Acad Psychiatry (2016) 40:514–516 DOI 10.1007/s40596-015-0378-x
COLUMN: EDUCATIONAL CASE REPORT
A “Middle Way”: Introducing a Flexible Year-Long Program to Prepare for Certification in Addiction Medicine Petros Levounis 1 & Erin Zerbo 1 & Rashi Aggarwal 1
Received: 18 August 2014 / Accepted: 25 May 2015 / Published online: 27 June 2015 # Academic Psychiatry 2015
Substance use is endemic in the USA. In 2012, an estimated 22 million Americans, or 8.5 % of the population, met criteria for a substance use disorder in the past year [1]. In 2011, there were 2.5 million emergency department visits that involved drug misuse or abuse, a 52 % increase since 2004. Half of these visits involved the nonmedical use of pharmaceuticals, which is an increase of 132 % since 2004 [2]. Yet despite the tremendous need for treatment, only 11 % of addicted individuals received specialized substance abuse treatment in 2012 [1]. So, how can this enormous treatment deficit be addressed? Given the high prevalence of substance use disorders in a variety of clinical settings (ranging from 8 to 29 % in inpatient settings and up to 20 % in primary care) [3, 4], it would make sense to identify individuals with substance use disorders in these settings and then connect them to treatment. Screening and brief intervention have been shown to be effective in primary care and an increasing number of settings, and models of integration into routine practice have been described [5]. Successful referral to substance abuse treatment from a primary care setting has even been shown to improve depression [6]. However, many surveys have found that physicians do not feel prepared to diagnose or treat addiction, and residents do not feel that they have received sufficient training in addictive disorders during residency [7]. In addition to proposals for curriculum design in residencies and medical schools, online-based programs have been implemented to teach skills * Petros Levounis [email protected] Erin Zerbo [email protected] 1
Rutgers New Jersey Medical School, Newark, NJ, USA
to physicians, residents, and medical students, with varied success [8]. Psychiatry residents can subspecialize in addiction psychiatry by training in an Accreditation Council on Graduate Medical Education (ACGME)-certified addiction psychiatry fellowship program. In addition, physicians from psychiatry and other specialties can become certified by the American Board of Addiction Medicine (ABAM). There are two pathways: (1) a 1-year fellowship training similar to addiction psychiatry programs but administered by the American Board of Addiction Medicine Foundation or (2) to qualify to take the ABAM exam after completing 50 h of addiction-related continuing medical education (CME) courses and practicing in the field of addiction medicine for 1 year. The first pathway requires an additional year of training, which can be difficult for many physicians with large amounts of medical education debt. The second pathway does not provide much structure, making it difficult to physicians to stay motivated. To encourage physicians to complete the second pathway, we developed the Rutgers New Jersey Medical School Executive Fellowship in Addiction Medicine (Exec-FAM). In addition to providing structure for ABAM exam requirements, we hope this fellowship will increase a practitioner’s confidence and accuracy in assessing and diagnosing addictive disorders, and raise her or his comfort level in providing evidence-based treatment for addicted patients.
Design and Implementation The Exec-FAM program was created to address the learning needs of both psychiatric and non-psychiatric physicians. Prior experience in directing an ABAM-certified addiction medicine
Acad Psychiatry (2016) 40:514–516 Table 1
515
E-FAM learning objectives
Table 3
Participant evaluations for the didactic series (N=69)
E-FAM component
Learning objectives
Question
5: “excellent” (%) 4: “good” (%)
Didactic series
Identify common drugs of abuse Recognize intoxication, withdrawal syndromes Discuss common treatment strategies Formulate clinical impressions Develop a treatment plan Discuss differential diagnoses
Overall quality of the course
65 (94)
4 (6)
Instructor’s knowledge of subject matter Instructor’s ability to communicate ideas Usefulness of course material in your work Registration and classroom comfort
68 (99)
1 (1)
68 (99)
1 (1)
55 (80)
14 (20)
54 (78)
15 (22)
Addiction medicine retreats Conferences
Expand knowledge base Exposure to workshops and research by experts
Clinical supervision
Apply addiction based knowledge to patient treatment Justify diagnosis and treatment plan and receive individualized feedback Troubleshoot difficult clinical issues
Self-directed learning
Assimilate further knowledge Research clinical issues
Describes the learning objectives associated with each component of the fellowship
fellowship, along with informal input from residents and attending colleagues, proved to be essential in developing the program. Exec-FAM consists of five major components, each with associated learning objectives (see Table 1): 1) Didactic Series. The Exec-FAM program starts with an intensive 6-day lecture series on the “Fundamentals of Addiction Medicine.” Topics covered include the neurobiology of addiction, alcohol, opioids, stimulants, cannabis, tobacco, and the behavioral addictions. Fellows also receive a course book which included lecture slides, a reading section with peer-reviewed journal articles and excerpts from novels about addiction, and a list of references and resources. 2) Addiction Medicine Retreats. In addition to the lecture series, a “retreat” is held every three months, in which fellows bring cases for discussion with an addiction specialist. These are informal round-table sessions,and are usually followed by a Grand Rounds lecture related to addiction. Table 2
E-FAM fellow primary specialties
Enrolled in fellowship Registered for ABAM examination Passed ABAM examination Withdrew from fellowship
All specialties: N (%)
Psychiatrists: N (%)
Non-psychiatrists: N (%)
24 (100)
12 (50)
12 (50)
10 (42)
4 (17)
6 (25)
9 (38)
4 (17)
5 (21)
4 (17)
2 (8)
2 (8)
Survey participants, 20 attendings, 22 residents, 5 graduate students, 22 “other”. Categorical responses from the evaluation for the didactic series
3) Conferences. Fellows are required to participate in a least two national conferences: The Annual Medical-Scientific Conference of the American Society of Addiction Medicine (ASAM) in the Spring and the ASAM Review Course in the Summer/Fall. Posters or presentations are encouraged but not required. 4) Clinical Supervision. Individual supervision provides ongoing, one-on-one consultation on complex clinical cases, as well as guidance in the process of becoming an addiction expert. As the program grows, recent graduates will be asked to serve as supervisors and mentors for the new generation of fellows. 5) Self-Directed Learning. Fellows are expected to actively engage in learning about addiction medicine. They are encouraged to review The ASAM Principles of Addiction Medicine textbook, The Addiction Casebook [9], and other addiction-related books and articles. Exec-FAM also organizes special events like the screening of the movie Flight, which are followed by an active discussion. Participation in each of the five components ensures a broad range of training and exposure to various learning environments. The didactic series provides traditional lecturebased content, while the retreats employ a problem-based learning format. Clinical supervision allows for one-on-one interaction, and conferences provide a wide view of the field and encourage networking. We have also found that including elements of the humanities, such as film screenings, can be crucial for fostering empathy in participants and providing a forum in which they can examine their own emotional responses to addicted persons.
Outcomes
Psychiatrist and non-psychiatrist enrollment and participation
The first year of the Exec-FAM program ran from Summer 2013 to Fall 2014. It was advertised at Rutgers New Jersey Medical School via e-mail, flyers, and word of mouth. It was very well received. A total of 24 attending physicians from
516
different specialties registered for the fellowship and engaged in activities (Table 2). Ten physicians (42 %) subsequently registered for the ABAM examination, and nine passed. These nine physicians represented the following specialties: four in psychiatry, two in internal medicine, two in obstetrics and gynecology, and one in pediatrics. In addition to the participants engaged in the certification process, the fellowship program has had an even larger impact since many more faculty and trainees attended the didactic series. Overall, there were 90–100 attendees for each didactic session. Trainees (residents and medical students) represented 50 % of all attendees. Fifty percent of all attendees were from psychiatry, and 50 % were from other departments. Evaluations were obtained from didactic participants, and they were asked to rate various aspects of the course on a scale from 1 to 5, with 1 being “poor” and 5 being “excellent.” Rutgers University Institutional Review Board approval was obtained in order to analyze this data. Overall, the series was rated highly on all measures, and the majority of responses were “excellent” (see Table 3). No scores were less than 4. Participants commented that the series was “engaging and relatable,” “well-organized,” and “an excellent course for people who are interested in addiction medicine.” There were suggestions to incorporate it formally into didactics for trainees in medicine, neurology, pediatrics, OB/GYN, and nursing and to include an additional training in buprenorphine prescribing.
Discussion Further evaluations in all areas of the program, and not just the didactic series, would be helpful to continue to improve the fellowship. In the future, outcome assessments such as practitioner confidence in treating addictive disorders or tracking of addicted patient caseloads could be used to determine the effectiveness of the fellowship in making long-term, sustainable changes to practice. We would also like to assess for any gaps in our current curriculum. While we expect that practitioners from any field are already seeing addictive disorders in their daily practice, it is possible that some might like a more structured clinical exposure to addicted patients. Similarly, if participants find that the self-directed learning component is not structured enough, additional group supervision could be incorporated into the program. The Exec-FAM program provides a structured pathway for physicians and trainees to expand their knowledge base of addiction and to effectively treat addicted patients. Unlike traditional ACGME-certified fellowships, this program is flexible and adaptable to the individual clinician’s needs and does not require “giving up” a current practice or extending training. At the same time, it provides support and assists clinicians in feeling more comfortable to treat the addicted patients that they are already seeing. It encourages ABAM
Acad Psychiatry (2016) 40:514–516
certification and ongoing participation in the network of addiction practitioners in the USA. This type of program has significant implications for educators and leaders: This is a novel, structured way to approach addiction training for attending physicians, which allows existing faculty to develop a new skillset. Many institutions struggle with addicted patients and lack the resources for appropriate treatment, and this type of training will fill a significant treatment gap. It is hoped that this “middle way” could be replicated at other institutions, since it only requires a few specialized addiction faculty, and learning methods such as conferences and self-directed study augment the curriculum. Above all, it creates an atmosphere of collegiality and scholarship with regard to addiction, and we hope this will encourage more physicians to engage in the training that is so greatly needed by our patients who have substance use disorders.
Disclosures On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1.
Substance Abuse & Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse & Mental Health Services Administration, 2013. http://www.samhsa.gov/data/sites/ default/files/NSDUHresults2012/NSDUHresults2012.pdf. Accessed 13 May 2015. 2. Substance Abuse & Mental Health Services Administration, Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. (SMA) 134760, DAWN Series D-39. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. http://www.samhsa. gov/data/sites/default/files/DAWN2k11ED/DAWN2k11ED/ DAWN2k11ED.pdf. Accessed 13 May 2015. 3. Brown RL, Leonard T, Saunders LA, Papasouliotis O. The prevalence and detection of substance use disorders among inpatients ages 18 to 49: an opportunity for prevention. Prev Med. 1998;27(1):101–10. 4. Manwell LB, Fleming MF, Johnson K, Barry KL. Tobacco, alcohol, and drug use in a primary care sample. J Addict Dis. 1998;17(1):67–81. 5. Agerwala SM, McCance-Katz EF. Integrating screening, brief intervention, and referral to treatment (SBIRT) into clinical practice settings: a brief review. J Psychoactive Drugs. 2012;44(4):307–17. 6. Chan YF, Huang H, Bradley K, Unutzer J. Referral for substance abuse treatment and depression improvement among patients with co-occurring disorders seeking behavioral health services in primary care. J Subst Abus Treat. 2014;46(2):106–12. 7. Wakeman SE, Baggett MV, Pham-Kanter G, Campbell EG. Internal medicine residents’ training in substance use disorders: a survey of the quality of instruction and residents’ self-perceived preparedness to diagnoses and treat addiction. Subst Abus. 2013;34(4):363–70. 8. Harris JM, Sun H. A randomized trial of two e-learning strategies for teaching substance abuse management skills to physicians. Acad Med. 2013;88(9):1357–62. 9. Levounis P, Herron AJ, editors. The addiction casebook. Washington: American Psychiatric Publishing; 2014.
COLUMN: EDUCATIONAL CASE REPORT
A “Middle Way”: Introducing a Flexible Year-Long Program to Prepare for Certification in Addiction Medicine Petros Levounis 1 & Erin Zerbo 1 & Rashi Aggarwal 1
Received: 18 August 2014 / Accepted: 25 May 2015 / Published online: 27 June 2015 # Academic Psychiatry 2015
Substance use is endemic in the USA. In 2012, an estimated 22 million Americans, or 8.5 % of the population, met criteria for a substance use disorder in the past year [1]. In 2011, there were 2.5 million emergency department visits that involved drug misuse or abuse, a 52 % increase since 2004. Half of these visits involved the nonmedical use of pharmaceuticals, which is an increase of 132 % since 2004 [2]. Yet despite the tremendous need for treatment, only 11 % of addicted individuals received specialized substance abuse treatment in 2012 [1]. So, how can this enormous treatment deficit be addressed? Given the high prevalence of substance use disorders in a variety of clinical settings (ranging from 8 to 29 % in inpatient settings and up to 20 % in primary care) [3, 4], it would make sense to identify individuals with substance use disorders in these settings and then connect them to treatment. Screening and brief intervention have been shown to be effective in primary care and an increasing number of settings, and models of integration into routine practice have been described [5]. Successful referral to substance abuse treatment from a primary care setting has even been shown to improve depression [6]. However, many surveys have found that physicians do not feel prepared to diagnose or treat addiction, and residents do not feel that they have received sufficient training in addictive disorders during residency [7]. In addition to proposals for curriculum design in residencies and medical schools, online-based programs have been implemented to teach skills * Petros Levounis [email protected] Erin Zerbo [email protected] 1
Rutgers New Jersey Medical School, Newark, NJ, USA
to physicians, residents, and medical students, with varied success [8]. Psychiatry residents can subspecialize in addiction psychiatry by training in an Accreditation Council on Graduate Medical Education (ACGME)-certified addiction psychiatry fellowship program. In addition, physicians from psychiatry and other specialties can become certified by the American Board of Addiction Medicine (ABAM). There are two pathways: (1) a 1-year fellowship training similar to addiction psychiatry programs but administered by the American Board of Addiction Medicine Foundation or (2) to qualify to take the ABAM exam after completing 50 h of addiction-related continuing medical education (CME) courses and practicing in the field of addiction medicine for 1 year. The first pathway requires an additional year of training, which can be difficult for many physicians with large amounts of medical education debt. The second pathway does not provide much structure, making it difficult to physicians to stay motivated. To encourage physicians to complete the second pathway, we developed the Rutgers New Jersey Medical School Executive Fellowship in Addiction Medicine (Exec-FAM). In addition to providing structure for ABAM exam requirements, we hope this fellowship will increase a practitioner’s confidence and accuracy in assessing and diagnosing addictive disorders, and raise her or his comfort level in providing evidence-based treatment for addicted patients.
Design and Implementation The Exec-FAM program was created to address the learning needs of both psychiatric and non-psychiatric physicians. Prior experience in directing an ABAM-certified addiction medicine
Acad Psychiatry (2016) 40:514–516 Table 1
515
E-FAM learning objectives
Table 3
Participant evaluations for the didactic series (N=69)
E-FAM component
Learning objectives
Question
5: “excellent” (%) 4: “good” (%)
Didactic series
Identify common drugs of abuse Recognize intoxication, withdrawal syndromes Discuss common treatment strategies Formulate clinical impressions Develop a treatment plan Discuss differential diagnoses
Overall quality of the course
65 (94)
4 (6)
Instructor’s knowledge of subject matter Instructor’s ability to communicate ideas Usefulness of course material in your work Registration and classroom comfort
68 (99)
1 (1)
68 (99)
1 (1)
55 (80)
14 (20)
54 (78)
15 (22)
Addiction medicine retreats Conferences
Expand knowledge base Exposure to workshops and research by experts
Clinical supervision
Apply addiction based knowledge to patient treatment Justify diagnosis and treatment plan and receive individualized feedback Troubleshoot difficult clinical issues
Self-directed learning
Assimilate further knowledge Research clinical issues
Describes the learning objectives associated with each component of the fellowship
fellowship, along with informal input from residents and attending colleagues, proved to be essential in developing the program. Exec-FAM consists of five major components, each with associated learning objectives (see Table 1): 1) Didactic Series. The Exec-FAM program starts with an intensive 6-day lecture series on the “Fundamentals of Addiction Medicine.” Topics covered include the neurobiology of addiction, alcohol, opioids, stimulants, cannabis, tobacco, and the behavioral addictions. Fellows also receive a course book which included lecture slides, a reading section with peer-reviewed journal articles and excerpts from novels about addiction, and a list of references and resources. 2) Addiction Medicine Retreats. In addition to the lecture series, a “retreat” is held every three months, in which fellows bring cases for discussion with an addiction specialist. These are informal round-table sessions,and are usually followed by a Grand Rounds lecture related to addiction. Table 2
E-FAM fellow primary specialties
Enrolled in fellowship Registered for ABAM examination Passed ABAM examination Withdrew from fellowship
All specialties: N (%)
Psychiatrists: N (%)
Non-psychiatrists: N (%)
24 (100)
12 (50)
12 (50)
10 (42)
4 (17)
6 (25)
9 (38)
4 (17)
5 (21)
4 (17)
2 (8)
2 (8)
Survey participants, 20 attendings, 22 residents, 5 graduate students, 22 “other”. Categorical responses from the evaluation for the didactic series
3) Conferences. Fellows are required to participate in a least two national conferences: The Annual Medical-Scientific Conference of the American Society of Addiction Medicine (ASAM) in the Spring and the ASAM Review Course in the Summer/Fall. Posters or presentations are encouraged but not required. 4) Clinical Supervision. Individual supervision provides ongoing, one-on-one consultation on complex clinical cases, as well as guidance in the process of becoming an addiction expert. As the program grows, recent graduates will be asked to serve as supervisors and mentors for the new generation of fellows. 5) Self-Directed Learning. Fellows are expected to actively engage in learning about addiction medicine. They are encouraged to review The ASAM Principles of Addiction Medicine textbook, The Addiction Casebook [9], and other addiction-related books and articles. Exec-FAM also organizes special events like the screening of the movie Flight, which are followed by an active discussion. Participation in each of the five components ensures a broad range of training and exposure to various learning environments. The didactic series provides traditional lecturebased content, while the retreats employ a problem-based learning format. Clinical supervision allows for one-on-one interaction, and conferences provide a wide view of the field and encourage networking. We have also found that including elements of the humanities, such as film screenings, can be crucial for fostering empathy in participants and providing a forum in which they can examine their own emotional responses to addicted persons.
Outcomes
Psychiatrist and non-psychiatrist enrollment and participation
The first year of the Exec-FAM program ran from Summer 2013 to Fall 2014. It was advertised at Rutgers New Jersey Medical School via e-mail, flyers, and word of mouth. It was very well received. A total of 24 attending physicians from
516
different specialties registered for the fellowship and engaged in activities (Table 2). Ten physicians (42 %) subsequently registered for the ABAM examination, and nine passed. These nine physicians represented the following specialties: four in psychiatry, two in internal medicine, two in obstetrics and gynecology, and one in pediatrics. In addition to the participants engaged in the certification process, the fellowship program has had an even larger impact since many more faculty and trainees attended the didactic series. Overall, there were 90–100 attendees for each didactic session. Trainees (residents and medical students) represented 50 % of all attendees. Fifty percent of all attendees were from psychiatry, and 50 % were from other departments. Evaluations were obtained from didactic participants, and they were asked to rate various aspects of the course on a scale from 1 to 5, with 1 being “poor” and 5 being “excellent.” Rutgers University Institutional Review Board approval was obtained in order to analyze this data. Overall, the series was rated highly on all measures, and the majority of responses were “excellent” (see Table 3). No scores were less than 4. Participants commented that the series was “engaging and relatable,” “well-organized,” and “an excellent course for people who are interested in addiction medicine.” There were suggestions to incorporate it formally into didactics for trainees in medicine, neurology, pediatrics, OB/GYN, and nursing and to include an additional training in buprenorphine prescribing.
Discussion Further evaluations in all areas of the program, and not just the didactic series, would be helpful to continue to improve the fellowship. In the future, outcome assessments such as practitioner confidence in treating addictive disorders or tracking of addicted patient caseloads could be used to determine the effectiveness of the fellowship in making long-term, sustainable changes to practice. We would also like to assess for any gaps in our current curriculum. While we expect that practitioners from any field are already seeing addictive disorders in their daily practice, it is possible that some might like a more structured clinical exposure to addicted patients. Similarly, if participants find that the self-directed learning component is not structured enough, additional group supervision could be incorporated into the program. The Exec-FAM program provides a structured pathway for physicians and trainees to expand their knowledge base of addiction and to effectively treat addicted patients. Unlike traditional ACGME-certified fellowships, this program is flexible and adaptable to the individual clinician’s needs and does not require “giving up” a current practice or extending training. At the same time, it provides support and assists clinicians in feeling more comfortable to treat the addicted patients that they are already seeing. It encourages ABAM
Acad Psychiatry (2016) 40:514–516
certification and ongoing participation in the network of addiction practitioners in the USA. This type of program has significant implications for educators and leaders: This is a novel, structured way to approach addiction training for attending physicians, which allows existing faculty to develop a new skillset. Many institutions struggle with addicted patients and lack the resources for appropriate treatment, and this type of training will fill a significant treatment gap. It is hoped that this “middle way” could be replicated at other institutions, since it only requires a few specialized addiction faculty, and learning methods such as conferences and self-directed study augment the curriculum. Above all, it creates an atmosphere of collegiality and scholarship with regard to addiction, and we hope this will encourage more physicians to engage in the training that is so greatly needed by our patients who have substance use disorders.
Disclosures On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1.
Substance Abuse & Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse & Mental Health Services Administration, 2013. http://www.samhsa.gov/data/sites/ default/files/NSDUHresults2012/NSDUHresults2012.pdf. Accessed 13 May 2015. 2. Substance Abuse & Mental Health Services Administration, Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. (SMA) 134760, DAWN Series D-39. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. http://www.samhsa. gov/data/sites/default/files/DAWN2k11ED/DAWN2k11ED/ DAWN2k11ED.pdf. Accessed 13 May 2015. 3. Brown RL, Leonard T, Saunders LA, Papasouliotis O. The prevalence and detection of substance use disorders among inpatients ages 18 to 49: an opportunity for prevention. Prev Med. 1998;27(1):101–10. 4. Manwell LB, Fleming MF, Johnson K, Barry KL. Tobacco, alcohol, and drug use in a primary care sample. J Addict Dis. 1998;17(1):67–81. 5. Agerwala SM, McCance-Katz EF. Integrating screening, brief intervention, and referral to treatment (SBIRT) into clinical practice settings: a brief review. J Psychoactive Drugs. 2012;44(4):307–17. 6. Chan YF, Huang H, Bradley K, Unutzer J. Referral for substance abuse treatment and depression improvement among patients with co-occurring disorders seeking behavioral health services in primary care. J Subst Abus Treat. 2014;46(2):106–12. 7. Wakeman SE, Baggett MV, Pham-Kanter G, Campbell EG. Internal medicine residents’ training in substance use disorders: a survey of the quality of instruction and residents’ self-perceived preparedness to diagnoses and treat addiction. Subst Abus. 2013;34(4):363–70. 8. Harris JM, Sun H. A randomized trial of two e-learning strategies for teaching substance abuse management skills to physicians. Acad Med. 2013;88(9):1357–62. 9. Levounis P, Herron AJ, editors. The addiction casebook. Washington: American Psychiatric Publishing; 2014.
