International Medical Graduates' Attitudes Toward Substance Abuse Blanca Fernandez-Po~M.D., NaUnl V.Jutbani, M.D. Harvey Bluestone, M.D., Mark S. Muzruchi, Ph.D.

Afterdeveloping ahypothesis that international medical graduates (IMGs) from diffrrent ethno-cultural backgrounds would havedifferent attitudes toward substance abuse, we compared the attitudes of 79 fMG applicants to our psychiatry residency training pr0gram using Chappel's Substance Abuse Attitude Survey. Except for the finding that men were less moralistic about substance abuse than women, wefound nosignificant attitudinal diffrrences among these IMGs despite their diverse backgrounds.

A lcoholism and drug abuse are major .fihealth problems in the United States according to the Epidemiologic Catchment Area Study (t). Until recently, alcoholics and drug abusers have been stigmatized/ and their behavior has been considered a matter of personal choice with moral and legal implications. As a result, physicians often did not diagnose or treat substance abusers (2-5). Several studies (6-8) have reported the pessimism and negative attitudes of medical students and physicians toward alcoholics and drug abusers. Chappel et al. (9) and Chappel (10) reported that medical students in the United States undergo attitudinal changes in response to substance abuse education. The topic of substance abuse has recently been an emphasis in medical education. Galanter et al. (11) conducted a survey of medical schools and psychiatry residency programs in the United States to determine how many offered psychiatric courses in alcoholism and drug abuse. They found that 97% of the 106 responding medical schools and 91% of the 169 responding psychiatry residency programs offered curriculum units in substance abuse disorders. To our knowledge, little is known about medicaleducation on substanceabuse in for-

eign medical schools, and no studies have been published about the attitudes of foreign-born international medical graduates (IMGs) toward substance abusers. There are worldwide discrepancies about what constitutes a substance abuse disorder. In the United States in 1987/ the American Medical Association's House of Delegates adopted policies endorsing the proposition that alcoholism and other substance dependencies are in fact diseases (3). However, in some developing countries drugs are used as a normal and integral part of their culture (12). Each country has its own historical, cultural, economic, and political approach to substance abuse. Religious beliefs against the use of alcohol are seen in fundamentalist Islamic countries/ where alDr. Fernandez-Pol and Dr. Juthani are assistant professors, Dr. Bluestone is professor, and Dr. Mizruchi is former assistant professor, Department of Psychiatry, Albert Einstein College of Medicine, Bronx. NY. All but Dr. Mizruchi are also affiliated with Bronx-Lebanon Hospital Center, where Dr. Fernandez-Pol is chief physician, Continuing Treatment Program. Dr. Juthani is director of residency training, and Dr. Bluestone is director of psychiatry. Address correspondence to Dr. Fernandez-Pol, Dept. of Psychiatry, Bronx-Lebanon Hospital Center, 1285 Fulton Ave., Bronx, NY 10456. Copyright C 1991 Aaulemic Psychiatry.

cohol is specifically forbidden by the Koran. In the United States, however, controlled drinking is socially acceptable. Cannabis has been a home remedy in India for thousands of years, and it is still widely used by some religious groups (13). In Jamaica, cannabis use has become an institutionalized pattern among cane cutters to alleviate fatigue in field work, and it is used extensively by the Rastafarian cultists (13).Mescaline and other psychedelic substances are used in folk healing in northern Peru (14). Millions of natives in Bolivia and Peru chew coca leaves regularly to reduce fatigue at high altitude regions (15) . In Laos, Hmong people survive by cultivating and frequently using opium poppies (16). Chewing the leaves of qat (an amphetamine-like alkaloid) is a widespread social activity among all social classes in northern Yemen (17). Negrete (18) has pointed out that there is transcultural variance in attitudes toward substance abuse among professionals. We hypothesized that because IMGs come from different countries with diverse ethnic, cultural, religious, and educational backgrounds, they would differ in their attitudes toward substance abusers. METHODS

The subjects of the study were applicants to the psychiatry residency program at BronxLebanon Hospital Center-Albert Einstein College of Medicine. One hundred applicants who had been selected for residency interviews were asked to take part in our study. Of those, 90 volunteered to participate. Nine applicants born in the United States and two born in Europe were not included in the study. This left a total 79 subjects. The applicants were informed that they were filling out an anonymous questionnaire for research purposes. Applicants were told that neither their decision on whether to participate in our study, nor what those participating said in their responses would have any effect on their acceptance as residents.

The study consisted of a self-administered questionnaire with two sections. Section 1 dealt with demographic variables such as sex, age, ethnicity, birth place, place reared, and religion. Section 2 consisted of the Substance Abuse Attitude Survey (SAAS) of Chappel et al. (19). This scale measures attitudes toward various aspects of alcohol and drug abuse. The SAAS,used most extensively to measure attitudinal change in medical students following different educational experiences, has been reported to have high reliability and validity (4,10,19). It is composed of 50 5-point, Likert-type items ranging from "strongly agree" to "strongly disagree." The SAAS was developed in cooperation with Career Teachers in Alcohol and Drug Abuse and the Association for Medical Education and Research in Substance Abuse. The items came from a pool of statements concerning a variety of beliefs about drug abuse etiology, patterns of use and abuse, and treatment approaches. Multiple administrations and factor analyses yielded five stable, coherent factors: permissiveness, treatment intervention, nonstereotypes, treatment optimism, and nonmoralism.Some sample items are: "Marijuana should be legalized," "It can be normal for a teenager to experiment with drugs," "Clergymen should not drink in public," "Alcoholism is associated with a weak will," "Drug addiction is a treatable illness," and "Urine drug screening can be an important part of treatment of drug addiction." RESULTS Table 1 presents frequency distributions of demographic variables of the IMG sample. All of the subjects were born outside of the United States. Eleven (14%) were reared in the United States. The Asian sample was composed of 30 (38%) physicians born in countries in South Asia, mainly India, and 5 (6%)in East Asia. None were born in Japan. All of the Hispanics were born in Latin

America. The black sample was composed of 10 (13%) subjects born in Caribbean, nonHispanic countries and 4 (5%) in Africa. Fifty-three subjects (67%) were raised in urban communities, 16 (20%) in suburban communities, and 10 (13%) in rural areas . Sixty-two (79%) belonged to the upper-middle class, 9 (11 %) to the lower-middle class, and 8 (10%) to the lower class. Their mean (±SO)years of residence in the United States was5.9±7.2andtheywere4.0±2.6yearspostgraduation from medical school. We constructed a variable for each of Chappel's five factors and used his factor loadings to compute composite scores for each variable. The factors were then compared using four demographic variables: sex, ethnicity, place reared, and religion. In only two cases were there significant associations between one of the factors and the demographic variables. Men scored higher than women on nonmoralism (t = -2.14, df = 75, P = 0.0355) and the analysis of variance comparing Asians, Hispanics, and blacks on nonstereotypes revealed a significant F (F = 4.10, df = 2.74,P = 0.0206). However, a mulTABLE L Demographic characteristics of 79 International Medial Graduate applicants to psychiatric residency Characteristics

F

Percentage

61 18

77.2 22.8

35 30 14

44.3 38.0 17.7

41 21 8 2 1 1 3 2

51.9

Sex Male

Female Ethnicity Asian Hispanic

Black Religion Roman Catholic Hindu

Protestant Muslim Eastern Orthodox Buddhist Other None Age (mean ± SO)

30.1 ±3.6

Note: F = frequency distribution.

26.6 10.1 2.5 1.3 1.3 3.8 25

tiple comparison (Tukey's highly significant difference test) among the three group means did not reveal any significantly different pairs, suggesting that the significant overall F was a marginal finding. DISCUSSION To our surprise we did not find substantive differences in the IMGs' attitudes toward substance abuse.The single difference found was that males were significantly less moralistic than females in their attitudes toward substance abusers. This might be explained by the fact that the female subjects came from non-Western countries, where women undergo a more conservative upbringing. In interpreting our findings, we have to consider that the sample was small and selfselected and that the SAAS is a self-report scale. It is therefore possible that our results represent a response set of social desirability from residency applicants hoping to fit the faculty's expectations. On the other hand, it has been shown in the United States that medical students undergo attitudinal changes toward patients in response to their education and training (20). Therefore it is possible that the medical school education experience of our subjects, even though it occurred in different parts of the world, may have diminished cross-cu1tural differences in attitudes toward substance abuse that might initially have existed. However, because we are not aware of published studies about the status of psychiatric education in alcoholism and drug abuse in foreign medical schools, this explanation is speculative.

Although there were no differences among our IMGs in their attitudes toward substance abuse, IMGs may have different attitudes than future psychiatrists schooled in the United States. We suggest another study that compares the attitudes of IMGs and United States medical graduates toward substance abuse to determine if IMGs need to receive different training during residency in this important area of psychiatry.

References 1. Myers JR, Weissman MM, Tischler Gl, et al: Sixmonth prevalence of psychiatric disorders in three communities. Arch Gen Psychiatry 1984; 41"959-JNJ7 2. Barnes SN, O'Neill SF, Aronson MO, et al: Early detection and outpatient management of alcoholism: a curriculum for medical residents. Journal of Medical Education 1984; 59:904-906 3. Bowen OR, Sammons ]H: The alcohol-abusing patient: a challenge to the profession. JAMA 1988;

260:2267-2270 4. Geller G, Levine PM, Mamon JA, et al: Knowledge, attitudes, and reported practices of medical students and house staff regarding the diagnosis and treatment of alcoholism.]AMA 1989; 261:3115-3120 5. Chappel ]N, Schnoll SH: Physician attitudes effect on the treatment of chemically dependent patients. JAMA 1977; 237:231S-2319 6. Chappel ]N: Attitudinal barriers to physician involvement with drug abusers. JAMA 1973; 224:1011-1013 7. Fisher]C, Mason Rl, Kelley RA, et al: Physiciansand alcoholics.Theeffect of medical training onattitudes toward alcoholics. ] Stud Alcohol 1975; 36:949-955 8. Lewis OC, Niven RG, Czechowicz D, et al: A review of medical education in alcohol and other drug abuse.]AMA 1987; 257:2945-2948 9. Chappel IN, Jordan RD, Treadway B], et al: Substance abuse attitude changes in medical students. Am] Psychiatry 1977; 134:379-383 10. Chappel]N: Teaching chemical dependence across four years of medical school. Substance Abuse 1986; 7:6-14

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11. Galanter M, Kaufman E, Taintor Z, et al: The current status of psychiatric education in alcoholism and drug abuse. Am] Psychiatry 1989; 146:35-39 12. Dobkin de Rios M: Cultural persona in drug-involved altered states of consciousness, in Social and Cultural Identity: Problems of Persistence and Change, edited by Fitzgerald TK. Athens, GA, University of GeorgiaPress, 1974 13. Rubin V: Variations and patters in the cultural response to cannabis use. International Mental Health Research Newsletter 1971; 12:5-10 14. Dobkin de Rios M: Folk curing with a mescaline cactus in northern Peru. Int J Soc Psychiatry 1969; 15:23-32 15. Van Dyke C: Cocaine, in Substance Abuse Clinical Problems and Perspectives, edited by Lowinson]H, Ruiz P. Baltimore, Williams &: Wilkins, 1981 16. Westermeyer]: Poppies, Pipes, and People. Berkeley, University of California Press, 1982 17. Kennedy ]C: The Flower of Paradise: The Institutionalized Use of the Drug Qat in North Yemen. Norwell, MA, D. Reidel Publishing Company, 1987 18. Negrete JC: Definition and historical perspective of thesubstanceabuse problem. SubstanceAbuse 1983; 5:3-7 19. Chappel ]N, Veach TL, Krug RS: The substance abuse attitude survey: an instrument for measuring attitudes. J Stud Alcohol 1985; 46:48-52 20. Rezler AG: Attitude changes during medical school: a review of the literature. Journal of Medical Education 1974; 49:1023-1030

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International medical graduates' attitudes toward substance abuse.

After developing a hypothesis that international medical graduates (IMGs)from different ethno-cultural backgrounds would have different attitudes towa...
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