula and research productivity.

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.

Evidence-based practice or imperfect seduction? Developing capacity to respond effectively to drug-related problems

ISSUES

The last two or three decades have seen some valuable investment in workforce development. However, significant challenges remain in developing effective practice across various systems. Despite the relevance alcohol, tobacco and other drug use have for a range of staff across diverse organisations, adoption of cross-sector and collaborative effective practice is not widespread. The most common response involves a rather singular focus on strategies that develop practitioner knowledge and skills, with much less consideration given to the complex nature of the work environment and the belief systems of people who work in these environments.

APPROACH

This paper explores the barriers to and facilitators of effective practice, extending beyond the common focus on education and training initiatives. A model of capacity building is explored as a template to inform workforce and organisational development strategies.

KEY FINDINGS

Numerous barriers, outside education and training, must be considered in order to develop and maintain effective practice across various systems of prevention and treatment. The paper culminates with recommendations on how to overcome such challenges.

IMPLICATIONS

Workforce and organisational development must extend beyond education and training initiatives. Along with a focus on organisational and system factors, we must also attend to the marginalisation of people affected by drug use and associated pejorative attitudes.

CONCLUSION

Developing effective practice in the drug field involves changing the structures, and expected outcomes of these structures, in which people work, not just encouraging a few to use new ways of working in spite of the system.

Have efforts to improve medical students' drug and alcohol knowledge, skills and attitudes worked?

A series of surveys were undertaken at one Australian medical school to examine alcohol and drug-related knowledge, skills and attitudes before and after the introduction of the National Campaign Against Drug Abuse and also before and after major alcohol and drug medical education initiatives. The surveys were conducted with 5th year medical students at the University of Sydney in 1986, 1990 and 1993 (total n = 379). Response rates of approximately 70% were achieved in each of the survey years. The three cohorts of students were similar demographically with the exception that significantly more males in 1990 and 1993 reported that English was not their first language. Very low prevalence levels for smoking were reported. By 1993, only 3% of 5th year medical students reported that they smoked. There was a significant decrease in the frequency of drinking occasions for males and females between 1986 and 1990. There was also a four-fold increase in both male and female abstainers. There was no significant difference in the amount of alcohol consumed on any drinking occasion, although there was a trend in that direction. There was a significant increase in alcohol and drug-related knowledge in the 1990 and 1993 groups, compared to the 1986 group. Skill levels were not found to change significantly across the three year groups. Students' ability to recognize NHMRC hazardous consumption levels increased substantially between 1986 and 1990. Only 4% of 1986 students considered <30 of alcohol a day to be hazardous for females compared to 47% in 1990. For men, only 8% of students considered 31-60 hazardous drinking in 1986 compared to 55% in 1990 and 61% in 1993. More recently trained students tended to express slightly more tolerant and accepting views about patients with alcohol and benzodiazepine dependence and had greater confidence in success of interventions. The present studies indicate important progress and achievements have been made. The paper discusses the further work needed to ensure that newly graduating medical practitioners are adequately equipped to deal effectively with alcohol and drug-related problems.

The impact of a brief interclerkship about substance abuse on medical students' skills

PURPOSE

To examine the immediate and delayed impact of an intensive one- or two-day interclerkship on substance abuse (SA) for third-year medical students. The program is a response to the problem of inadequacy of substance abuse education in the standard curriculum.

METHOD

Each year since 1997-98 all third-year students at the University of Massachusetts Medical School have participated in a one- or two-day SA interclerkship to enhance their knowledge and competence with SA assessment and brief intervention. Students' knowledge, attitudes, and confidence were assessed immediately before and after the interclerkship. In addition, during 1998-99, each student's clinical skills in SA assessment and intervention were evaluated at the completion of the student's six-week psychiatry clerkship using objective standardized clinical examinations (OSCEs) with two simulated patients, one with and one without active SA issues. Students who took the psychiatry clerkship in the first half of the year had not yet participated in the interclerkship. Students' pooled performances before and after the interclerkship were compared.

RESULTS

Students' attitudes toward and knowledge about SA disorders and their confidence about SA assessment and intervention all showed significant positive changes immediately after the interclerkship. The OSCE performance data demonstrated a significant sustained improvement in clinical skills in SA assessment and intervention as measured up to six months following the interclerkship.

CONCLUSION

These data suggest that brief intensive training in SA during the clinical years of medical school can have a positive and lasting impact on students' clinical performances.

Psychoactive drug use by medical students: a review of the national and international literature

Non-medical drug use among medical students is a major concern among researchers and policy makers in several countries, not only because of the personal harmful consequences that may arise from this behavior, but also for the social consequences. This article aims to evaluate national and international data available on non-medical drug-use among medical students and risk factors associated with these problems, as well as social and institutional implications. Prevalence rates, in Brazilian and international samples, of alcohol and drug use, abuse and dependence, reasons for onset, methodological issues, and the role of medical education are presented, compared and discussed. The authors suggest some issues that should be a addressed in order to deal with this complex situation.

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.

Managing alcohol and drug problems in general practice: a survey of trainees' knowledge, attitudes and educational requirements

To establish baseline data on Family Medicine Programme trainees' knowledge of and attitudes to drug and alcohol problems, we posted questionnaires to all trainees in New South Wales, Queensland, Victoria and South Australia. A total of 1647 trainees was surveyed, with a response rate of 55 per cent (n = 908). The mean age of respondents was 29 years and 54 per cent were female. The majority of respondents (58 per cent) were in their final year of training. Overall knowledge levels were reasonably good (the mean score was 76 per cent), but there were significant areas of deficit. Senior trainees generally performed better than their junior counterparts. Knowledge was best for alcohol and weakest for opiates. Attitudes towards involvement with drug and alcohol problems were very positive; however, confidence in the efficacy of various interventions was mixed.

Establishment and evaluation of a statewide drug and alcohol specialist advisory service

The New South Wales Drug and Alcohol Specialist Advisory Service aims to provide prompt, relevant and reliable advice on the clinical management of drug- and alcohol-related problems to health professionals throughout New South Wales. We gauged the performance of the Service against present indicators by interviewing 120 callers who had contacted the Service during its first two years. Accessibility and the quality of information provided were rated highly. Of the 120 respondents, 105 (90 per cent) rated the speed of response to their calls as very good or excellent, and 109 (91 per cent) considered the advice given to be very relevant to their needs. Nearly all (97 per cent) indicated their intention to reuse the Service, and 78 (65 per cent) nominated it as their preferred source of clinical advice on drug and alcohol problems. The Service has established itself as an accessible and reliable source of advice on the management of drug and alcohol problems, especially for rural health professionals. This model of a telephone-based consultancy could have application in other medical specialities.

The treatment mapping survey; a descriptive study of drug and alcohol treatment responses in 23 countries

This WHO key informant survey looked at services for the treatment of drug and alcohol problems in 23 different countries. Not surprisingly, there were many differences between treatment responses in the different countries. However, the survey also revealed many similarities in treatment responses. Most countries are confronted by problems of scarcity of resources for substance abuse treatment and many countries also noted the inadequate levels of staff training. Treatment was often primarily delivered in a non-residential setting (especially for alcohol problems). However, some countries treated drug and alcohol problems mainly in residential or inpatient settings. Psychiatrists were one of the professional groups most frequently involved in treatment, and the psychiatric hospital is one of the most common treatment locations. Most key informants reported a lack of basic information about the effectiveness of particular treatment interventions and treatment programmes. Drug services and alcohol treatment services were generally integrated in terms of staff, location, or treatment programmes and in some countries this integration was a feature of the national treatment system. Sometimes the integration of drug and alcohol treatment services was due to the scarcity of national treatment resources. Not all countries operated an integrated drug and alcohol treatment system. In several countries drug and alcohol treatment services were usually provided separately, and a number of countries expressed a preference for this independence. Countries also differed in the extent to which they provided drug or alcohol treatment in conjunction with other health care services with about half of the countries operating with close links with health care services and the other half operating largely independently.(ABSTRACT TRUNCATED AT 250 WORDS)