13. 14. 15.
16.
17.
18. 19. 20.
21.
manuals by problem drinkers. In Miller WR, Heather N (eds): Treating Addictive Behaviors: Processes of Change, Plenum Pr, New York, 1986: 331-359 Elvy GA, Wells JE, Baird KA: Attempted referral as intervention for problem drinking in the general hospital. Br J Addict 1988; 83: 83-89 Wallace P, Cutler S, Haines A: Randomized controlled trial of general practitioner intervention in patients with excessive alcohol consumption. Br Med J 1988; 297: 663-668 Babor TF, Korner P, Wilber C et al: Screening and early intervention strategies for harmful drinkers: initial lessons from the Amethyst Project. Aust Drug Alcohol Rev 1987; 6: 325-339 Acuda SW: Intervention: Is simple intervention really simple? In Waahlberg R (ed): Proceedings of the 35th International Congress on Alcoholism and Drug Dependence, vol 1, National Directorate for the Prevention of Alcohol and Drug Problems, Oslo, 1988: 1-14 Miller WR: Motivational interviewing with problem drinkers. Behav Psychother 1983; 11: 147-172 Festinger L: A Theory of Cognitive Dissonance, Har-Row, New York, 1957 Kelman HC: Processes of Opinion Change. Public Opin Q, 1961; 25: 57-78 French JRP, Raven BH: The bases of social power. In Cartwright D (ed): Studies in Social Power, U of Mich Pr, Ann Arbor, Mich, 1959: 118-149 Hodgson RJ, Miller PM: Selfwatching: Addictions, Habits,
Compulsions, Century, London, 1982 22. Goldfried MR, Merbaum M: Behavior Change through SelfControl, Holt, New York, 1973 23. Robertson I, Heather N: So You Want to Cut Down Your Drinking?, Scottish Health Education Group, Edinburgh, 1982 24. Barchha R, Steward M, Guze S: The prevalence of alcoholism among general hospital ward patients. Am J Psychiatry 1968; 125: 68 1-684 25. Lisansky ET: Why physicians avoid early diagnosis of alcoholism. N YState JMed 1975; 75: 1788-1792 26. Hauser ST: Physician-patient relationships. In Mishler EG, AmaraSingham LR, Hauser ST et al (eds): Social Contexts of Health, Illness, and Patient Care, Cambridge U Pr, New Rochelle, NY, 1981: 104-136 27. Plaja A, Cohen S: Communication between physicians and patients in outpatient clinics: social and cultural factors. Milbank Mem Fund Q, 1968; 46: 161-213 28. Byrne PS, Long BE: Doctors Talking to Patients, HMSO, London, 1976 29. Milmoe S, Rosenthal R, Blane HT et al: The doctor's voice: postdictor of successful referral of alcoholic patients. J Abnorm Psychol 1967; 72: 78-84 30. Parsons T: The Sick Role and the Role of the Physician Reconsidered, Milbank Mem Fund Q, 1975; 53: 257-278 31. Szasz T, Hollander M: A contribution of the philosophy of medicine: the basic models of the doctor-patient relationship. Arch Intern Med 1956; 97: 585-592
Preventing alcohol problems: survey of Canadian medical schools Joan M. Brewster, PhD; Eric Single, PhD; Mary Jane Ashley, MD; Yuen-Ching Chow, BSc, MLS; Harvey A. Skinner, PhD; James G. Rankin, MB In preparation for a national conference on medical education in the prevention of alcohol problems, a survey of conference participants was conducted. Participants were undergraduate and postgraduate representatives from each Canadian medical school and representatives from 11 provincial and territorial alcohol and other drug agencies. There was agreement that physicians and medical schools have important roles in prevention and treatment of alcohol problems, with "traditional" medical roles seen as the most important. Current training is variable and was seen as inadequate, with more time devoted to treatment than prevention. To correct this situation, renewed priorities and faculty leadership are needed. Respondents felt that there should be uniform standards for assessing undergraduate students' skills in dealing with alcohol problems. Provincial alcohol and other drug agencies are underused in medical education in the prevention and treatment of alcohol problems.
T he goals of the national conference "Preventing Alcohol Problems: the Challenge for Medical Education" (held at Niagara-on-the-Lake, Ont. Oct. 16-17, 1989) were to "ensure that physicians at the undergraduate and postgraduate levels of
training acquire the necessary knowledge, attitudes and skills to prevent alcohol problems in clinical practice and to play leadership roles in community efforts to prevent alcohol problems." Representatives of Canadian medical schools and government
From the Addiction Research Foundation of Ontario and the Division of Community Health, Faculty ofMedicine, University of Toronto The views expressed in this article are those of the authors and do not necessarily reflect those of the Addiction Research Foundation of Ontario.
Correspondence to: Dr. Joan M. Brewster, Psychiatry Program, Addiction Research Foundation of Ontario, 33 Russell St., Toronto, Ont.
M5S 2SI 1076
CAN MED ASSOC J 1990; 143 (10)
This report has not been peer reviewed.
and regulatory agencies interested in medical education were brought together to exchange ideas on how to accomplish these goals. The organizing committee believed that discussion would be enhanced by Canadian medical educators' views on the roles of physicians in the prevention and treatment of alcohol problems and of medical schools in preparing physicians to practise. Therefore, a survey of participants was performed so that national data would be available for presentation and discussion at the conference. The survey had three functions. First, it is difficult to evaluate the need to change the emphasis on alcohol in the general medical curriculum if the present status is unknown. Second, the questions alerted conference participants to the issues and focused their thinking. Third, questions about the current alcohol-related curriculum and policy at each school obliged participants to determine the situation in their schools. We summarize the key results from the survey. Detailed data will be published elsewhere. (A detailed data summary prepared for the conference may be obtained from Dr. Joan M. Brewster at the Addiction Research Foundation of Ontario.)
Method Subjects
* Existing university and medical school alcohol policies and assistance programs. * Existing undergraduate and postgraduate alcohol-related curricula elements. * Roles of provincial and territorial alcohol and other drug agencies in alcohol-related medical education. Three questionnaires were designed, one each for undergraduate and postgraduate university representatives and one for provincial and territorial agencies. All the questionnaires covered the first three areas listed above. The university forms included questions on university policies and programs. The undergraduate and postgraduate representatives were asked about their curricula offerings, and the questions on the role of provincial and territorial agencies were asked only of those agencies.
Data collection and analysis The questionnaires were mailed to all participants in mid-April 1989. After 3 weeks, repeated telephone follow-up of those who had not responded was conducted. By mid-July a response rate of 100% was achieved for the 32 university representatives. One province chose not to participate in the survey or the conference; hence, there were responses from 11 government representatives. All data were analysed with the SPSS (Statistical Package for the Social Sciences).' Most of the data were averaged within and compared among the three groups of respondents. With the small numbers of respondents, and a high degree of variability within groups, few significant differences were found between the groups. Therefore, the data presented are mostly descriptive. None the less, the findings are important because all Canadian medical schools are represented.
The sample comprised undergraduate and postgraduate representatives from each Canadian medical school and a representative from each provincial and territorial alcohol and other drug agency. Initially, a letter was sent to the dean of all 16 medical schools in Canada requesting that two delegates be named to attend the conference, one each for undergraduate and postgraduate medical education. A questionnaire was then mailed to each delegate. Letters, including the questionnaire, were also Results sent to the president or chief executive officer of each of the 12 provincial and territorial alcohol and Respondents other drug agencies in Canada inviting them or a Every Canadian medical school sent two repredelegate to attend the conference and asking them to and 11 of 12 provincial and territorial sentatives, the return questionnaire. complete and alcohol and other drug agencies participated. Most of the university respondents were in a Questionnaire position to influence curriculum development, being The major content areas of the questionnaires chairpeople of undergraduate curriculum committees or directors of postgraduate education. Most were as follows: * Roles of physicians in the prevention and were also involved in alcohol-related medical education through teaching, curriculum development or treatment of alcohol problems. * Roles of medical schools in preparing physi- service on committees setting university alcohol cians in the prevention and treatment of alcohol policy. Several government agencies were represented by their president or executive director; others problems. for * Impediments to and requirements change sent representatives concerned with alcohol-related medical education. Of the 32 university representacurricula. school medical in alcohol-related CAN MED ASSOC J 1990; 143 (10)
1077
tives 31 were physicians, and 3 of the 11 agency representatives were physicians. Many respondents commented on the usefulness of completing the questionnaire before the conference. Some mentioned that the survey highlighted gaps in the alcohol-related curriculum or that its arrival fortuitously coincided with a review of alcohol-related teaching in their schools.
attributed more relative importance than did the university representatives to the role of physicians in the advocacy of alcohol policy. Respondents listed additional roles as important for physicians in dealing with alcohol problems: education of physicians and other professionals, formation of treatment teams with other professionals, consulting with community services, support and treatment of family members, assessment of related suicide risk, follow up and relapse prevention. Role ofphysicians Respondents were also asked to rate their level Respondents were asked about the ideal role of of agreement with several statements about physiprimary care physicians in the prevention and treat- cians and alcohol problems. The most extreme and ment of alcohol problems. Thirteen roles, listed consistent responses were made to the following two under the major headings "patient centred", "com- statements. * "Most primary care physicians see relatively munity centred" and "other", were rated on a scale from 1 (not at all important) to 3 (very important). few patients for whom alcohol use is a problem" Although there was some variation in the degree of (strong disagreement). * "Most physicians are inadequately trained to importance assigned, all but one of the group average ratings had a value of 2 (somewhat important) or deal with alcohol problems" (strong agreement). Thus, the respondents agreed that alcohol probmore. The roles receiving the highest and lowest im- lems among patients are common and that most portance ratings are shown in Table 1. All the groups physicians are inadequately trained to handle them. gave the highest ratings to the "traditional" medical Evidently, the conference was aimed at a perceived roles of early detection and intervention, assessment need. However, the respondents also agreed that the and referral, and treatment of the physical conse- most important roles of physicians in dealing with quences of alcohol use. Least important roles were their patients' alcohol problems are those they traditreatment of the social consequences of alcohol use, tionally have played. Their roles in the treatment of treatment of drinking behaviour and community social consequences and drinking behaviour and in activities. public education and policy advocacy were seen as The three groups of respondents generally less important. Those advocating increased roles in agreed on the importance of physicians' various these activities will need to convince medical educaroles; however, the government agencies rated physi- tors of their importance. cians' roles in the treatment of the psychologic and social consequences and treatment of drinking beha- Role of medical schools viour as less important than did the medical school respondents. The average government agency rating The same list of physician roles served as the of treatment of social consequences by primary care response categories for the roles of medical schools physicians was the only group role importance rating in preparing physicians for the prevention and treatto fall below 2 (mean 1.91). Also, the agencies ment of alcohol problems. Not surprisingly, the pattern of responses for medical school roles was almost the same as that for physician roles. Prepara4 tion for traditional medical roles was stressed, - nLi treatrner E A alooro whereas nonmedical treatment, public education, ;--ioles given [igrhest overali importanrce atinas. policy advocacy and research were de-emphasized. rI 98 irty detectionr anC ntenrfe University representatives were asked to rank a 'eatmer:o cf pli.sicai 2(.or1,,s(qL)en:e~ e list of teaching vehicles that might be used to sesmsrenr a ,eterri ral ^ | .; 4 :- ~~ri o;-^i1:ietEti.jnr r,'}),hjrc;:,^ la jl.itff prepare physicians to deal with alcohol problems. Reflecting the differences between undergraduate . givel uw e 2ver-ah mW:'a e 1diQm and postgraduate education, the lists presented to -t r b r. ' : 4r (eLic:ati vX,,Cacy 11 poiCy 2 42 the two groups of representatives were not the same. t ie e atfrrent behaviuuj ofdrinking Both groups rated "clinical placements" near the -atient-cerntred research. `2 34' The undergraduate representatives also pretop. eatrrmy e' OC1a 2OS quCFe & ferred "integration with other topics" and courses in preventive medicine or psychiatry, whereas the postgraduate representatives preferred "patient contact" and ongoing lectures or seminar courses. Both l,
d
r
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CAN MED ASSOC J 199u, 143 (1 )
groups rejected electives and occasional lectures or seminars, which could be avoided by uninterested students. Spontaneous comments from respondents stressed the need for good clinical role models at all levels of education. When asked which department would be most appropriate to teach topics concerning alcohol-related problems, psychiatry and family practice were most popular, followed by medicine and "all departments". Several respondents commented that such an area should be integrated with teaching in all departments, since alcohol problems require a multidisciplinary approach.
Most of the undergraduate and agency representatives (81.5%) - the two groups questioned agreed that there is a need for uniform standards for assessing physicians' skills in dealing with pkatients' alcohol problems. However, there was no corisensus on specialty training. Though most of the agency representatives (63.6%) agreed that there is a need for specialty certification in education on alcohol and other drug problems, most of the postgraduate representatives (62.5%), who are responsible for specialty education, disagreed with this position. Thus, those advocating a medical specialty in this area will need to convince postgraduate educators of its necessity. Most of the respondents agreed on a need for uniform standards to assess undergraduate physicians' skills in dealing with alcohol problems. However, most of the postgraduate respondents did not see the need for postgraduate specialty certification in education on alcohol and other drug problems. The postgraduate and agency representatives were asked with which specialty or specialties alcohol and drug problems should be affiliated if a subspecialty were created. The responses were consistent with those on the departments best suited to teach about alcohol; family medicine, psychiatry and internal medicine being chosen most frequently. Several respondents suggested that such a subspecialty should be interdisciplinary.
ranged from 0 to 14 (mean 4.75), and the number spent on treatment ranged from 2 to 20 (mean 7.75), a significantly greater (p < 0.05) difference. The representatives from eight schools reported that they offer undergraduate courses or other major curriculum elements devoted exclusively to problems related to alcohol or other drugs. Some of the elements are elective or form a substantial part of another course. In six of the eight schools these offerings are in the second or third undergraduate year. Most schools offer workshops, clinic placements and addresses by Alcoholics Anonymous (AA) members. Community resources such as AA, private practitioners and physicians who have had problems with alcohol are used by several schools to teach undergraduates about alcohol problems. At seven schools alcohol-related undergraduate teaching is coordinated by one faculty member; at three others it is handled by a committee. Presumably, there is no formal coordination at the remaining six schools. Schools where a person or committee coordinates the alcohol-related curriculum do not have more curriculum elements or hours than schools without such coordination. As well, these schools are not necessarily the ones offering major curriculum elements devoted to alcohol. The undergraduate representatives were asked to rate, on a four-point scale, the coverage of each of a list of alcohol-related topics in their curricula (Fig. 1). Topics most extensively covered are pharmacology and treatment of physical consequences, followed by etiology and physicians' own alcohol problems. Attracting least coverage are public education and alcohol control policies. These data are consistent with judgements of the importance of physicians' roles in preventing and treating alcohol problems, although the options offered in the two questionnaire sections were not identical. One important discrepancy was in the relatively inadequate coverage of early detection and intervention, despite its high rating of importance. Early detection and treatment of alcohol problems ranked first in importance among the perceived roles of primary care physicians but received little coverage in the undergraduate curriculum.
Undergraduate curriculum
Postgraduate curriculum
The undergraduate representatives were asked how many hours their medical school curricula devoted, separately, to prevention and treatment of alcohol problems. There was great variability among the schools. Some respondents said that, because alcohol-related topics were combined with others and taught in different courses, it was impossible to estimate the number of hours. For the 12 who did respond, the number of hours spent on prevention
The postgraduate representatives were asked to indicate the type .of alcohol-related curriculum elements offered in each of 20 listed residency programs. Not all the schools responded for all the programs. Programs offering the most such elements are psychiatry, family medicine, community medicine, gastroenterology, geriatrics and internal medicine, which correspond to the departments chosen most frequently as the best suited to teach about
Needfor uniform standards or specialization
CAN MED ASSOC J 1990; 143 (10)
1079
alcohol: family medicine, psychiatry and internal medicine. There is wide variability among schools in alcohol coverage in the postgraduate curriculum. Even for programs where the mean level of coverage (across schools) was relatively high, some schools offer little or no alcohol-related elements. For many postgraduate programs (e.g., physical medicine and rehabilitation, infectious diseases, neurosurgery, orthopedic surgery and plastic surgery) "no alcohol-related curriculum" was by far the commonest response to questions about alcohol coverage. Postgraduate education also uses community resources in teaching about alcohol; treatment centres and other clinical settings were used most commonly, which reflects the clinical nature of postgraduate education. In two of the schools one faculty member is responsible for coordinating the alcohol-related postgraduate curriculum; in two others this function is handled by a committee. The lower level of overall coordination in postgraduate programs is no doubt related to the departmental focus of postgraduate education.
Campus alcohol policies The undergraduate and postgraduate university representatives were asked about alcohol policies and programs on their campuses. These data are
reported by the schools, rather than by individual representatives. When one representative from a school reported that there is a policy and the other reported that there is not it was assumed that there is a policy. The differences probably arose from one representative being unaware of the policy or programs or from different interpretations of what constitutes a "policy". Thus, the sample size for this discussion is the 16 Canadian medical schools. Eleven schools reported that a campus alcohol policy or program exists at their university. The most common were policies on special events and sports events, server-training programs, provision of educational material and employee assistance programs. Most universities have regulations specifying conditions under which alcohol may be served, and some reported designated driver programs for university events. Only two of the schools reported having an alcohol policy distinct from that for the university. All the representatives (32) were asked how well the administrators at their universities understand the civil liabilities and penal consequences associated with serving alcohol at university events; 17 perceived that they were well understood, but some commented that the students organizing the events might not share this understanding. At 10 of the 16 medical schools alcohol is "usually" or "always" served at social functions. No school reported that alcohol is "never"" served. One respondent commented that medical school faculty set a poor example for students at social events; another said that alcohol is central to such events at that school.
Employee assistance programs Fewer than half (7) of the universities with medical schools offer employee assistance programs for staff who have problems with alcohol. Two report separate programs for medical school faculty. Eleven schools offer programs for university students, usually through the university health service. Three schools offer programs for medical students and residents separate from the university student program; one other school has a separate program for medical students and one has a separate program for residents. Most programs for both staff and students deal with alcohol problems in the context of more general programs that also treat stress and psychological problems.
Roles ofprovincial and territorial agencies Fig. 1: Coverage of alcohol-related topics in undergraduate medical curriculum: mean responses from 16 Canadian medical schools. 1080
CAN MED ASSOCJ 1990; 143 (10)
The 11 provincial and territorial alcohol and other drug agencies were asked to indicate ways in which they contribute to medical education in the prevention and treatment of alcohol problems. Most
of the agencies provided courses or seminars, guest lecturers, staff for teaching, advice on curriculum content or educational materials through organizing conferences or workshops or as a site for clinical placements. These services are provided to a wide variety of medical schools, usually in the same province as the agency. There is little involvement in the funding of curriculum development, in the funding of medical students and physicians through fellowships or in research training. Some of the agencies provide services to physicians after graduation through continuing medical education courses and by acting as a referral agency for practising
aboriginal populations or transient workers. The agencies also were asked about their roles in reducing alcohol problems at universities, apart from medical education. The roles were rated on a threepoint scale ranging from "not at all important" to "very important", and the mean importance rating for all roles was "somewhat important" (2.0) or higher (Table 2). Those seen as most important are consultation about employee assistance programs and the development of campus alcohol policies. The actual provision of employee assistance programs and the lobbying of governments about education funding are seen as less important. Of the 11 agencies 4 have a formal policy or goal physicians. The agencies were asked to indicate in which of statement on the education of medical students and the same list of activities their agency ideally should physicians in the prevention and treatment of alcobe involved. The responses closely parallelled those hol problems. However, those not having a policy for the agencies' actual involvement, but several stated that such education fits clearly into their wanted to be a site for clinical placements or a overall mandate to prevent and treat such problems research training facility or to be more involved in in the population. The active involvement of wellthe funding of curriculum development. Some of the trained physicians is seen as essential in accomplishdiscrepancy between actual and desired involvement ing this end. Indeed, it was mentioned that the is no doubt because two of the provinces and both of effectiveness of such agencies is reduced if physithe territories do not have medical schools; the cians are not well trained in this regard. agencies in these areas thus have less opportunity for Most of the agencies comprise a wide range of involvement. disciplines and services and are enthusiastic about The agencies were asked to choose the three participating in medical education on alcohol probmost important roles they can play in medical lems. Nevertheless, only five undergraduate and education; those chosen most often were site of seven postgraduate representatives reported that clinical placements, advice on content of alcohol- provincial alcohol and other drug agencies are used related curriculum and the provision of courses or in their alcohol-related curricula; hence, most mediseminar series. Several commented that government cal schools have left a major source of expertise and agencies can provide a more multidisciplinary per- resources untapped. spective than that available in medical schools and that hands-on community experience, available in Requirements for change provincial treatment programs, is invaluable in medAll the respondents were asked to rate the ical training. Northern agencies also are able to provide training relevant to special risk groups such degree of impediment presented by suggested factors as
Table 2: Possible contributions of provincial and territorial agencies to reduction of alcohol problems on campus* Roles given highest overall importance ratings (n = 11) Consultation regarding employee assistance programs
(EAP) (2.64)
Development of campus alcohol policies (2.64) Roles given medium overall importance ratings (n = 1 1) Provision of literature for campus distribution (2.36) Provision of training on responsible beverage service (2.36) Advice on legal responsibility in serving alcohol (2.27) Roles given lowest overall importance ratings (n = 11 ) Provision of EAP programs (2.00) Lobbying governments on education funding (2.00) *Mean importance ratings in
parentheses. 1
=
not at all
important; 3 = very
important. CAN MED ASSOC J 1990; 143 (10)
1081
in medical teaching about alcohol problems. There was little perceived distinction among the alternatives presented. However, higher average ratings went to "other areas are higher priority" and "curriculum time" than to "financial resources", "faculty", "interest among faculty" and "faculty leadership in this area". The agency representatives saw faculty leadership or lack of it as a greater impediment than did university representatives. Some respondents mentioned that no one medical school department claims ownership of alcohol problems, which leads to a lack of focused leadership for their inclusion in the curriculum. Alcohol problems do not fit into traditional medical school curricula, and there is a lack of faculty involvement in this field. Postgraduate representatives also cited a lack of interdisciplinary curriculum coordination, and agency representatives cited a lack of internship opportunities and the fact that alcohol problems are ignored on medical licensing examinations. Other impediments were the perception of hopelessness of these problems, negative attitudes and prejudice toward those with alcohol problems, and competition with other professions that have a role to play. Requirements to effect change produced more diversity in average ratings. "Adjustment of priorities", "increased expertise of faculty" and "leadership of interested faculty" were seen as essential, whereas "pressure from government" and "pressure from other groups" were not. Additional requirements were treatment wards where training can take place and interdisciplinary teams to coordinate education and treatment. The theme of interdepartmental cooperation was strong, and more than one respondent mentioned the need for an interdepartmental division with a dedicated head.
Discussion The collection of data by questionnaire before
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CAN MED ASSOC J 1990; 143 (10)
the conference was met with enthusiasm by participants. The three goals of the questionnaire baseline data collection, a focus of participants' thinking and collection of preconference information by the participants - were clearly met. The results show widespread agreement that primary care physicians have an important role in the prevention and treatment of their patients' alcohol problems. There also is agreement that current training is inadequate. All schools currently have some level of alcohol-related teaching, but coverage is generally inadequate and uneven across departments and schools. If the role of physicians is to be enhanced, improvements in medical school curricula are needed. The weight of opinion in this area leans toward an interdisciplinary approach to teaching about alcohol problems, with some overall coordination of the teaching in the various departments. Those who attended the conference were also the survey respondents. The university representatives, both undergraduate and postgraduate, are in positions to effect changes in their medical school curricula to strengthen the teaching of alcoholrelated topics. The results of the survey document current deficiencies and, equally important, show what future directions are considered important by these key educators. The results also show that provincial and territorial alcohol and other drug agencies can be valuable allies in training physicians to deal with alcohol problems. Not only are government agencies sources of expertise and resources on these topics but also they share the views of educators on the importance of physicians' roles and are eager to be involved in medical education.
Reference 1. SPSS (Statistical Package for the Social Sciences), User's Guide, 2nd ed, SPSS Inc, Chicago, 1986
16.
17.
18. 19. 20.
21.
manuals by problem drinkers. In Miller WR, Heather N (eds): Treating Addictive Behaviors: Processes of Change, Plenum Pr, New York, 1986: 331-359 Elvy GA, Wells JE, Baird KA: Attempted referral as intervention for problem drinking in the general hospital. Br J Addict 1988; 83: 83-89 Wallace P, Cutler S, Haines A: Randomized controlled trial of general practitioner intervention in patients with excessive alcohol consumption. Br Med J 1988; 297: 663-668 Babor TF, Korner P, Wilber C et al: Screening and early intervention strategies for harmful drinkers: initial lessons from the Amethyst Project. Aust Drug Alcohol Rev 1987; 6: 325-339 Acuda SW: Intervention: Is simple intervention really simple? In Waahlberg R (ed): Proceedings of the 35th International Congress on Alcoholism and Drug Dependence, vol 1, National Directorate for the Prevention of Alcohol and Drug Problems, Oslo, 1988: 1-14 Miller WR: Motivational interviewing with problem drinkers. Behav Psychother 1983; 11: 147-172 Festinger L: A Theory of Cognitive Dissonance, Har-Row, New York, 1957 Kelman HC: Processes of Opinion Change. Public Opin Q, 1961; 25: 57-78 French JRP, Raven BH: The bases of social power. In Cartwright D (ed): Studies in Social Power, U of Mich Pr, Ann Arbor, Mich, 1959: 118-149 Hodgson RJ, Miller PM: Selfwatching: Addictions, Habits,
Compulsions, Century, London, 1982 22. Goldfried MR, Merbaum M: Behavior Change through SelfControl, Holt, New York, 1973 23. Robertson I, Heather N: So You Want to Cut Down Your Drinking?, Scottish Health Education Group, Edinburgh, 1982 24. Barchha R, Steward M, Guze S: The prevalence of alcoholism among general hospital ward patients. Am J Psychiatry 1968; 125: 68 1-684 25. Lisansky ET: Why physicians avoid early diagnosis of alcoholism. N YState JMed 1975; 75: 1788-1792 26. Hauser ST: Physician-patient relationships. In Mishler EG, AmaraSingham LR, Hauser ST et al (eds): Social Contexts of Health, Illness, and Patient Care, Cambridge U Pr, New Rochelle, NY, 1981: 104-136 27. Plaja A, Cohen S: Communication between physicians and patients in outpatient clinics: social and cultural factors. Milbank Mem Fund Q, 1968; 46: 161-213 28. Byrne PS, Long BE: Doctors Talking to Patients, HMSO, London, 1976 29. Milmoe S, Rosenthal R, Blane HT et al: The doctor's voice: postdictor of successful referral of alcoholic patients. J Abnorm Psychol 1967; 72: 78-84 30. Parsons T: The Sick Role and the Role of the Physician Reconsidered, Milbank Mem Fund Q, 1975; 53: 257-278 31. Szasz T, Hollander M: A contribution of the philosophy of medicine: the basic models of the doctor-patient relationship. Arch Intern Med 1956; 97: 585-592
Preventing alcohol problems: survey of Canadian medical schools Joan M. Brewster, PhD; Eric Single, PhD; Mary Jane Ashley, MD; Yuen-Ching Chow, BSc, MLS; Harvey A. Skinner, PhD; James G. Rankin, MB In preparation for a national conference on medical education in the prevention of alcohol problems, a survey of conference participants was conducted. Participants were undergraduate and postgraduate representatives from each Canadian medical school and representatives from 11 provincial and territorial alcohol and other drug agencies. There was agreement that physicians and medical schools have important roles in prevention and treatment of alcohol problems, with "traditional" medical roles seen as the most important. Current training is variable and was seen as inadequate, with more time devoted to treatment than prevention. To correct this situation, renewed priorities and faculty leadership are needed. Respondents felt that there should be uniform standards for assessing undergraduate students' skills in dealing with alcohol problems. Provincial alcohol and other drug agencies are underused in medical education in the prevention and treatment of alcohol problems.
T he goals of the national conference "Preventing Alcohol Problems: the Challenge for Medical Education" (held at Niagara-on-the-Lake, Ont. Oct. 16-17, 1989) were to "ensure that physicians at the undergraduate and postgraduate levels of
training acquire the necessary knowledge, attitudes and skills to prevent alcohol problems in clinical practice and to play leadership roles in community efforts to prevent alcohol problems." Representatives of Canadian medical schools and government
From the Addiction Research Foundation of Ontario and the Division of Community Health, Faculty ofMedicine, University of Toronto The views expressed in this article are those of the authors and do not necessarily reflect those of the Addiction Research Foundation of Ontario.
Correspondence to: Dr. Joan M. Brewster, Psychiatry Program, Addiction Research Foundation of Ontario, 33 Russell St., Toronto, Ont.
M5S 2SI 1076
CAN MED ASSOC J 1990; 143 (10)
This report has not been peer reviewed.
and regulatory agencies interested in medical education were brought together to exchange ideas on how to accomplish these goals. The organizing committee believed that discussion would be enhanced by Canadian medical educators' views on the roles of physicians in the prevention and treatment of alcohol problems and of medical schools in preparing physicians to practise. Therefore, a survey of participants was performed so that national data would be available for presentation and discussion at the conference. The survey had three functions. First, it is difficult to evaluate the need to change the emphasis on alcohol in the general medical curriculum if the present status is unknown. Second, the questions alerted conference participants to the issues and focused their thinking. Third, questions about the current alcohol-related curriculum and policy at each school obliged participants to determine the situation in their schools. We summarize the key results from the survey. Detailed data will be published elsewhere. (A detailed data summary prepared for the conference may be obtained from Dr. Joan M. Brewster at the Addiction Research Foundation of Ontario.)
Method Subjects
* Existing university and medical school alcohol policies and assistance programs. * Existing undergraduate and postgraduate alcohol-related curricula elements. * Roles of provincial and territorial alcohol and other drug agencies in alcohol-related medical education. Three questionnaires were designed, one each for undergraduate and postgraduate university representatives and one for provincial and territorial agencies. All the questionnaires covered the first three areas listed above. The university forms included questions on university policies and programs. The undergraduate and postgraduate representatives were asked about their curricula offerings, and the questions on the role of provincial and territorial agencies were asked only of those agencies.
Data collection and analysis The questionnaires were mailed to all participants in mid-April 1989. After 3 weeks, repeated telephone follow-up of those who had not responded was conducted. By mid-July a response rate of 100% was achieved for the 32 university representatives. One province chose not to participate in the survey or the conference; hence, there were responses from 11 government representatives. All data were analysed with the SPSS (Statistical Package for the Social Sciences).' Most of the data were averaged within and compared among the three groups of respondents. With the small numbers of respondents, and a high degree of variability within groups, few significant differences were found between the groups. Therefore, the data presented are mostly descriptive. None the less, the findings are important because all Canadian medical schools are represented.
The sample comprised undergraduate and postgraduate representatives from each Canadian medical school and a representative from each provincial and territorial alcohol and other drug agency. Initially, a letter was sent to the dean of all 16 medical schools in Canada requesting that two delegates be named to attend the conference, one each for undergraduate and postgraduate medical education. A questionnaire was then mailed to each delegate. Letters, including the questionnaire, were also Results sent to the president or chief executive officer of each of the 12 provincial and territorial alcohol and Respondents other drug agencies in Canada inviting them or a Every Canadian medical school sent two repredelegate to attend the conference and asking them to and 11 of 12 provincial and territorial sentatives, the return questionnaire. complete and alcohol and other drug agencies participated. Most of the university respondents were in a Questionnaire position to influence curriculum development, being The major content areas of the questionnaires chairpeople of undergraduate curriculum committees or directors of postgraduate education. Most were as follows: * Roles of physicians in the prevention and were also involved in alcohol-related medical education through teaching, curriculum development or treatment of alcohol problems. * Roles of medical schools in preparing physi- service on committees setting university alcohol cians in the prevention and treatment of alcohol policy. Several government agencies were represented by their president or executive director; others problems. for * Impediments to and requirements change sent representatives concerned with alcohol-related medical education. Of the 32 university representacurricula. school medical in alcohol-related CAN MED ASSOC J 1990; 143 (10)
1077
tives 31 were physicians, and 3 of the 11 agency representatives were physicians. Many respondents commented on the usefulness of completing the questionnaire before the conference. Some mentioned that the survey highlighted gaps in the alcohol-related curriculum or that its arrival fortuitously coincided with a review of alcohol-related teaching in their schools.
attributed more relative importance than did the university representatives to the role of physicians in the advocacy of alcohol policy. Respondents listed additional roles as important for physicians in dealing with alcohol problems: education of physicians and other professionals, formation of treatment teams with other professionals, consulting with community services, support and treatment of family members, assessment of related suicide risk, follow up and relapse prevention. Role ofphysicians Respondents were also asked to rate their level Respondents were asked about the ideal role of of agreement with several statements about physiprimary care physicians in the prevention and treat- cians and alcohol problems. The most extreme and ment of alcohol problems. Thirteen roles, listed consistent responses were made to the following two under the major headings "patient centred", "com- statements. * "Most primary care physicians see relatively munity centred" and "other", were rated on a scale from 1 (not at all important) to 3 (very important). few patients for whom alcohol use is a problem" Although there was some variation in the degree of (strong disagreement). * "Most physicians are inadequately trained to importance assigned, all but one of the group average ratings had a value of 2 (somewhat important) or deal with alcohol problems" (strong agreement). Thus, the respondents agreed that alcohol probmore. The roles receiving the highest and lowest im- lems among patients are common and that most portance ratings are shown in Table 1. All the groups physicians are inadequately trained to handle them. gave the highest ratings to the "traditional" medical Evidently, the conference was aimed at a perceived roles of early detection and intervention, assessment need. However, the respondents also agreed that the and referral, and treatment of the physical conse- most important roles of physicians in dealing with quences of alcohol use. Least important roles were their patients' alcohol problems are those they traditreatment of the social consequences of alcohol use, tionally have played. Their roles in the treatment of treatment of drinking behaviour and community social consequences and drinking behaviour and in activities. public education and policy advocacy were seen as The three groups of respondents generally less important. Those advocating increased roles in agreed on the importance of physicians' various these activities will need to convince medical educaroles; however, the government agencies rated physi- tors of their importance. cians' roles in the treatment of the psychologic and social consequences and treatment of drinking beha- Role of medical schools viour as less important than did the medical school respondents. The average government agency rating The same list of physician roles served as the of treatment of social consequences by primary care response categories for the roles of medical schools physicians was the only group role importance rating in preparing physicians for the prevention and treatto fall below 2 (mean 1.91). Also, the agencies ment of alcohol problems. Not surprisingly, the pattern of responses for medical school roles was almost the same as that for physician roles. Prepara4 tion for traditional medical roles was stressed, - nLi treatrner E A alooro whereas nonmedical treatment, public education, ;--ioles given [igrhest overali importanrce atinas. policy advocacy and research were de-emphasized. rI 98 irty detectionr anC ntenrfe University representatives were asked to rank a 'eatmer:o cf pli.sicai 2(.or1,,s(qL)en:e~ e list of teaching vehicles that might be used to sesmsrenr a ,eterri ral ^ | .; 4 :- ~~ri o;-^i1:ietEti.jnr r,'}),hjrc;:,^ la jl.itff prepare physicians to deal with alcohol problems. Reflecting the differences between undergraduate . givel uw e 2ver-ah mW:'a e 1diQm and postgraduate education, the lists presented to -t r b r. ' : 4r (eLic:ati vX,,Cacy 11 poiCy 2 42 the two groups of representatives were not the same. t ie e atfrrent behaviuuj ofdrinking Both groups rated "clinical placements" near the -atient-cerntred research. `2 34' The undergraduate representatives also pretop. eatrrmy e' OC1a 2OS quCFe & ferred "integration with other topics" and courses in preventive medicine or psychiatry, whereas the postgraduate representatives preferred "patient contact" and ongoing lectures or seminar courses. Both l,
d
r
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groups rejected electives and occasional lectures or seminars, which could be avoided by uninterested students. Spontaneous comments from respondents stressed the need for good clinical role models at all levels of education. When asked which department would be most appropriate to teach topics concerning alcohol-related problems, psychiatry and family practice were most popular, followed by medicine and "all departments". Several respondents commented that such an area should be integrated with teaching in all departments, since alcohol problems require a multidisciplinary approach.
Most of the undergraduate and agency representatives (81.5%) - the two groups questioned agreed that there is a need for uniform standards for assessing physicians' skills in dealing with pkatients' alcohol problems. However, there was no corisensus on specialty training. Though most of the agency representatives (63.6%) agreed that there is a need for specialty certification in education on alcohol and other drug problems, most of the postgraduate representatives (62.5%), who are responsible for specialty education, disagreed with this position. Thus, those advocating a medical specialty in this area will need to convince postgraduate educators of its necessity. Most of the respondents agreed on a need for uniform standards to assess undergraduate physicians' skills in dealing with alcohol problems. However, most of the postgraduate respondents did not see the need for postgraduate specialty certification in education on alcohol and other drug problems. The postgraduate and agency representatives were asked with which specialty or specialties alcohol and drug problems should be affiliated if a subspecialty were created. The responses were consistent with those on the departments best suited to teach about alcohol; family medicine, psychiatry and internal medicine being chosen most frequently. Several respondents suggested that such a subspecialty should be interdisciplinary.
ranged from 0 to 14 (mean 4.75), and the number spent on treatment ranged from 2 to 20 (mean 7.75), a significantly greater (p < 0.05) difference. The representatives from eight schools reported that they offer undergraduate courses or other major curriculum elements devoted exclusively to problems related to alcohol or other drugs. Some of the elements are elective or form a substantial part of another course. In six of the eight schools these offerings are in the second or third undergraduate year. Most schools offer workshops, clinic placements and addresses by Alcoholics Anonymous (AA) members. Community resources such as AA, private practitioners and physicians who have had problems with alcohol are used by several schools to teach undergraduates about alcohol problems. At seven schools alcohol-related undergraduate teaching is coordinated by one faculty member; at three others it is handled by a committee. Presumably, there is no formal coordination at the remaining six schools. Schools where a person or committee coordinates the alcohol-related curriculum do not have more curriculum elements or hours than schools without such coordination. As well, these schools are not necessarily the ones offering major curriculum elements devoted to alcohol. The undergraduate representatives were asked to rate, on a four-point scale, the coverage of each of a list of alcohol-related topics in their curricula (Fig. 1). Topics most extensively covered are pharmacology and treatment of physical consequences, followed by etiology and physicians' own alcohol problems. Attracting least coverage are public education and alcohol control policies. These data are consistent with judgements of the importance of physicians' roles in preventing and treating alcohol problems, although the options offered in the two questionnaire sections were not identical. One important discrepancy was in the relatively inadequate coverage of early detection and intervention, despite its high rating of importance. Early detection and treatment of alcohol problems ranked first in importance among the perceived roles of primary care physicians but received little coverage in the undergraduate curriculum.
Undergraduate curriculum
Postgraduate curriculum
The undergraduate representatives were asked how many hours their medical school curricula devoted, separately, to prevention and treatment of alcohol problems. There was great variability among the schools. Some respondents said that, because alcohol-related topics were combined with others and taught in different courses, it was impossible to estimate the number of hours. For the 12 who did respond, the number of hours spent on prevention
The postgraduate representatives were asked to indicate the type .of alcohol-related curriculum elements offered in each of 20 listed residency programs. Not all the schools responded for all the programs. Programs offering the most such elements are psychiatry, family medicine, community medicine, gastroenterology, geriatrics and internal medicine, which correspond to the departments chosen most frequently as the best suited to teach about
Needfor uniform standards or specialization
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alcohol: family medicine, psychiatry and internal medicine. There is wide variability among schools in alcohol coverage in the postgraduate curriculum. Even for programs where the mean level of coverage (across schools) was relatively high, some schools offer little or no alcohol-related elements. For many postgraduate programs (e.g., physical medicine and rehabilitation, infectious diseases, neurosurgery, orthopedic surgery and plastic surgery) "no alcohol-related curriculum" was by far the commonest response to questions about alcohol coverage. Postgraduate education also uses community resources in teaching about alcohol; treatment centres and other clinical settings were used most commonly, which reflects the clinical nature of postgraduate education. In two of the schools one faculty member is responsible for coordinating the alcohol-related postgraduate curriculum; in two others this function is handled by a committee. The lower level of overall coordination in postgraduate programs is no doubt related to the departmental focus of postgraduate education.
Campus alcohol policies The undergraduate and postgraduate university representatives were asked about alcohol policies and programs on their campuses. These data are
reported by the schools, rather than by individual representatives. When one representative from a school reported that there is a policy and the other reported that there is not it was assumed that there is a policy. The differences probably arose from one representative being unaware of the policy or programs or from different interpretations of what constitutes a "policy". Thus, the sample size for this discussion is the 16 Canadian medical schools. Eleven schools reported that a campus alcohol policy or program exists at their university. The most common were policies on special events and sports events, server-training programs, provision of educational material and employee assistance programs. Most universities have regulations specifying conditions under which alcohol may be served, and some reported designated driver programs for university events. Only two of the schools reported having an alcohol policy distinct from that for the university. All the representatives (32) were asked how well the administrators at their universities understand the civil liabilities and penal consequences associated with serving alcohol at university events; 17 perceived that they were well understood, but some commented that the students organizing the events might not share this understanding. At 10 of the 16 medical schools alcohol is "usually" or "always" served at social functions. No school reported that alcohol is "never"" served. One respondent commented that medical school faculty set a poor example for students at social events; another said that alcohol is central to such events at that school.
Employee assistance programs Fewer than half (7) of the universities with medical schools offer employee assistance programs for staff who have problems with alcohol. Two report separate programs for medical school faculty. Eleven schools offer programs for university students, usually through the university health service. Three schools offer programs for medical students and residents separate from the university student program; one other school has a separate program for medical students and one has a separate program for residents. Most programs for both staff and students deal with alcohol problems in the context of more general programs that also treat stress and psychological problems.
Roles ofprovincial and territorial agencies Fig. 1: Coverage of alcohol-related topics in undergraduate medical curriculum: mean responses from 16 Canadian medical schools. 1080
CAN MED ASSOCJ 1990; 143 (10)
The 11 provincial and territorial alcohol and other drug agencies were asked to indicate ways in which they contribute to medical education in the prevention and treatment of alcohol problems. Most
of the agencies provided courses or seminars, guest lecturers, staff for teaching, advice on curriculum content or educational materials through organizing conferences or workshops or as a site for clinical placements. These services are provided to a wide variety of medical schools, usually in the same province as the agency. There is little involvement in the funding of curriculum development, in the funding of medical students and physicians through fellowships or in research training. Some of the agencies provide services to physicians after graduation through continuing medical education courses and by acting as a referral agency for practising
aboriginal populations or transient workers. The agencies also were asked about their roles in reducing alcohol problems at universities, apart from medical education. The roles were rated on a threepoint scale ranging from "not at all important" to "very important", and the mean importance rating for all roles was "somewhat important" (2.0) or higher (Table 2). Those seen as most important are consultation about employee assistance programs and the development of campus alcohol policies. The actual provision of employee assistance programs and the lobbying of governments about education funding are seen as less important. Of the 11 agencies 4 have a formal policy or goal physicians. The agencies were asked to indicate in which of statement on the education of medical students and the same list of activities their agency ideally should physicians in the prevention and treatment of alcobe involved. The responses closely parallelled those hol problems. However, those not having a policy for the agencies' actual involvement, but several stated that such education fits clearly into their wanted to be a site for clinical placements or a overall mandate to prevent and treat such problems research training facility or to be more involved in in the population. The active involvement of wellthe funding of curriculum development. Some of the trained physicians is seen as essential in accomplishdiscrepancy between actual and desired involvement ing this end. Indeed, it was mentioned that the is no doubt because two of the provinces and both of effectiveness of such agencies is reduced if physithe territories do not have medical schools; the cians are not well trained in this regard. agencies in these areas thus have less opportunity for Most of the agencies comprise a wide range of involvement. disciplines and services and are enthusiastic about The agencies were asked to choose the three participating in medical education on alcohol probmost important roles they can play in medical lems. Nevertheless, only five undergraduate and education; those chosen most often were site of seven postgraduate representatives reported that clinical placements, advice on content of alcohol- provincial alcohol and other drug agencies are used related curriculum and the provision of courses or in their alcohol-related curricula; hence, most mediseminar series. Several commented that government cal schools have left a major source of expertise and agencies can provide a more multidisciplinary per- resources untapped. spective than that available in medical schools and that hands-on community experience, available in Requirements for change provincial treatment programs, is invaluable in medAll the respondents were asked to rate the ical training. Northern agencies also are able to provide training relevant to special risk groups such degree of impediment presented by suggested factors as
Table 2: Possible contributions of provincial and territorial agencies to reduction of alcohol problems on campus* Roles given highest overall importance ratings (n = 11) Consultation regarding employee assistance programs
(EAP) (2.64)
Development of campus alcohol policies (2.64) Roles given medium overall importance ratings (n = 1 1) Provision of literature for campus distribution (2.36) Provision of training on responsible beverage service (2.36) Advice on legal responsibility in serving alcohol (2.27) Roles given lowest overall importance ratings (n = 11 ) Provision of EAP programs (2.00) Lobbying governments on education funding (2.00) *Mean importance ratings in
parentheses. 1
=
not at all
important; 3 = very
important. CAN MED ASSOC J 1990; 143 (10)
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in medical teaching about alcohol problems. There was little perceived distinction among the alternatives presented. However, higher average ratings went to "other areas are higher priority" and "curriculum time" than to "financial resources", "faculty", "interest among faculty" and "faculty leadership in this area". The agency representatives saw faculty leadership or lack of it as a greater impediment than did university representatives. Some respondents mentioned that no one medical school department claims ownership of alcohol problems, which leads to a lack of focused leadership for their inclusion in the curriculum. Alcohol problems do not fit into traditional medical school curricula, and there is a lack of faculty involvement in this field. Postgraduate representatives also cited a lack of interdisciplinary curriculum coordination, and agency representatives cited a lack of internship opportunities and the fact that alcohol problems are ignored on medical licensing examinations. Other impediments were the perception of hopelessness of these problems, negative attitudes and prejudice toward those with alcohol problems, and competition with other professions that have a role to play. Requirements to effect change produced more diversity in average ratings. "Adjustment of priorities", "increased expertise of faculty" and "leadership of interested faculty" were seen as essential, whereas "pressure from government" and "pressure from other groups" were not. Additional requirements were treatment wards where training can take place and interdisciplinary teams to coordinate education and treatment. The theme of interdepartmental cooperation was strong, and more than one respondent mentioned the need for an interdepartmental division with a dedicated head.
Discussion The collection of data by questionnaire before
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the conference was met with enthusiasm by participants. The three goals of the questionnaire baseline data collection, a focus of participants' thinking and collection of preconference information by the participants - were clearly met. The results show widespread agreement that primary care physicians have an important role in the prevention and treatment of their patients' alcohol problems. There also is agreement that current training is inadequate. All schools currently have some level of alcohol-related teaching, but coverage is generally inadequate and uneven across departments and schools. If the role of physicians is to be enhanced, improvements in medical school curricula are needed. The weight of opinion in this area leans toward an interdisciplinary approach to teaching about alcohol problems, with some overall coordination of the teaching in the various departments. Those who attended the conference were also the survey respondents. The university representatives, both undergraduate and postgraduate, are in positions to effect changes in their medical school curricula to strengthen the teaching of alcoholrelated topics. The results of the survey document current deficiencies and, equally important, show what future directions are considered important by these key educators. The results also show that provincial and territorial alcohol and other drug agencies can be valuable allies in training physicians to deal with alcohol problems. Not only are government agencies sources of expertise and resources on these topics but also they share the views of educators on the importance of physicians' roles and are eager to be involved in medical education.
Reference 1. SPSS (Statistical Package for the Social Sciences), User's Guide, 2nd ed, SPSS Inc, Chicago, 1986
