Article

Teaching family medicine residents brief interventions for alcohol misuse

The International Journal of Psychiatry in Medicine 2015, Vol. 50(1) 81–91 ß The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0091217415592363 ijp.sagepub.com

J Chris Rule1,2 and Pearl Samuel2

Abstract Across the lifespan, alcohol misuse affects a large percentage of patients seen in primary care clinics. It can lead to alcohol use disorders, ranging from risky use to alcohol dependence. Alcohol use disorders frequently complicate acute and chronic illnesses of patients seen in FM clinics. Screening patients for alcohol and substance use has become a standard of practice in most primary care settings. This report describes how a family medicine residency program solidified a residency curriculum in substance abuse screening, assessment, and brief intervention by merging three presentation-style didactics into a blended approach. The curriculum combines didactic teaching, motivational interviewing, and behavioral rehearsal of clinical practice skills. Qualitative feedback suggests that the curriculum has been successful in exposing residents to a variety of practical assessment methods and, through rehearsal, has improved resident confidence in addressing alcohol use and misuse in a primary care population. Keywords Primary care, alcohol misuse, brief interventions, motivational interviewing, curriculum

Conceptual background Across the lifespan, alcohol misuse affects a large percentage of patients seen in primary care clinics. It can lead to alcohol use disorders (AUD), ranging from 1

Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA Department of Family and Preventive Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA 2

Corresponding author: J Chris Rule, Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W. Markham St. Slot 530, Little Rock, AR 72205, USA. Email: [email protected]

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risky use to alcohol dependence.1 AUDs frequently complicate acute and chronic illnesses of patients seen in FM clinics.2–4 Screening patients for alcohol and substance use, as well as commonly seen mental health problems such as mood disorders and anxiety spectrum disorders, has become a standard of practice in most primary care settings. This article describes how a family medicine program solidified a residency curriculum for substance abuse identification, assessment, and intervention by merging three different presentation-style didactics into a blended approach. The curriculum combines didactic teaching, motivational interviewing (MI), and behavioral rehearsal of clinical practice skills. Screening Brief Intervention and Referral to Treatment (SBIRT) for alcohol misuse is an evidenced-based approach recommended by the United States Preventative Services Task Force (USPSTF).5–7 ‘‘The USPSTF recommends that clinicians screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse.’’5 The USPFTF represents an expert panel in primary care and prevention, independent of the U.S. government, that reviews current evidence and promulgates recommendations for clinical preventive services (for details and overview of grading definitions see http://www.uspreventiveservicestaskforce.org/ Page/Name/home). The USPFTF recommendations often serve as roadmaps for primary care resident training clinics to follow when seeking to implement interventions such as the ones addressed in this article. Several screening tools for alcohol misuse are utilized in primary care: AUDIT, AUDIT-C, CAGE, and TWEAK, and they are frequently used in FM settings as part of routine annual screenings or preventive health visits.8 Data on sensitivity and specificity for these instruments have been evaluated by multiple research studies across various populations and compiled by the National Institute of Alcohol Abuse and Alcoholism (NIAAA).8 For example, among older adults, the CAGE questionnaire has the sensitivity/specificity of 14% to 39%, respectively, and for pregnant women 38% to 49%. Of all these screening instruments, the 10-item Alcohol Use Disorders Identification Test (AUDIT) and the abbreviated 3-item AUDIT-Consumption (AUDIT-C) have the highest sensitivity (74%–76%) and specificity (80%–83%).9 The AUDIT and AUDIT-C have high levels of reliability and validity across the multiple settings where FM residents commonly practice (e.g., inpatient, outpatient, emergency, and obstetrics).9,10 Brief interventions (BI) range from the ‘‘matter-of-fact’’ physician advice to ‘‘cut down’’ on drinking to a series of brief (5–30 min) counseling sessions that utilize MI.11–13 The 5A’s model, Ask, Assess, Advise, Assist, Agree, is a common guideline that clinicians follow.8 Since it is easy to teach this model in stages, it was applied to the case studies developed for the curriculum.

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Referral to a higher level of addiction treatment is common in FM and other primary care disciplines. Because the referral sources and access to care issues vary depending upon what is available in a local community or region, resident physicians’ training is focused on communicating with patients and family members about this process, coordinating care with addiction specialists, and reducing barriers to care.13 Working with care managers and behavioral health team members in the Patient Centered Medical Home, resident physicians gain deeper knowledge of the referral process to these specialty providers. MI and the transtheoretical model serve as the frameworks around which BI can be formulated. In the program described, these are introduced to the resident physicians in the first month of their training. Prochaska, DiClemente, and Norcross’ transtheoretical model, also referred to as the stages of change, fits well to this curriculum.14 The trainees learn about the six stages of change which can be seen as a superstructure upon which the patient’s progress through any health behavior change (HBC) can be monitored (Table 1).14,15 The stages are used to identify where a patient is in the change process, so the practitioner can tailor an appropriate intervention to ‘‘where the patient is.’’ Relapse, or ‘‘backsliding,’’ can occur at almost any stage. Trainees use casebased discussions to understand how patients’ health behaviors are often cyclical as they move backwards and forwards in their decision-making and maintenance of healthier behaviors.15 Rather than interpreting relapse as a failure, resident physicians learn that relapse should be conceptualized as an expected part of the ongoing pathway to better health. MI has been shown in multiple controlled trials to produce significant change in patient health behaviors in general and for patients with alcohol and substance use in particular.16 This curriculum’s use of MI and HBC helps resident physicians support patient self-efficacy, autonomy, and use the patient’s expertise to shape BI and treatment.17 Applying MI to patient care calls for several provider behaviors, some of which run counter to the formal instruction that resident physicians receive. With this approach, resident physicians need to be acutely aware of how to enhance a patient’s readiness by helping them identify the real or perceived obstacle to change by resolving their ambivalence.18

Table 1. Stages of change.14 1 2 3 4 5 6

Precontemplation Contemplation Preparation Action Maintenance Termination

Not yet considering change Evaluating reasons for and against change Planning for change Making the identified change Working to sustain changes and prevent relapse No longer in formal treatment

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By using SBIRT methods and communication skills, residents are able to enhance a patient’s self-efficacy so that they become more active participants in their health.19 As resident physicians learn to support self-efficacy in their patients and to take on the patient’s perspective, this curriculum creates an opportunity for understanding parallel process and can lead to a teachable moment for the developing physician: learning to change their practice behaviors parallels what they will ask their patient’s to do in regard to HBC.

Curriculum development The curriculum grew out of a resident-created quality improvement (QI) ‘‘Prevention Project’’ that gives resident physicians an opportunity to design and implement a quality-improvement process. Prevention projects are based on evidenced-based information supported by USPSTF guidelines. The topic selection was based on the second author’s observation and clinical experiences which revealed an uneven application of screening and treatments for alcohol misuse. A QI pilot study was conducted to implement using the AUDIT-C in the Family Medical Clinic. The results were presented to the faculty and resident physicians at a departmental conference. The project was then expanded in collaboration with the program’s behavioral scientist to include clinical communication skills for screening and identification of alcohol use/misuse in a busy, urban, FM clinical population. Both authors worked together to create three case-based behavioral rehearsal scenarios to give residents the opportunity to practice their skills using the 5A’s model and MI techniques.8,20 Before this curriculum was created, the behavioral science faculty provided post-graduate year-1 (PGY1) residents with a lecture and overview of identifying and assessing alcohol and substance use problems and then gave PGY2 residents lectures on treating alcohol use in primary care and some additional skills for BI and treatments. All residents also have a 2-week rotation with a psychiatrist at a substance abuse treatment clinic. The current curriculum combines the formal instruction in screening for and conducting BI using the SBIRT model and 5A’s approach for all PGY years. The program follows this up with two behavioral rehearsal sessions to practice applying the 5A’s and polishing communication skills using three case-based scenarios. Presently, most of the program’s resident physicians have been through one wave of training. In addition, the electronic health record system used in the clinic has been updated with the AUDIT screening tool to identify alcohol misuse. Support for screening and BI has been well established in the literature.19 The case-based behavioral rehearsal breaks the 5A’s into smaller steps so resident physicians can practice when they need to use this in their clinical encounters. Behavioral rehearsal differs from role play in that it gives the resident physicians a structured scenario with instructions to rehearse only the specific

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communication skills that are central to each case.20 Trainees work in small groups of three or four and each rotate through being in the role of the physician and the patient. Each case is designed to take 7 to 8 min to simulate the pace at which these conversations often occur in the fast-paced clinic environment (Figure 1). After all resident physicians complete turns as practitioner and patient, they provide feedback to each other focusing on the most effective interventions that Case #1 Central Dilemma: Determine weekly average of alcohol consumption and educate patient about standard drink amounts Case: Joe is a 36 year-old African-American male who came to the clinic for a routine physical. He has no complaints at this time. Past Medical History: Hyperlipidemia (currently on a statin); Elevated blood pressure (controlled by lifestyle modification); BMI of 32 Past Surgical History: ACL repair 5 years ago Social History: Single parent of a 7 year-old girl; Works as a manager at an auto parts store. Past smoker – quit 3 years ago; enjoys spending time with his daughter, going to football games and watching sports with friends. Alcohol use history: Joe describes himself as a “social drinker” Rehearsal skills: Ask: 1. Do you drink…{type of alcohol}? 2. How many days/week and drinks/day, etc… (Make questions specific) Advise and Assess: 1. Determine whether at-risk vs. alcohol abuse 2. Use MI skills to assess readiness for change Case #2 Central Dilemmas: 1. Determine whether at-risk or alcohol abuse; 2. Develop a plan that fits with patient’s willingness to change. Case: Catherine is a 46 year-old Caucasian female who presented to the clinic with a chief complaint of insomnia. Past Medical History: Borderline Diabetic, Depression diagnosed in her late 20’s; Generalized Anxiety diagnosed in her 30’s Social History: She is a mother of two: 12 y/o girl and 10 y/o boy; divorced from children’s father ten months ago (relationship was stressful and divorce was contentious); works as an investment banker for a large national firm; active social life - volunteers in the community, planning and hosting multiple non-profit charitable and fundraising events; likes to consume alcohol during such events. Reported alcohol use history: Frequently drinks wine – 1-2 glasses an evening; often more (5-7+) when having parties or attending social events; occasionally drinks mixed drinks at parties/events; Use has increased in the past 18 months. Does not consider herself a “heavy drinker” compared to her friends. Audit score = 8 Rehearsal skills: 1. 2. 3.

Advise: State concerns and recommendations clearly Assess readiness for change using the Change Scale or Readiness Ruler Assist and Agree: set goals and pick from menu of options

Figure 1. Case-based behavioral rehearsals.

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Case #3 Central Dilemmas: Evaluate progress toward goals and determine next steps for intervention. Case James is a 61 year-old Asian-American who presented to the clinic for follow-up on his goals of addressing alcohol use disorder. Past Medical History: Long history of alcohol abuse. Social History: Divorced from 2nd wife 3 years ago; has 3 children from his first marriage, ages James Jr. 30 y/o; Jasmine 26 y/o, and Olivia 22 y/o; 2 grandchildren – 3 y/o and 14 months; Works as an Internist in a small/medium-sized town (< 25,000 pop.); He has lived and worked in this town for over 25 years; Social life is mainly spent with family and close friends in the town. Recently had a car accident where he hit a traffic light pole after he had been drinking; was ticketed for reckless driving by local police. Has history of 2 DUI’s in past 10 years. Car insurance is being canceled. Heavy drinker and prefers hard liquor, consumes anywhere from 4-12 drinks/day. He expressed frustration that he is not getting better and is ambivalent that changing his drinking habits will do any good. Rehearsal skills: 1. 2. 3.

Assist: Revise goals (since he is struggling to meet previously stated goals). Use spirit of MI: be empathic and affirming of past efforts at change Re-state your concerns and recommendations Agree and Arrange follow-up: Explore treatment options.

Figure 1. Continued.

they heard; they then proceed to the next case.21 Once the residents have rehearsed all three cases in their small groups, the entire group is given 10 to 15 min to discuss the experience and share the most effective communication approaches and that they heard. The curriculum has been in use for nearly 12 months. The content of the curriculum attempts to build resident physicians’ knowledge base in incremental succession. As with any busy residency program, setting aside time where all or most resident physicians were available to participate was a barrier to be conquered. Creating case scenarios that were diverse, stimulating, and could be tackled in the 7-min timeframe allotted was crucial. The techniques of interactive role-playing and behavioral rehearsal are utilized less often than standard lectures. Initially, there was some resistance from a few trainees, but most adapted to the notion fairly quickly.

Curriculum goals and objectives The curriculum meets several ACGME program requirements and core competencies such as medical knowledge, interpersonal and communication skills, and patient care.22

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The curriculum provides resident physicians with current data on the national and global burden of AUD, as well as research supporting the benefits of alcohol screening in primary care. The curriculum educates residents regarding the changes in diagnosing AUDs in DSM-5 and exposes resident physicians to the most recent literature on various screening tools.23,9 The curriculum teaches resident physicians the skills for recognition and assessment of patients with AUDs and at-risk drinking in the fast paced outpatient primary care setting. This was established by providing resident physicians with BI skills for managing patients at-risk for AUD and increasing competency in applying the 5A’s model (Ask, Assess, Advise, Assist, and Agree/Arrange follow-up) for alcohol use in a clinical encounter. The curriculum provides protected time for resident physicians to rehearse specific communication strategies using case studies and interaction with their peers. The curriculum addresses the AAFP Guidelines which require residents to demonstrate competencies, and the ability to effectively interview and evaluate patients for mental health disorders using appropriate techniques and skills to enhance the doctor–patient relationship.24 This curriculum raises resident physician’s awareness of health maintenance and screening guidelines developed by USPSTF.5 It stresses the importance of communicating with patients in an empathic manner and developing the skill set to empower patients, with the goal being shared decision making about ways the patient can reduce their alcohol intake. Patient care is enhanced as resident physicians learn to apply evidence-based scientific data to better understand the importance of alcohol misuse and its potential negative impact on the patients’ health.

Performance to date The curriculum has been in place for one year, and data are still being gathered on the impact of the training and its applicability to practice. Qualitative feedback from residents obtained four months after the final training suggests that they have retained information about the training, and it has been a valuable addition to their practice skills. Below are samples of responses received: PGY1 resident: It was very helpful it shows different ways to ask questions to get information out of patients. One particular case was a patient who you wouldn’t have thought had a problem with alcohol but the role play held by showing different ways to ask questions and to extract information from patients to get a better history to learn about their condition and be able to tailor treatment. PGY1: The rehearsal skills are extremely helpful. I personally found it practical and useful; just wish I had it (pocket guide) on me for a better application to patients.

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PGY2: There are instances when I use the 5 A’s if the patient primarily came for alcohol cessation. The counseling session last year taught me: 1. How to elicit a thorough history re: alcohol use 2. How to give advice about treatment and the complications of alcohol misuse in a non-judgmental way 3. The importance of acknowledging the patient’s feelings re: alcohol cessation PGY3: I think it is crucial to assess alcohol usage in a busy clinic setup and focus in depth if suspicious of any substance use. Primary care docs need more awareness as it gets mostly overlooked in a busy practice, so this was helpful, it provided a step by step approach.

Generalization The curriculum was designed to be carried out in an outpatient setting in which the physician can establish a trusting continuity relationship with the patient. However, the versatility of the curriculum may also be applicable in other settings including, but not restricted to, the Emergency Department and when a patient is discharged from the hospital. Barriers to implementing the skills taught in this curriculum in the above-mentioned settings are: the limited time available and the lack of a continuity relationship between the patient and the resident physician. A work-around could be crafted to have trained team members (e.g., nurses, care managers, or social workers) conduct the BI in these settings since they often have more face-to-face time that they can spend with patients. The curriculum may work best broken up in stages or smaller chunks, such as an overview of the medical knowledge needed to ask and assess in PGY1 with some orientation to the case study and behavioral rehearsal method, and then the application of the advanced communication skills and increased rehearsal with the case studies for PGY2 and PGY3 resident physicians. This has been borne out by several of the comments we have received from resident physicians when asked to comment on what they retained from the training. There may also need to be booster sessions added at certain intervals following the main workshop that would involve brief rehearsal of skills and review of content. Placing the NIAAA handouts and pocket guides in patient rooms so that residents can access the information more readily should improve resident’s recall and application of information in the moment.8 The basis of this curriculum is to utilize various methods of learning and interacting to help reenergize and provide resident physicians with techniques to assist in building a more concrete patient–physician relationship. As a PGY2 resident stated, ‘‘I thought it was . . . a good practice tool. It was nice to have a physician play the role of a patient because it helps us feel what the patient feels.’’ This statement captures the essence of this type of training where the

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resident physicians engage in the design of the curriculum, participate in its development, and rehearse the communication skills from both perspectives (physician and patient). This approach seeks to ‘‘flip’’ the classroom, providing learners the opportunity to become teachers in the same moment. Future directions for this type of training and these interventions involve more use of e-health and online technologies. Adaptation to the rapidly shifting environment for using these technologies in clinical practice is well underway, and successful residency programs will be able to incorporate these tools as part of their training so that family physicians can use these to facilitate patient care and communication rather than be a barrier.25,26 As health care continues to gear more toward patient empowerment, it is essential that the instruction of future physicians adjusts and provides residents with the knowledge base to better understand the patients’ needs and collaborate with the patient to provide optimal care. Authors’ note This article is based on a presentation at the Forum for Behavioral Science in Family Medicine, September 18–21, 2014.

Conflict of interest None declared.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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7. O’Donnell A, Anderson P, Newbury-Birch D, et al. The impact of brief alcohol interventions in primary healthcare: a systematic review of reviews. Alcohol Alcohol 2005; 49: 66–78. DOI: 10.1093/alcalc/agt170 66–78. 8. US Department of Health and Human Services. National Institute on Alcohol Abuse and Alcoholism. Helping patients who drink too much: a clinician’s guide. Bethesda, MD: National Institute of Health, 2007. 9. Babor TF, Higgins-Biddle JC, Saunders JB, et al. AUDIT: the alcohol use disorders identification test; Guidelines for use in primary care. 2. Geneva: World Health Organization, 2001. 10. Burns E, Gray R and Smith LA. Brief screening questionnaires to identify problem drinking during pregnancy: a systematic review. Addiction 2010; 105: 601–614. 11. Bertholet N, Daeppen JB, Wietlisbach V, et al. Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Arch Intern Med 2005; 165: 986–995. 12. Babor TF, Higgins-Biddle JC, Higgins PS, et al. Training medical providers to conduct alcohol screening and brief interventions. Subst Abuse 2004; 25: 17–26. DOI: 10.1300/J465v25n01_04. 13. www.integration.samhsa.gov/SBIRT_Issue_Brief.pdf (2006, accessed 13 June 2015). 14. Prochaska JO, DiClemente CC and Norcross JC. In search of how people change: applications to addictive behaviors. Am Psychol 1992; 47: 1102–1114. 15. Williams EC, Kivlahan DR, Saitz R, et al. Readiness to change in primary care patients who screened positive for alcohol misuse. Ann Fam Med 2006; 4: 213–220. DOI: 10.1370/afm.542. 16. Martins RK and McNeil DW. Review of motivational interviewing in promoting health behaviors. Clin Psychol Rev 2009; 29: 283–293. 17. Vasilaki EI, Hosier SG and Cox WM. The efficacy of motivational interviewing as a brief intervention for excessive drinking: a meta-analytic review. Alcohol Alcohol 2006; 41: 328–335. 18. Seale JP, Clark DC, Dhabliwala J, et al. Impact of motivational interviewing-based training in screening, brief intervention and referral to treatment on residents’ selfreported attitudes and behaviors. Addict Sci Clin Pract 2013; 8(Suppl 1): A71. 19. Pringle JL, Kowalchuk A, Meyers JA, et al. Equipping residents to address alcohol and drug abuse: the National SBIRT Residency Training Project. J Grad Med Educ 2012; 4: 58–63. DOI: 10.4300/JGME-D-11-00019.1. 20. Joyner B and Young L. Teaching medical students using role play: twelve tips for successful role plays. Med Teac 2006; 28: 225–229. 21. McKimm J. The ‘TRIALOGUE’: a new model and metaphor for understanding clinical teaching and learning and developing skills. Paper presented at ASME conference, 10–12 September, Leicester, 2008. 22. Accreditation Council for Graduate Medical Education Program Requirements for Graduate Medical Education in Family Medicine, https://www.acgme.org/acgmeweb/ Portals/0/PFAssets/ProgramRequirements/120_family_medicine_07012014.pdf (2013, accessed 13 June 2015). 23. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychiatric Association, 2013.

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24. American Academy of Family of Physicians Recommended Curriculum Guidelines for Family Medicine Residents Human Behavior and Mental Health, www.aafp.org/ dam/AAFP/documents/medical_education_residency/program_directors/Reprint 270_Mental.pdf (2011, accessed 13 June 2015). 25. Wallace P and Bendtsen P. Internet applications for screening and brief interventions for alcohol in primary care settings – implementation and sustainability. Front Psychiatry 2014; 5: 1–7. DOI: 10.3389/fpsyt.2014.00151. 26. White A, Kavanagh D, Stallman H, et al. Online alcohol interventions: a systematic review. J Med Internet Res 2010; 12. DOI: 10.2196/jmir.1479.

Teaching family medicine residents brief interventions for alcohol misuse.

Across the lifespan, alcohol misuse affects a large percentage of patients seen in primary care clinics. It can lead to alcohol use disorders, ranging...
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