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A correctable failure: Leaders propose five-point plan to train MDs in addiction

January 10, 2011
by Gary A. Enos, Editor
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Emergence of parity, primary care screening makes the goal more attainable

Graduate medical education gets a failing grade when it comes to training physicians to recognize and address addiction. But a group of addiction field leaders who attended a Betty Ford Institute consensus conference on the subject two years ago believe the time is right for a full integration of addiction topics into medical school curricula.

The group’s five recommendations for achieving this transformation in training were officially published last week in the Annals of Internal Medicine. In an interview with Addiction Professional, Betty Ford Institute president Garrett O’Connor, MD, said reaction has been swift and overwhelmingly positive. O’Connor adds that the group will seek to breathe life into these recommendations by scheduling a follow-up conference in the coming months to evaluate medical educators’ progress in implementing the recommendations. “Medical curricula are political terrains,” says O’Connor. “People have had territory in these curricula for years.” There hasn’t always been room to introduce previously unaddressed subjects, “especially for something so encrusted with shame such as addiction.”

The journal paper, which lists former Office of National Drug Control Policy (ONDCP) deputy director A. Thomas McLellan, PhD, as a co-author, states that according to one study of primary care physicians a staggering 94 percent failed to offer a diagnosis for a patient presenting with an early alcohol abuse problem. “At the center of this inability to provide adequate care is lack of training about substance use in residency programs,” the journal article states. “This is a critical failure of medical education but is eminently correctable.”


Five recommendations
Participants in the consensus conference have outlined five steps for improving substance abuse-related training in residency programs in family practice and internal medicine:

  • Integrating core competencies in substance abuse into residency training, through use of established curricula already developed for this purpose.
  • Giving substance abuse education the same priority as that for other illnesses. “Assigning the same priority to teaching about substance use as is given to teaching about common chronic conditions, such as cardiovascular disease, is essential for trainees to accept substance abuse as a major patient care responsibility,” the paper states.
  • Enhancing faculty development, with the suggestion that organizations that accredit residency programs require a presence of faculty with addiction medicine expertise.
  • Creating an infrastructure for addiction medicine in academic medical centers, through the establishment of multidisciplinary units comprising substance abuse education, research and treatment.
  • Making substance abuse screening and management a part of routine care in primary care practice, with evolving team-based medical home models offering an ideal structure for this.

It is in the latter of the five recommendations where the consensus conference participants see several recent trends improving prospects for success.

“Although physicians often express concern that adding evaluation for substance abuse to their to-do list is not feasible, the broad effect of substance abuse on their patients’ health requires that these issues be addressed,” the paper states. “The combination of team-based care approaches, parity for mental health services, and the availability of new Medicare billing codes for screening and brief intervention ideally will enhance feasibility.”




Status update
The Betty Ford Institute’s O’Connor sees some progress in the presence of addiction topics in medical school curricula, although he attributes that largely to groups such as the American Society of Addiction Medicine (ASAM) stepping in to make up for deficits at the residency program level. The Betty Ford Center itself conducts a weeklong summer institute that attracts more than 100 medical students each year. O’Connor and his colleagues believe it is important for each medical school to enlist one faculty member to focus on integrating substance abuse into the curriculum. “We have no leverage on this,” he says. Yet it can be difficult to identify someone to champion the cause from within the ranks of a medical school’s leadership—after all, you’re asking this of people who essentially never had medical training in addiction topics themselves, O’Connor points out. “Everyone feels that their corner of the field is the most important one for people to pay attention to,” O’Connor says. He adds that when he addresses a typical group of about 150 practicing physicians and asks them if they believe they received anything close to an adequate training in addiction topics, only two or three raise their hand; he says that lack of response ultimately has to change. “For the ones who do raise their hand, most got their training in the Navy or in the VA,” O’Connor says.

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