that destroyed its products. For many years automobile owners appeared resigned to the fact that their vehicles would have short lives before they rusted and deteriorated from exposure to salt. In some cases expensive repairs were done; nevertheless, the cause and prevention of the rust were ignored. Ultimately the industry was forced to adopt a new standard because of public dissatisfaction and the availability of foreign cars that were manufactured with rust proofing. Now it is accepted by the public and the automotive industry that automobiles can and must be protected in this manner. The time is long overdue for Canadian medicine to respond to the "rusting" of its patients from the ravages of alcohol and other drugs.

I acknowledge the pioneering work of Dr. Harold Kalant and many others who have contributed to the development and conduct of medical education on alcohol- and drug-related problems at the University of Toronto. Particular thanks are due to Mrs. Yuen-Ching Chow for her efforts in course development and coordination.

References 1. Schneiderman JF, Rankin JG: Attitudes towards alcohol dependence: medical students vs professionals working in alcohol and drug services. Clin Invest Med 1987; 10 (suppl 4): 364 2. Devenyi P, Saunders S: Physicians' Handbook for Medical Management ofAlcohol- and Drug-related Problems, Addiction Research Foundation of Ontario/Ontario Medical Association, Toronto, 1986

Medical education for alcohol and other drug abuse in the United States David C. Lewis, MD Initiatives by individuals, private foundations and government have led to improvements in the United States in medical education dealing with alcohol and drug-related problems. Progress has been made, particularly in the past 5 years, in developing new medical school curricula and in faculty development. Greater activity by national professional organizations has helped raise the priority of training in alcohol- and drug-related areas for undergraduate and postgraduate medical education. As an example, Project ADEPT (Alcohol and Drug Education for Physician Training in primary care) at Brown University in Providence, Rhode Island, is described. The importance of positive and motivated faculty role models and of skills training is emphasized.

n analysis of US medical education initiatives in the alcohol and drug field reveals a history of efforts by individuals, private organizations and government to put this subject into the mainstream of undergraduate and graduate medical training.3 The founding of organizations interested in this field and the actions they took were notable milestones in those efforts (Table 1). Several seminal elements in this history give a sense of the direction for future activities. Efforts in the 1950s were directed primarily at strengthening the role of physicians in addiction treatment, particularly alcoholism treatment. Essential to the definition of this role were recommendations for better medical training. Both the American Medical Association Committee on Alcoholism, headed by Dr. Marvin Block of Buffalo, and the New York City A

Medical Society on Alcoholism, forerunner of the 3800-member American Society of Addiction Medicine, focused on physician training. The first formal attempt to remedy the-absence of an effective curriculum in medical education was the Career Teacher Program, which supported faculty in 59 schools. It established a core of knowledgeable and committed faculty by holding regular meetings to design curricula, compare teaching strategies and discuss how to overcome difficulties in implementing effective teaching programs.4'5 Many former career teachers now provide leadership in medical education. Generally considered a success, the program represented the major activity during its decade of existence from 1971 to 1981. AMERSA (Association for Medical Education and Research in Substance Abuse) was founded by

Dr. Lewis is Professor ofMedicine and Community Health and Donald G. Millar Professor ofAlcohol and Addiction Studies at the Brown University Center for Akohol and Addiction Studies.

Correspondence to: Dr. David C. Lewis, Director, Center for Alcohol and Addiction Studies, Brown University, Box G, Providence, RI 02912, USA This report has not been peer reviewed.

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career teachers in 1976 to enlarge the forum for their discussions. It now has almost 10 times the membership of the original group; it holds an annual national conference and publishes Substance Abuse, a quarterly journal. What is apparent from the Career Teacher Program and AMERSA is the strong need for faculty support groups to deal effectively with the issues medical education raises in this field. The 1985 AMERSA national conference played a unique role in developing medical education. The conference was oriented toward reaching a consensus concerning the knowledge and skills physicians in training and practising physicians need to diagnose and care for patients with alcohol and other drugabuse problems. A report of the conference consensus statements was published and distributed to the deans of medical schools and heads of national professional societies.6 The very format of the consensus conference provided a significant model for the future. Small groups selected the essential knowledge and skills that their disciplines needed; psychiatry, pediatrics, family medicine and internal medicine were the disciplines chosen for the task groups. Another group refined the list even further to represent the generic knowledge and skills that all physicians need. Because the leaders of national professional societies participated in this consensus process, the confer-

ence helped foster the subsequent formation of special interest groups in those societies. Psychiatry, pediatrics, family medicine and internal medicine now have cohesive groups within their societies that provide this support and serve as cosponsors of AMERSA's annual meeting. As a direct outgrowth of the consensus conference the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA) issued contracts in 1986 to develop and implement curricula. Those receiving the contracts were instructed to take the conference consensus statements as a starting point and to further refine them before developing new curricula.7 The 1986 contracts established a process of defining competencies, choosing the best teaching methods to teach those competencies and evaluating the teaching effort. This has set in motion an effective way to develop and implement medical curricula. Specifying a working committee of faculty to carry out the process ensures the continuation of faculty development. The government-sponsored grant program of 1988 carries forth the faculty development theme. When the program began it was directed only to medical and nursing schools, but now schools that teach social work and psychology are eligible. The schools may choose up to five faculty members, each

Table 1 Milestones in alcohol/drug medical education

1954 1967 1970

1971

972

1973

DruQ

1 97-

Dependencies AMERSA (Association for Medical Education and Research n Substance Abuse) founded by Career Teachers Project Cork at Dartmouth Medical School Brown University and University of California at Los Angeles endowed faculty positions in addiction studies

1983 1984

American Academy of Pediatrics issued position statement Society of Teachers of Family Medicine published residency

1976

1985

1986

1987 1988 1092

New York City Medical Society on Alcoholism American Medical Society (AMA) on Alcoholism National Council on Alcoholism forum Career Teacher Program Macy Foundation conference AMA Council on Mental Health report California Society for the Treatment of Aicoholism and Other

training curriculum guide Johns Hopkins Medical School launched institution-wide alcohol medical education program American College of Physicians issued position paper Consensus conference cosponsored by AMERSA, National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute on Drug Abuse (NIDA), Betty Ford Center and Annenberg Center American Academy of Psychiatrists in Alcohol and Addictions American Society of Addiction Medicine established certificatior examination for practising physicians NIAAA/NIDA signed contracts with medical schools and national professional societies to develop and implement curricula Fellowship Center at New York University coordinated information about fellowship training F-aculty development grant program begun by NIAAA and NIDA

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from a different department, to receive 15% to 20% in salary support. Recipients must develop a plan for their own education and teaching activities. The meetings of the first cohort of faculty awardees so far have resembled the early career teacher meetings; their esprit and dynamic sense of mission attest to their feelings that a support structure is needed. It is noteworthy that government is not alone in supporting these efforts. Private funding and philanthropy have given impetus to the further definition of teaching standards. The endowments at Brown and Cornell universities and the University of California at Los Angeles, the Kroc Foundation gift to Dartmouth University, the JM Foundation summer program for medical student education and the national Citizen's Commission sponsorship of faculty development workshops are but a few examples of such support. Once competency levels were being defined, an organized effort arose to see that those levels were met. One such effort is the certification examination given by the American Society of Addiction Medicine.8 About half (1826) of its members have passed this examination. Another effort at standardization is being made by a consortium of national organizations and the fellowship centre at New York University, which have prepared a preliminary list of fellowships and are drafting guidelines for an American Board of Medical Specialities fellowship in the alcohol and drug field. One theme that pervades progress in alcohol and drug medical education is the need for faculty development.9-'3 The key to sustained development is the provision of individual and institutional role models for training. Hence, faculty development is essential to the training of medical students and residents, and university-sponsored clinical programs in the addictions must reflect the same attention to rigorous evaluation and responsiveness to the spectrum of clinical presentations as to the clinical services for other diseases. This is also why support of the leadership in a medical school is vital for addressing alcohol and drug problems in the educational mainstream.'4

Brown University experience The Brown University Center for Alcohol and Addiction Studies is a case study in faculty development because we have specialized in internal faculty development for the past 5 years.'5 Furthermore, we have conducted a series of small faculty development workshops for medical faculty from across the United States twice a year. The workshops focus on problem-centred learning and skills training, and from them we have learned how faculty must develop a keen sense of student needs and a flexible

teaching style so that the responsibility and achievement for learning are clearly student centred. Internally, our faculty members have developed a new medical curriculum in the addictions Project ADEPT - Alcohol and Drug Education for Physician Training in primary care. Initial funding was provided though an NIAAA/NIDA-sponsored federal contract; Project ADEPT is a multidisciplinary effort whose primary mission is to design, implement, evaluate and disseminate a model curriculum in drug and alcohol abuse. Some details about Project ADEPT will illustrate the importance of developing the curriculum and how we motivated faculty members and helped them become more effective teachers. The aim of the program is the routine integration of drug and alcohol topics into the clinical teaching of primary care medicine through the efforts of trained faculty members. Project ADEPT was carried out by a working committee whose charge was to create curriculum content, develop faculty skills and implement the new curriculum in medical school clerkships and residency programs. The working committee comprised faculty members from six disciplines: medicine, family medicine, pediatrics, obstetrics/gynecology, psychiatry and community health. A primary focus of working committee meetings has been the selection and grooming of these key faculty members. Other central activities include the analysis and organization of competencies into instructional units based on instructor needs'6-'8 and the development of teaching materials. In setting priorities for competencies, attention was paid to the skill, knowledge and attitude components of learning. A master competency list was compiled and reviewed by Brown University faculty representatives in four target primary care disciplines: internal medicine, pediatrics, obstetrics/ gynecology and family medicine. Each group worked independently to assess the priority of each competency within its discipline. Those competencies that were assigned top priority by all disciplines were identified as truly generic and therefore applicable to the training needs of all primary care physicians. The high priority competencies became the focus for the development of Project ADEPT instructional modules. We wanted flexible and easy-to-use materials. All the groups agreed that the modules needed to be self-contained, designed to accommodate a variety of presentation needs and compact, yet detailed enough to satisfy the teaching time limit.'9 These materials have included numerous roleplaying scenarios in the printed material and in an accompanying videotape. The scenarios were created to emphasize practice and feedback. To focus both teacher and student on skills development, compreCAN MED ASSOC J 1990; 143 (10)

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hensive skill checklists are incorporated in the ADEPT curriculum (Table 2). Students review the checklists before an interview to keep in mind the skills upon which their performance is being evaluated. Once several practice sessions have been completed under the supervision of an instructor, students can practise this role playing on their own, and other students can take the instructor's advisory role in providing feedback. The ADEPT curriculum has fostered increased training in the addictions, in part because the teaching faculty had developed and practised teaching them. In the past 5 years curriculum hours for the subject have increased four times, and various timely and vital electives have blossomed. The written and video materials prepared by the working committee are now routinely used by our faculty and are available to other medical and nursing schools and hospitals. Two volumes of instructional modules have been developed, pilot tested and published.20'21 A third, AIDS and Substance Abuse, is soon to be published. My personal recollections will describe the "real-world" factors that contributed to an enthusiastic and committed faculty in Project ADEPT and emphasize the importance of process from the

beginning of the project. Each of the sections is headed by a decidedly informal but truly illustrative heading.

Getting started! What do they want and who can do it? Part of the strategy involved asking medical students to prepare a report on their training needs. Most suggested increasing curriculum time and adding intensive weekend activities. The other part of the strategy was to identify the key multidisciplinary actors in the various departments. No one in the senior faculty was identified in that group; they were all junior faculty.

Should we do this? I realized that to try to engage a group of junior faculty in this kind of process and build it from the student report wasn't going to work because it didn't pay attention to the power issues of the medical school. I went to the dean and asked, "Should we develop a new alcohol/drug curriculum?" If you make a good presentation, most deans are going to be very cordial and supportive, particularly if you

Table 2 Presentirng the diagnosis and initiating treatment

skill checklist*

Establish a supportive rielationship (PEARLS) Partnership: Makes a statement of partnership (e.g., 'We ll work together on this Empathy Makes empathic comments (e.g. 'This seems upsetting to you ) Assurance. Makes staternents that predict a cositive outcome (e.g Our past experience has shownr a high success rate.' m nt e Respect. Makes a respeCtfUll comment V:You seem Lo be dealing with this problem very

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Medical education for alcohol and other drug abuse in the United States.

Initiatives by individuals, private foundations and government have led to improvements in the United States in medical education dealing with alcohol...
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