doman resume - eric · ed 192 216. author. title institution. pons agency. report no pup eats grant...
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ED 192 216
AUTHORTITLEINSTITUTION
PONS AGENCY
REPORT NOPUP EATSGRANTNOTEAVAILABLE Pint
EDES PRICEDESCRIPTORS
Doman RESUME
CG 014 672
Galanter, Marc. Ed.Alcohol and Drug Abuse in Medical Education.State univ. of New York, Brooklyn., Downstate MedicalCenter.: Yeshiva univ.. Bronx, N.Y. Albert EinsteinColl. of Medicine.National Inst. on Drug Abuse (DBZW/PHS), Rockville,Md.ADM-79 -891SOTO1-DA-00083: T01-CA-00197128p.superintendent of Documents, O.S. Government PrintingOffice, Washington, DC 20402
mF01/FC06 Plus Postage.*Alcohol Education: *Drug Abuse: *Drug Education:Higher Education: *Medical Education: medical SchoolFaculty; Medical Services; *Physician PatientRelationship: Physicians: *social Responsibility:State cf the Art Reviews
ABSTRACTThis book presents the state of the art of American
medical education in alcohol and drug abuse, and is the culminationof a four-year collaborative effort among the medical school faculty,of the Career Teacher Program in Alcohol and Drug Abuse. The firstpart contains reports, curricula, and survey data prepared for themedical education community, focusing on drug abuse and alcoholismteaching in medical/osteopathic schools, i course on alcoholism forphysicians, the Career Teacher Program and Resource Handbook, and therole of substance abuse attitudes in_treatment. The second part is --the proceedings of the National Conference on Medical Education andDrug Abuse, November 1977. The conference sessions address issuessuch as: (1) the physician's role in substance abuse treatment; (2)physicians' use of drugs and alcohol: (3) drug abuse questions on theNational Board Examinations: and (4) an overview of the CareerTeacher Program activities. (Author/HLM)
* *s * * * * * * * * * * * * * * ** ***************** * * * * ** * * * * * * * * * * * * * * * * * * * * * * * *0
Reproductions supplied by EDRS are the best that can be madefrom the original document.
***************************************************************1. -gl
National Institute on Drug Abuse
National Institute on Alcohol Abuse and Alcoholism
Alcohol andDrug Abusein MedicalEducati o n
US OilIAMTMErav OF HEAtrocADUCATION A WELFARENATIONAL INSTITUTE OF
AM AT ION
THIS 00CUMINT HAS BEEN ReeaoOutt0 IXACttY AS elECEIvED FROMTHE IIIRS411400 CiaGANItAssolv °atom,-A flA16 IT POINTS vIEW OR opiAloALSTATED 00 NOT NECEssAaeLvSENT 00itittas NATIONAL INSTITUTE OFSOUCAT411A1 POSstIoN cla POLICY
U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFAREPublic Health ServiceAlcohol, Drug Abuse, and Mental Health Administration
4 2 t, 2
Association for Medical Educationand Research in Substance Abuse
EXECUTIVE COMMITTEE
MARC GALANYER, M.D.President
JOHN E, FRYER, M.D.Vice President
JOSEPH WESTERMEYER. M.D., Ph.D.Secretary-Treasurer
ROBERT MILLMAN. M.D.JOHN N. CHAPPEL. M.D.
SIDNEY H. SCHNOLL, M.D., Ph.D.JOHN SEVERINGHAUS. M.D.
Career Teachers in Alcoholand Drug Abuse
GEARY ALFORD, Ph.D.RUDY ARREDONDO. Ed.D.ROLAND M. ATKINSON, M.D.JOSEPH M. BENFORADO, M.D.KENNETH BLUM, Ph.D.LOUIS pozzErn, M.D.ALAN BROWN, M.D.JOHN N. CHAPPEL M.D.THOMAS J, CROWLEY, M.D.DONALD I. DAVIS, M.D.DAVID EILAND, M.D.WILLIAM E. FLYNN, M.D.JOHN E. FRYER, M.D.MARC GALANTIR, M.D.JULES GOLDEN, M.D.JOHN S. GRIFFIN, Jr.. M.D.ALYCE C. GULLATTEE M.D.JAMES HALIKAS, M.D.ANDREW K. S. HO, Ph.D.GEORGE JACKSON, M.D.KIM A. KEELEY, M.D.
RONALD S. KRUG, Ph.D.LEON KU HS, M.D.JOSEPH LEVIN, Ed.D.JEROME LEVY, Ph.D.KARIN MACK. M.D.MARVIN MATTHEWS. M.D.ROBERT MILLMAN, M.D.JOHN MORGAN, M.D.JAMES O'BRIEN, Ph.D., M.D.PAUL PASCAROSA, M.D.ROBERT), RHODES, Ph.D.JACK M, ROGERS, M.D.HENRY II ROSETt, M.D.KENNETH S. RUSSELL, Ed.D.JOHN SEVERINGHAUS, M.D.SIDNEY H. SCHNOLL M.D.CLAUDIO TORO, M, D,GEORGE S. TYNER. M.D.LUCAS S. VAN ORDEN, M.D., Ph.D.JOSEPH WESTERMEYER, M.D., Ph.D.CHARLES L. WHITFIELD, M.D.
KENNETH WILLIAMS. M.D.
Career Teacher Centers
STATE UNIVERSITY OF NEW YORKDownstate Medical CenterBENJAMIN KISS1N, M, D, 0
DirectorJOEL SOLOMON, M.D.
Program CoordinatorCHARLES BUCHWALD. Ph.D.
Program Administrator
BAYLOR COLLEGE OF MEDICINE
JOSEPH SCHOOLAR. M.D., P".D.Director
ALEX POKORNY, M.D.Program Codirector
3
Alcohol andDrug Abusein MedicalEducation
Marc Galante,. M.D.EditorDepartment of PsychiatryAlbert Einstein College of Medicine
The Medical Career Tischer Program ofThe National institute on Drug Abuse endThe National Institute on Alcohol Abuse end AlcoholismandThe Association for Medical Education and Researchin Substance Abuse
National Institute on Drug AbuseNational institute on Alcohol Abuse and Alcoholism5600 Fishers LaneRockville, Maryland 20857
The U.S. Oovernment does not endorse, favor, or disparage any specificproduct or commodity. Trade or proprietary names appearing in thispublication are used only because they are considered essential in the con-text of the studies reported herein.
This publication was written under grants 1101 DA 00083 to the StateUniversity of New York, Downstate Medical Center, Brooklyn, N.Y., and1101 DA 00197 to the Albert Einstein College of Medicine, YeshivaUniyersky, Bronx, N.Y.
DREW Publication No. (ADM) 79-891Printed 1980
5
Per Isla by tha leperlataadene of Doemasata, 13.8, Clevanteene Printing MoeWaa Marton. D.C. 80108
Editorial Board
Charles Buchwald, Ph.D.Downstate Medical CenterState University of New York
John N. Chappel, M.D.University of Nevada
Thomas J. Crowley, M.D.University of Colorado
Donald I. Davis, M.D.George Washington University
John B. Griffin, Jr., M.D.Emory University
George Jackson, M.D.Mount Sinai School of Medicine
Alex Pokorny, M.D.Baylor College of Medicine
Sidney H. Schnoll, M.D., Ph.D.Eagleville Hospital
John Severinghaus, M.D.Columbia University
Joel Solomon, M.D.Downstate Medical CenterState University of New York
iii 6
Foreword
A systematic and intensive study of medical education in alcohol and drug abuse is relativelynew. As national awareness of the medical problems resulting from alcoholism and drug abusehas grown during thiPut decade, medical educators, practicing physicians, treatment pro-gram staffs, clients in treatment, and others have drawn attention to the need for trainingphysicians to recognize, diagnose, treat, and properly manage patients with substance abuseproblems. With the establishment of the National Institute on Alcohol Abuse and Alcoholismand the National Institute on Drug Abuse, a career teacher program was developed. Thepurposes of the program have been to educate medical school faculty for a teaching career indrug abuse and alcoholism and to develop medical school curriculums in the field. A significantindication of the growing interest in medical education in substance abuse has been theformation, by career teachers and colleagues from their medical schools, of the Association forMedical Education and Research In Substance Abuse (AMERS A). This volume is the first of aseries of publications in which career teachers and members of AMERS A will collaborate. It isoffered to the medical educator in the hope that it will be a valuable resource In consideringsome of the issues involved in preparing physicians to treat drug or alcohol patients and theirfamilies.
James F. CallahanDeputy ChiefManpower and Training BranchDivision of Resource DevelopmentNational Institute on Drug Abuse
y L.
v
Jeanne TrimbleAssistant Chief
Paining BranchDivision of Resource Development
National Institute on Alcohol Abuse andAlcoholism
7
.
CONTENTS
FOREWORD v
INTRODUCTION: A PERSPECTIVE ON ALCOHOL AND DRUG ABUSEIN MEDICAL EDUCATIONMare Ga/anter 1
THE STATE OF THE ART
1. DRUG ABUSE AND ALCOHOLISM TEACHING IN U.S. MEDICAL ANDOSTEOPATHIC SCHOOLS. 1975-77Alex Pokorny, Patsy Putnam, and John E. Fryer 7
2. MEDICAL EDUCATION IN ALCOHOL AND DRUG ABUSE:THE CAREER TEACHER PROGRAMMare Ga/anter 20
CURRICULUM MATERIAL
3. PHYSICIAN EDUCATION IN SUBSTANCE ABUSE:CURRICULUM OBJECTIVESDonald ! Davis 27
4, A COURSE ON ALCOHOLISM FOR PRIMARY CARE PHYSICIANSGeorge Jackson 34
S. THE CAREER TEACHER RESOURCE HANDBOOKCharles Buchwald 40
EVALUATION TECHNIQUES
6. SUBSTANCE ABUSE ATTITUDES: THEIR ROLE AND ASSESSMENT INMEDICAL EDUCATION AND TREATMENTJohn N. Chappel and Ronald S. Krug 49
7, EVALUATION OF KNOWLEDGE IN SUBSTANCE ABUSEAlex Pokorny, Ronald S. Krug, David Smith, John B. Griffin,and Kenneth S. Russell 58
muJ u . 8
PROCEEDINGS OF THE NATIONAL CONFERENCEON MEDICAL EDUCATION IN ALCOHOL AND DRUG ABUSE
Jointly sponsored by the Association for Medical Educationand Research in Substance Abuse and the Career Teacher
Program in Alcohol and Drug Abuse (A DAMHA)
November 5-6. 1977. Washington. D.C.
OPENING REMARKSMarc Galante 75
KEYNOTE ADDRESSErnest Noble 77
DEBATING THE ISSUES I: THE ROLE OF THEPHYSICIAN IN SUBSTANCE ABUSE TREATMENTFrank Seixas. Moderator 83
SHOULD ALL PHYSICIANS BE 'TRAINEDTO TREAT ALCOHOL AND DRUG ABUSE?
In Favor: Benjamin gissin 85Against: E. Mansell Paulson 88
DEBATING THE ISSUES 2: PHYSICIANS' USE OF ALCOHOL AND DRUGS:IMPLICATIONS FOR MEDICAL EDUCATIONSidney Cohen. Moderator 93
HAS MEDICAL EDUCATION FOCUSED TOO MUCH ON THE ADVERSECONSEQUENCES OF THE NONMEDICAL. USE OF PSYCHOACTIVE AGENTS?
In Favor: Norman Zinberg 95Against: LeClair Bissell 97
AMERICAN MEDICAL EDUCATION IN ALCOHOLAND DRUG ABUSE: THE STATE OF THE ART
REPORT ON A NATIONAL SURVEY
Results of the SurveyAlex Pokorny
Report on the She VisitsJohn E. Fryer .
THE NATIONAL BOARD EXAMINATIONS
SUBSTANCE ABUSE QUESTIONSON THE NATIONAL BOARDS
IntroductionJohn B. Griffin
Report on Substance Abuse Questions on the National BoardsDavid Smith 114
105
109
113
9
viii
EDUCATIONAL ACTIVITIES OF THE CAREER TEACHERSJoseph Schoo lar, Moderator 119
A DEAN'S PERSPECTIVEGeorge S. Tyner 121
DATA ON STUDENT ATTITUDESJohn N. Choppel 123
CURRENT FINDINGS ON STUDENT ATTITUDESRonald S. Krug 123
OLD DOGS AND NEW TRICKSJohn E. Fryer 125
BIOBEHAVIORAL STUDIES IN SUBSTANCE ABUSEThomas J. Crowley 128
AA AND THE PHYSICIANKenneth Williams 130
.! Ix 10
Introduction: A Perspective on Alcoholand Drug Abuse in Medical EducationMarc Galanter, M.D.
This book presents the "state of the art" of Ameri-can medical education in alcohol and drug abuse. Itprovides both a historical and a contemporaryperspective on this important issue at a time whenthe American public and the medical professionhave acknowledged a responsibility to treat theseserious multisystem illnesses. It also includes valu-able educational materials recently developed forthis field.
This book is the culmination of 4 years of collabo-rative effort among the medical school faculty of theCareerTeacher Program in Alcohol and DrugAbuse. This program, established in 1971, is sup-ported by the National Institute on Drug Abuseand the National Institute on Alcohol Abuse andAlcoholism. Since 1976, the career teachers haveworked together under the organization they estab-lished, the Association for Medical Education and Re-search in Substance Abuse ( A MERSA). A MERSAwas opened to other medical faculty in this field inthe year after its inception.
Under the career teacher program, a number of_projects were carried out to define the scope ofeducation in the addictions and to implement moreeffective teaching. The results of this work are pre-sented here in two parts. The first part contains
-. reports, curriculums, and survey data prepared for: the medical education community. The second partis the Proceedings of the National Conference onMedical. Education in Alcohol and Drug Abuse,
."-iieia in- NOieMbei 1977. It drain on the work ofcareer teachers and their colleagues and reviews
... . ...:*inajoe issues in this field.
-'.- Th e hook begins with the report of a national sur-vey
..ve evaluating the state of current teaching prac-
1
tires in substance abuse in all American medicalschools. Alex Pokorny and his associates have con-ducted a carefully conceived and thorough study,which allows us to define future progress by thespecific standards of current achievement. This isfollowed by a review of the development of thecareer teacher program in its historic context.
An ensuing section deals with specifics of curricu-lum. "Curriculum Objectives" have been developedby a committee of the career teacherschaired byDonald I. Davis. They represent a distillation of theknowledge and skill areas related to substanceabuse which the physician should master, and theyserve as a useful outline for preparing curriculum.
A model program which uses these objectives, a"Course on Alcoholism for Primary Care Physi-cians," was developed by another committee chairedby George Jackson to illustrate specific teachingtechniques which may be employed. After thischapter, Charles Duch wald describes the ampleeducational aids available in this field.
The need for measuring change in attitudes is ofmajor importance in substance abuse education.On the basis of another working group, both theinstruments used and results in a study assessingmedical attitudes toward the substance abuser arepresented. This material, developed by John N.Chappel and Ronald S. Krug, allows for thesequential study of changes in student and graduatemedical groups. The final part of the first sectionpresents examination techniques developed in ajoint effort by the career teachers and the NationalBoard of Medical Examiners. John B. Griffin'swork with his associates on this project has allowedfora more prominent role of substancenbuse in the
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
board examinations. Their material is also nowunder consideration by medical specialty boardsfor inclusion in their examinations. This work maybe particularly useful, since policy in the profes-sional examinations is highly influential in deter-mining medical curriculum.
The material described was drawn together prior tothe National Conference on Medical Education inAlcohol and Drug Abuse. That conference wasestablished by AMERSA to strengthen communi-cations among workers in this field. It was held inNovember 1977 in the hope that it would serve as afocus for growth of our working group. The pro-ceedings, which constitute the second half of thisbook, reflect the excitement and controversy inher-ent in the conference. Over 200 physicians gatheredto discuss issues of mutual concern, issues for whichonlya limited forum had been previously available.Most of those in attendance had worked diligentlyin the face of limited support and often active oppo-sition to develop curriculums in the area of addic-tive diseases. They felt strongly that a united effortfeatly enhanced their opportunity for success.
Ernest Noble, Director of the National Institute onAlcohol Abuse and Alcoholism at the time of theconference, delivered the keynote address whichdocuments the status of Federal programs at a timewhen there had been considerable expansion in thescope of research activities. He also indicatedavenues that the Institute planned to pursue, withincreased primary prevention being one majorthrust. Dr. Noble helped to put the conference in abroader public health perspective and urged thoseattending to reflect on the relative investment of theFederal Government in their activities in the field ofmedical education.
The principal talks of the plenary sessions of thisconference were reviewed and edited by our edito-rialboard.These proceedings consist oftwo debates,two status reports, and illustrative career teacherprograms. The first debate, between Benjamin Kis-sin and E. Mansell Pattison, focuses on defining theappropriate clinical role for the physician in rela-tion to alcohol and drug abuse. The relative benefitsof training all physicians to assume care for suchpatients are presented. Similarly considered is theoption of limiting the physician's training to refer-ral of such patients to specialists in the addictions.
2
A second debate examines whether medical educa-tion has focused too much on the adverse conse-quences of the nonmedical use of psychoactiveagents. It asks, In effect, whether the physician'sresponsibility is to emphasize considered warningof the dangers of addictive illness, a position sup-ported by LeClair Bissell. Alternatively, shouldphysicians serve simply as educators for the sensibleand appropriate use of psychoactive agents, as sug-gested by Norman Zinberg? This attitudinal issue isa very important one, since the substance abuseeducator may set the tone for students' responsestoward drug use among their patients and towarddrug abusers in general.
Alex Pokorny and John E. Fryer reviewed majorpoints from their national survey, which is pre-sented in the first part of this book. They providedinteresting insights into the conduct of this surveyand their dealings with medical faculty from thevarious schools.
As stated above, the career teachers were providedwith an invitation by the National Board of Medi-cal Examiners to develop questions in the field ofsubstance abuse. At the conference, David Smith,director of the board, and John B. Griffin, whochaired the committee for the career teacher group,reviewed the status and import of their work. Thiscomplements their report on this issue in the initialpart of this book.
The final section provides an overview of the type ofactivities undertaken by the career teachers at theirrespective campuses. George S. Tyner, for example,gives a perspective on substance abuse educationfrom the office of the dean, since he was a careerteacher while serving as dean of the medical schoolat Texas Tech University. John N. Chanel andRonald S. Krug present reviews ofa survey that theyundertook on student attitudes toward the sub-stance abuser. This, too, is an update and summa-tion of material in the first half of the book. John E.Fryer presents an analysis of the communicationsstructure in his school, as played out in the hands offigures such as the department chairperson, whomaintains control over much oldie curriculum time..He provides a lesson in navigating the variouscommittees on curriculum and the director's oftraining in order to institute changes in substanceabuse teaching.
. .
iNTRODOtriON--
-= .. - -.
.Many.of:the career teachers were actively engaged __-,..,.'irliel'earc_6AUktrigtheConrse of their grant Periods.
,th;iiiiisTi:to08i/ley:sigilieri,chinges in motility inchiicIlid settings ins relation to inetha..
VAAliCitilininiitration...He_ reviews the._iiiius gi961h::0 .0-Oat-Cory __Ind illustrates the
iiidi4hichiCcue from combining research
.ri4;#.t1';..';ar:*e*
ar. frequently involved inproduc.aiiOVisual.*aterialsjortheirowncamncsee01,baner5i4q4Futton. ne such project
ia1idertakeb whose long ex .perienceIn clinical collaboration with-Alcoholics
6'64AA) allowed him to film* nature of AA membership.material
tdiscussed
foislev.elo. ping audiovisualred:the:Waft that physiciansy
titiight.t o Utilize AA. . .
rhii !'y. lume:therefore provides historical and sur .' alcohol and drug abuse educe.
of techniques useful to Medi..71 '.....i eiiticaters 10.1...this.fleld:::Although such work is
;tIfuUy...-aOsepted
in altschools oftmedicine, the
rOkr*naue4 the e hbeen rema rksOii:ictOOtheveProgressedfron virtually
r"1 '-."iientionaliciivities.itifthie'field to modest but
eqii.niii-O7irriOniO.-ii.e..A.s.recently as a, d ecad e ago it
iteitird to imagine alcoholism and drug abuse as. _.
::::
1,""..:;.
. .
:
-Standard components in:appiapriate;clinicttliA.:;:-.departpents. This now exists on many Campuies..1f,,....,:.4;i:may seem unlikely that established .pOstgratinMI,..7-1:medical fellowships in the addictioosiceO:4VC:the-,..-standing of.their counterparts iii*CardiolOgy.,:suigi:.:.-ca l specialties, or child psychiatry: Non: etheleSe.,!..suchleilowships are already being *developed. -
Medical students instructed by meMbiriefth.C...::::.career teacher program at its inception havealreadyapproached the house staff On their wardi, iskiiii.whattreattrient was available for addicts hospital-ized for sequelae of their illness. These students arenow themselves members-of the house staff. We seethem- exorcising grater concern 'Aid iespëi.f6rthis major clinical issue. Many hoUseitaff membershave also been instructed by other medical faculty
'who.have been-active in this field for many years:.All these members of the medical training hierarchy _ _
now reflect changes generated by merliceleducatorf.:and by programs which- have sensitized the publicto the Importance of alcoholism and drug abuse. it.is a time for considerable optimism.
AUTHOR
Marc Oalanter is affiliated with the Albert Einite inCollege of Medicine.
The State of the Art
W.7; 7...7', -
Abuse and Alcoholism Teaching in'cal and Osteopathic Schools,
-
. ..
Alex Pokomy, M.D., Patsy Putnam, BA.,and John E. Fryer, M.D.
4-140141115150-- CTION
This is a report of the principal findings of a survey ofdrug abuse alcoholism teaching in schools ofiriegaridliitibitithYintheUnited States.' These schools
between November 1915 and February..tlifllhereferre; largely represent the situa-
tliiiiiiil97firrhii'reliortooneentrates on the positive or": significant findings Individual medical and osteopathic
tiChooks,stre not identified.
cicGRouND
has beenYid,e1Y...recognir.ed that medical education in
.-0:1'17;!drug. abwre and alcoholism his been generally scantyfla:-...andipa.dequate.41.1tisalso.been.noted.that in the course
of ti:iirittaining medical students tend to acquire nega-
uve patients with substance abuse dis-
Theie perceived.ilefielentiei-in medical educa-to.;.: A*01t0......tirient'Of the Career Teacher
. Drug Abuse, a joint effort of
qt eL1000:41,10itituie.04.0iiii.Abuse and the NationalInstitute on 'Mahal Abuse and Alcoholism.
. .
orreyieWs,...of substance abuse teaching in
schools were made 5 to.7.years ago. In 1970, a
.
. Ortifyjleo_hielbrl.ed dental, 0711610 assistant, and nurseMiiitiOnOr schools, but those mulls:Will be teporserl elsewhere.
conference sponsored by the National Council on Alco-holism reviewed the situation regarding training inalcoholism (1).
. . ._ ._
-This study was supported by grant No. DA00061-05--awarded to Baylor College of Medicine by the Na-tio nal Institute on Drug Abuse and igrant No. 101. -
AA07086awarded to Dr. John E. Fryer by the National:Institute on Alcohol Abuse and Alcoholism,
The conference report stressed that alcoholism is a--major cause of medical and psychiatric pathelogy_and:.that it baS been called the No. I iiirblic healthikeiblem-htthe United States. Despite this, teachingregardingalcoholism has been riegleeiedchapter of the conference report described fhe.Onfricti-lums of various medical and osteopathic schools repre-sented by conference partiCipants. The descriptions_indicated considerable variability between schools; withclinical facilities and affiliations 'frequently determiningthe amount of teaching in the field, The- rejitirt'alscicommented on the'reluctance of curriculumto assign sufficient time to alcoholism education;.gested as possible reasons a defeatist attitude and -the*..
emotional reactions of committee member's..
The situation regarding substance vasreviewed in a 1972;Macy Conference, with some
participants drawn from the ,baliC ***arid clinicaldepartments of medicaiSchools,frorn Federal arid 'SUL
_ agencies, profeiaionalaisociatiunik4010.*1104ti6alindiniry (2). The ioliteiejiC tOcii.44 4011:00.0;::,marijitank-barbituratesiamphetarninii;nnd.
ALCOHOL AND DRUG ABUSE' IN MEDICAL EDUCATION
thou h short on details, the report of this conferenceof the issues. It presented a
wofoid.rOle:fOr medical education: (1) to equip physi-.ns With appropriateknowledge and skills, and (2) to
iti.*ieit.generation of dontatiii CapiOlty_ foreraltiPiiitNiaree. h alio di:eV/attention
bility.i.otiatrOgilic drug 'nbiise;The reporta 'Model:program which would include a
director, appropriate clinical facilities, and theowing COrrinulurn:f
iire. to concepts concerning alcoholism_et% .64:Jenny.
cio.--,petailed teaching on pharmacological aspects
drygdependencyjn.appropriate
ear..4. Suitable electives for students who wish tosubject in greater detail.
he:Macyreport also recommended that medicalitOOlibffer continuing educationcourses in substance
abuse for practicing physicians Participants agreed thathoT abuse are major medical and social
ptibleins,arici that physicians have ilesponsibility to...r.traat:them:.They. agreed that core-curricultain time
--4itedlo.theieSobjects should be increased; but thereconcerning just hoW much timeshould
linted,,Thcreport emphasized the need forappro-Ai faci:itir
.. ,.
In a .presented at the Macy Conference, and. later,published .sepaiSitely,"-pi:BarrY Summed outlined an
it -iiiiitintdnin:in substance abuse (3). -Dr. Stimmelear, integrated, interdeparimental cur -3t wired courses provide the strident
knavilidP, and multiple elective coursesrtunttytoatudy the subject in nine-detail
anexcellent review of topics that need to bentnitifid;;OCiiis -and departments that .might be in-
.' volved, and teaching" methods that have been successful.
W-19774th-a AMA COUncil on Mental Health issued athe "need for effective
education-on the use and abuse of drugs . . . hasY 'been focOscd to a point of urgency" (4). The
r:stressed- he'yecent increase in_ ding abuse and:!a pointed out that such problems were
tOlegal;'mbral, ecOnOttiic, and socialquestions,e,*ne, many medical, schools were revising their
ditigtO offer:MOM options, and the paper sus-,
uieOf -eickriential teaching in the area of
.. substance abuse. It also suuisted that a curriculumshould include these elements: (a) A unifyingconcept of -
behavior, .(b) teaching about the broad spectruin ofpharmacological agents Involved; (c)*systemati4.sintelysis of the research literature; (d) the statusOf Public"' 72-beliefs and attitudes toward substance abuse;(e)graphic considerations; and (1)a-invieW Ofroutes to development-of drug abusi, includingcustoms, self-medication, self-expression, criminaleXtploitadon; and iatrogenic drug abuse.
. _
A studerit-Peisiective edhorial in Private Practice statedthat medical ichools hive no unified approach to :-
training physicians to treat sin-04°HO (5). Thewriter described one medical school in whichsecond-year itidents received four lectures on alcoholismth fee from the department -of psychiatry and -onefrom the department of neurology. During clinical.'rotations in the third and fotirth years, the studentsencountered many alcoholics who werebeing treatedfor other disorders but not for the underlying prob-lent of alcoholism. The writer noted that psychiatryseemed to deal more directly: than _other cleOrt-rifeuts with alc-oholism but did not cover -the con-comitant medical and surgical problems: He theirefoinTrecommended comprehensive didaCtic and clinicalinstruction on alcoholism-in all mecilial_schoolcurrieu--hints. He stilted thiai inedioal schools needto train Physi."..clans to fulfill the major responsibilities they will hiiveregarding management of alcoholic patients,-treatment of the chroninalcoliolic:In addition, "medicalschools must strive to inculcate in the -physician.anattitude of compassion toward thealcoholic-pitieitt."These several reports were therefore in agreeiriniithatmedical education in the area of substance abuse has .
been- inadequate:
Some reviews of substance abuse training for otherrelated professionals have been made. hia studysored by the Drug Enforcement Administration, -theAmerican Association of Colleges of Pharmacy(AACP) surveyed the status of drugabuse education inpharmacy schools (6).-The AACP askedeach pharmacyschool to list substance abuse coursesoffered only to-pharmacy students, courses for pharmacy ancrotherstudents, courses for educators, continning educationprograms, and extracu rri cu le r activities. The reportindicated fairly widespread activity in :the' Schools, .as -= .-:_ -_::.`
well as rapidiiinansion in substance abriselion at the time (1972).
TEACHING DRUG ABUSE AND ALCOHOLISM
sen(questiiiiinairei tol75 regiatered-.nurses.at alarge.Califonia hospital asking about the _
striourit .of. inatruction they had received inalcoholism (7). Ninety-three nurses, who!fromIchools-of -nursing- between 1941
The responses indicated .that sub-ahuTsttelehing habeen sorely neglected and that
ininiberrnf trainees had received little or noinstruction in this area: Those who had received imam>'tion'10;r1F.fivid it mainly during the psychiatryrotation.
-1Tlie National Institute of Mental Health announced theCareir_Teicher. Program in Alcohol and Drug Abuse in
`laeoeinler'I971: 'the piegrani; sponsored by theon Alcoliol Abuse and Alcoholism
and the Division of Narcotic Addiction and Drug=Abuse (which later -the National Institute on:Drug Abuse); was designed to help medical school:faAlty.tneirihersdevelopexpertise in narcotic addiction,-."arig_abuie;and alcohol abuse.'A selected faculty-member, supported by a career- teacher grant, would beable tokend 1 to3 yeartatudYing4 facetkOfaddictionaitd its treattnent:ffolloWifigntraining peiiod; the ip=
students animake his/ her substance abuse expertiseavailable to the wiiwirsity. ThiCibjeCtiireof this
:was to inereaseaiid improve substance abuse educationcontinuing medical education.
firkeareet were appointed in 19'72. One`'ca tleer teaclicr.traming center-waialineitiblished-thit.
_estahlialiedinthefollowing yaw.. _
National Institute on Drug Abuse assem-foict recOnsider the initial objectives of the
pr :to. Suggest additional:ways of achieving;those objectivcs.;'Ibe task force;which included Careertea_ ellers ankrepresentatives from the training centers,
NIDA, and NIAAA,' held a..s..e0eKilif,rii-eitirigs and ultimately adopted eight Objets-
iCiii4-,tleniktly;and nursing, and programs forLand 'nurse- practitioners AO develop
taon "state of the art" regarding drug and,a1C0hOlabuse (teaching) in existing curricula. The goal
'7"±itTititO learn t:tyPe'ofsubStan-ce' abuse informationwas g 1; which departments were responsible,
-oda being Used; and how much time wasreel *the -core curriculum and in elective hours. The
tlie_questionnaire would be verified by site
The task force also- made these decisions regarding the-survey: . . _ _-._
1. -The sample .would be 100 percent of U.S: medical -schools:100percent of osteonathyschools, 2.1 percent of-dental schools, 50 percent of physician's assistants mut-ing picigrami; and 50 percent of the generalist nurse-practitioner training programs. Pharmacy schools wereexcluded because they had recently been surveyed2. Each schooleven thoSe with a career teacherwOuld be approached through the dean. The task forcehoped that the dean would provide greater supportthis inquiry throughout each medical school and thatthis method would increase the comparability of the .
answers.3. -Individual-schools-would not be identified in-thesurvey report.4. For baseline purposes, we would make use of allavailable information, such as that presented in theA A MC curriculum directories and the annual JA MAreports on medical education in the United States.
PROCEDURE
The Baylor Career-Teacher Training Center accepted"responsibility fortoinpleting the survey. Staff membersfrom the training center developed .a pilotquestiOnnairewhich was mailed to three Texas medical schooli-Onthe basis-of their responses; and questions, we revised
hportions of the questionnair. Ambiguous wording was;not detected during the local reviews or dUring the pilot-survey. -As a result,- we could not reliably distinguishbetween the time spent on alcoholism and the tirne spenton drug abuse and will mostly report these together.
The questionnaire was mailed to each mediCal and.oste-_opathy school in the United States in November1975.
In April 1976, we Sent a follov-aiP letter to non;responding school, and in Jilk 1976, we sent a secondletter to those sehoolsiiticlistill had not replied. Laterwe worked through career teachers, other friends onmedical school faculties, and through personal visits topush the completion rate to 90 percent.
FINDINGS
Completion RateThe completion rates as of April 1977 were as followi
duinTrAfalWi'"
._
ALCOHOL AND DRUO ARISE IN MEDICAL Eppciatori. _
schools 105/117Mite eiScbaols 39/42
Nesichcr schools 66/75pithy. schikols 9/9'
114/126
Percent.909388
100
90
itned, a sample of medical schools was visited toihancetra0:Of Di. 'John-the career teacher from Temple University; took
e major responsibility for:thii and visited _10 schools.Pokorny,-codirector' of the Baylor CUM'
etTrainiiiiCanter,- visited two schools, It wasconcluded thatin their replies to the questionnaire, 10
-= of= the I2 schools had,.given adequate 'arid accuratedeSciiptions of their teaching in drug abuse and alcoho.
school had- underestiniated 'such teaching,because the penon completing the questionnaire
:hot aware 'of certain relevant- teachblg. AnotherhaOiappeovedto have overstated its substance abuseucation. We concluded that the questionnaire was an
*Otte indicator of the amount of substance abuseticatien being Provided.
- Amy -
e Findings
edicil seh6ols
7-lie:105-Medical schools that replied to the survey varygnratly in age, size, size of city in which lo'cated; etc. For
.pUipOtes of analysis, we grouped the'105 schools asfollows:
(a) Sectiori of country:NortheastSoutheastWest (of Mississippi River)
(b) City size:iUnder 100,000100,000,500,000Otier 500,000
(c ) Founding dates:3ore 1900 51
3024
Number ofschools Percent
4719
39
254040
451837
243838
4928
23
(d) Ownership: 2
Public 64. _Private
Number oschools -'FEm it
41 39(e) lst.year enrollment (1974-75): 3
41-120 48121-330 57
(f) Total enrollment (1975-76): 2
Under 400 35400,599 42GOO and over 28
(g) Career teacher in theaddictions
Have current or previous --career teacher 39 37
Have never had acareer teacher 66 63
4026
load at taftemeaMerha&Maim, Airmen et* Value.Sam. 107.f,slash ho ahonaMos ken the 191546 A A hiC DemeeterieMiarel tineeikft/Wed eaiafen ahlionftosaAMA* 7J4.4massi &Pm.* Make Sibregosio
she Urefisi Saxes. 1974-75.
(We included as "career teacherschools three med-icalschools which -have had faculty. memberi who -functioned fully as career teachers although fundedfro'm'other'iOurces.)
Hours of teaching and number of courses hisubstance abuse _
We obtained information On both required andelective learning' experiences in substanceFor purposes of reporting, these are handled sepa
_ rat ely because they have different implications:::Required activities are Minimally satisfactOrY-teaching exposureactivitiei 'the . medical schoolrequires. of each graduate-Since these courses aretaken by 'each student; it is meaningful to report. --,average hOuri of teaching per school,-department,and student.
Elective activities reflect the richness of the curricu-lum, the opportunity to pursue 'a tine of study-indepth. We rnutrecognize, however, that these'areefferinSii. And many an *n0Ya ja.Pev.er7chtb*ri:.It isnot .meafriiiiftilia sPeik Joie: **Uri of eleitiVeit.per school, student, it deParinient::***.te...to remedy this by asking, hoW:ntentirideb-ti:14etch-elective during the past-..ifear;':,0,fOSiii4Selmany respondents did supply this inforMatiO
.41
TZACHINO DRUO ABUSE AND ALCOHOLISM
. .
erefore; the number of courses is our best avail-_ .
a ble measure of the elective program since it is some.indication of the variety of opportunities that stu-dents have to pursue substance abuse education in
verage hours of required teachintin substanceabuse. The. required substance abuse hours rangefrom zero to 126. The distribution is shown intable I.
;"- TABLE 1.Required substance abuse hours
Required substanceabuse hours
Number of schOols Percent
o -- 9 91 -7 17 178-16 25 2517-37 25 25
- 38-126 26 25
-Table 2 presents the number and percent of schoolsWith required courses containing teaching on sub-stance abuse.
TABLE 2.=-Required substance abuse courses
Required courses'containing substance Number of schools Percent_- abuse Inching _ _
0 9 91-2 18 17
34 26 25'5-6. 26 257-17 24 23
For the 102 medical schools which gave informs-tiOn on this point, the average hours of requiredinetruetiee-11, departments are shown. in-table 3.(Departments which average less than 0.1 hour
, Maitre-0c,
in.Substance abuse. As discussedouslY, it is moremeaningful to discuss electives
number of courses-rather than number ofhours:lrhe.MediCal School , offerings of electives in
:bliatOitbusertre.distributed as shovin in table 4.
TABLE 3.Re4iiiredsubstance abateby departineni
Bask science departments AVerage regaire4.substance abate hiaia
Pharmacology 4.71.1Pathology
Community and environ-mental medicine
Preventive medicineBiochemistryForensic medicineMedical humanities
.8
.6
.2
.1
.1
Total, basic science departments 7.6
Clinical science departmentsPsychiatry 12.0Medicine 3.4Neurology .8Family practice .8
Anesthesiology .4Pediatrics .2Surgery, .1
Total, clinical sciencedepartments 17.7
Interdisciplinary or multidisciplinary :4
Overall total 25.7
TABLE 4.Elective substance abuseteachingactivities
Number of elective- Number of schools Pernaauboaaos abuse courses
01
23-10
352720
21
342619
20-
We also asked how many_ students had actual*taken these electives, with the results Presented*.table S. -Even if we assume that all of the "not reported"courses had zero enrollment, this still represents, a_substantial student interest in the subiance abuse"area.
Alcoholism teaching vs, dry tibia teachinge.:asked respondents to indicate whether eacli,coursedealt with ildaholisM or drug abuse, or
LT; -st -
ALCOHOL AN DDHUO ABUSE IN MEDICAL EDUCATION. ,
.B.L.E.5.z.-47ettiVe substance abuse teaching.
Ciivittes: Number of students enrolled.1m.Innbcr:oritudfifis
- Number of courses Percentenrolled
15-35r 35
NuMber not reported
42532333041
215
19
2018
25
.. .
:-.7:411,-courses-=both required and electivethe
mtnti of medicine bear the primary responsibilityfor substance abuse teaching (8).-As ho,dalteiid y-shown, departments of psychiatry teach the greatest:.number of required hours. The same _distribution 1S,'true for the lottliiuMber of Cowles offeted (table6). In considering elective courses only, there aresome shifts,: bu t psychiatry departments offereven larger percentage (table7).
TABLE 6.Departments teaching substanceabuse courses
--responses areas follows:
Number of
Department
courses Percent PsychiatryDrug abuse only -54 8 -Phirmitcology
. Alcoholism only 124 18 MedicineBoth 522 75 Pathology
---.For.Oquired courses;the distribution is almost thesame; 81 percent of the required courses deal with
_
Since we did ask respondents to apportion timetrepp-a1c6holisrii sad -drug abuse, we cannotablydetermine total time for alcoholisin or total
lime. for drug abuse. Therefore most of our reportwill be in terms. of substance ibUse, which includesboth.Sitbstance abuse teaching es percentage of required
:CurricidurrS:-:For_ each Of .97 medical schools, wethe -*tared hours of substance abuse
instruction as a percentage of total required hoursThe percentage ranged from zero to
Mein of 0.6 percent.
Depirtments Involved
,:lke trend for departmental responsibility in sub-stance.abtise seems to be running counter to the
-.'reco,mmenclitiona of the 1972 Macy Conference onMedical Education and Drug Abuse. The confer-
:lance report. ug:tile* the efficacy of psychiatric.frec iment:for u bit a n ce abuse' nd suggested that:_41,herils.now:consideiable doubt as to whether the
s-iprObleinf drug and alcohol abuse originSte as;:'psychiatric or-behavioral or whether drugabuse itself simply geiiitaies behaviOral abnormali-fitit,The- report' recommended -that the depart-
.....
Courses thatcolumn substance Percentabuse teaching
Neurology _
Family practice/family medicine -
Community /community andenvironmental medicine
PediatricsBiochemistryPublic healthAll others
287,_101863733
40.214.112.05.24.6
29- -4:1:
28 -3.919 - 3.015 1721 2.158 8.1
TABLE 7.-- Departments teaching electivesubstance abuse courses
Department Number ofPercent
electives
PsychiatryMedicinePharmacologyCommunity/community andenvironmental medicine
Family practice/family medicine
Public healthNeurology, neuroscienceContinuing educationAll others -
7-T17,7Pill7441,r,m;7454-g;
,
:TEACHING DRUG ABUSE AND ALCOHOLISM
ormidon. and skilli .___tojmgkcatnns,.or both. For courses that includedb th k d ci nis 6sUe,yWOrkiiiiiitinnitded a list of skills and
ei4;0_1;:infOiniation Lrelatingioalao holism andleg n1014;7.FOi.aaili-course 'or teaChi4eSPOOsients,Were ,asked to chick those itemssclurlacl .19 thocourse.. For most coUries,-respond-ntielieckedi large number of these, and we found
it:diffictilt to Sumniariiithis nformation. Tables 8,.0i and Mist, in order of frequency, the items
faked by: Medical' schools for all courses, ThisitiVes some idea which are regarded as more im-pOrtint, and which are therefore most often taught.
. .
TABLE 8.-- Alcoholism: Information taught.in substance abuse courses.
. .
(n 672)
::,Type of informadoi*Number of
courscs.teaching Percentinformation
-DeflidtiOnildeadription 437Edifiredi-Olidations 408
reatmenttrehabilitation 3807Psychlaoic-complications -----348
_Social complications,.inchsding legal
_
.rmacology-tiological factors/.rcYentlon
adfoltigyarniolOgy
-1f4help'grouptLegal regulations; -
;including-history'Public health
-1Public education
65615652
342 - - -._51 __
309 46
392 58287 43272 40
241 -36
178169103
262515
arY dliorder_versus complications
t has,baiii our impression that medical school cur-ahavegenerally provided good coverage of
,._:,-thaeOjiliCittioas of alcoh olism and drug abuse but. .
-V,eterided tO:be deficient in-teaching concerninge7.pflinitn&dlaord0-777in teaChirigabbutihe.etiol-
rmeObaniartailigtiOttli,iand treatment .thee sObetaii-e-a;de pa Ode ha y disorder Itself.etki:OrefOreitskec17. alto her;taCh course Or- teach-
'0:01Vi deelt tiie...ptimary disorder, the
1WIINS:Pt . ,
o ,wease r on e opordon of teaching devoted to each: The rest:tin:0iindicate that instruction regarding the primaii,ditiorder, rather than the complications of drug abaseofalbOhnlism;predominates-inmoet substance -.-_ _
TABLE 9. Alcoholism: Skills taught insubstance abuse courses
(n = 671)
Type of skillsNumber of
courses teaching Percentskills
Diagnosis/ differentialdiagnosis 381 $7
Interviewing /examination 313 47Medical treatment methodsother than counseling 275 41
Referral/collaboration inother it:habilitation programs 266 40
Counseling 222 33
. . . . . . . .
TABLE 10.Drug abuse: Information taughtin substance abUse courses' -
(n = 672)
Type of informationNumber of .
courses teaching Percent.,. .
inforthation- - .
Compilations,medical/psychiatric
Definitions/descriptionPoisoning/overdoseTreatment/rehabilitationPharmacologySocial complications,
402 60399346331308
59 . -
52 . _ ,
4946
including legal 294 44Etiological factors/prevention 264 39
Epidemiology 254 38Pathology 235 35Legal.regulations,including history 176 26 .7...-
Self-help groups . 150- 7-. 22... _.Public health aspects 144 21.-Public eduCation 97 , 1
A1,9311c0t. AND DRUG AMitt
.use teaching activities; (See table _I 2.) Nearly_
r_cerittaf: subtance abuse teachingactiyitietikereported as devoting mare thin half of
lie time. to the-Pritriary disorder.(table 13).
11.Drug-abuse: Skills 'taught tosubstance abuse courses
(n = 671)
Number ofType of skills courses leaching
skillsPercent
--.-,:.Diagnosis/ differentialdiagnosis 327 49
-Interviewing/examination 271 40-Medical treat/heat methods
7 other thin counseling 244 36Referral/collaboration In-other_rehabilitationprograms 224 33
Counseling 183 27. .
TABLE t2.Division of teaching time between.primary-Os-Order-and complications --all courses
Number ofPercent
courses
Teaching activities that devote morethin.1/2 time to primary disorder 341 58.
--Teaching activities that devote morethin 1/2:time to complications 189 32
-Teaching activities that devote1/2 time to each 58 10
TABLE 13.Division of teaching time betweenprimary disorder and complications
required courses
. .
IN MEDICAL EDUCATION
This may seem to contradict-the infoririatiOnTintable 10, where complications' are .shaWnmost commonly taught topic. -Tables.ever, do not have mutually exclusive categortea;complication; may be _mentioned in a larger:::!,number of courses while the primary.disordermay..v1.-actually receive thegreater amount of teaching dine.-
Method of teaching
Although lectures seem to be the most prevalene..-teaching method, students are taught about sub-stance abuse by a variety of methods in a variety ofsettings. Students visit hospitals, community _ _hot and drug programs, and self-help groups; theyattend seminars, view demonstrations and flints Of.tapes; and they gain practicalexperience in hosiiItif_or outpatient clerkships (tables 14 and 15).
Affiliated programs
The medical schools were asked whether they had,in their university-affiliated hospitals or other affili-ated clinical programs, one or more separate andidentified treatment and rehabilitation programs. .for alcoholism and/or drug abuse; Twenty 'pertain .of those responding to this question have rione;46percent' have= one or two affiliated -programs- for._
.-
treatment of substance abuse, and 34 percent havethree or more. .
TABLE H.Educational methods wed insubstance abuse teaching
(n = 667)
Teschins method
Number ofPercentcourses Lecture
SeminarHospital clerkshipFilm or video tapeDemonstrationOUtpatient clerkshipField tripSelf-initnittional packet
Teaching activities. that devote more__shin 1/2 time to primary, disorderTiiithinftieti4ties that devote more
---77thati:1/2 tinitio cornplicitionscaching activities that devote_ ___
eachVine to each ---. -- ----.. ..
246
158
'42
SS
35
9
Number ofCOMM using Percent
method
*cation or site of teachigg
TABLE i5:44.chicational facilities used in^' "sr bsrirnce abuse:teaching
(n 658)
. . . . . _
TEACHING DRUG ABUSE AND ALCOHOLISM
salty-
ice! school classroom_.. University affiliated hospital:Corninunitylospital .
Community alcohol ordrug program
Library, learning center, etc.Self heapgroup
_
Jail, prison, or other7 correctional facility
Number ofcourses using
facilityPercent
445 68305 46
81 12
81 12
46 7
31 5
17 3
. .--
Residerferteaching.
-We 'askedeach.school to identify those residencyprOgiiini which included some substance abuse
=teaching, Table 16 summarizes their responses.
TAILI i itellitekyiiirograms. that Includesubstance abuse teaching
Numbs. of residency programs-;that include 'substance abuse Number of Percent
instruction . schools
0
2-6
49 4931 - 31
19 19
-.Thg.residency programs that were reported asincluding substance abuse teaching were as follows:sychiatrY, 51; -median!, 13; family practice, 7;
peurbi iitrice;5;Tan eithesiology, 3; _
pithOlOgy, 1; obi gya, 1; surgery, 1.. . .
%dog education
ne .the.More *disappointing statistics to come.. .
_rant.the survey data relates to continuing educe-tit 105 riiiiiCif.eifiCkolittliat replied to the
7160. -)7.iridlCated. that. they "offer-any con-ucitibn programs dealing with substance:.. . .
Interrelationship of Findings
_Correlations and eross-tsbulatlins
We ran correlations and cross-tabulations to .
tify factors that might be affecting the amount ofsubstance abUse teaching in-medical schools. Thenumber of substance abuse teaching activities,(courses) and the required substance 'abiiiewere correlated with age of school,first-year enroll-ment of school, total enrollment, and city size. Wefound a Small but significant correlation betweenthe number of substance Wise teaching activitiesand the population of the city in which a medicalschool is located (r = 27). The number of required _ _
substance abuse hours did not correlate with schoolage, enrollment, or city size.
Since we considered this the single item most reflec-tive of actual teaching, additional wits were madewith the number ofrequirecisubstance abuse hours.-We compared mean required hourswith geographi7-.cal location, ownership, career teacher. versus non-.career-teacher schools, size of entering class, andsize of city in which the 'school is,locateddown into categories as listed earlier). We found nosignificant differences between geogra phic loCa- --Lion, ownership, or city size,
_ . . .
We expected the age of the medical school to be inImportant factorin the amount of time devoted to .substance abuse education. Edward Stainbrooknoted that it is sometimes difficult for establishedmedical colleges to make necessary adaptations forinclusion of rapidly developing behavioral sciencesrelevant to medical theorrand-practice;:the nio re _. , .
recently founded schools have much more freedomin designing curriculum, hiring faculty, and obtain- _ing space (9). Considering the recent public atten-tion to substance abuse, encouragement by Federaland State GoViiiime-nti-to teach it, and statements`-by medical educators that medical schools=should '° =:devote more time to the topic, it seemed likely thitnewer schools with their greater flexibility :IOWhave more hours in drug abuse and alcoholisirit hen-the older, established schools, This impressionbeen streigtbined by the experiences -of several ofthe career teachers in sUbstanceabuse:programs hive been developed in threierfoii new,:schools represented in ,the career..teacherigrauThe data from our nitiOnwideiiiii,ey, howiVer;.-49
:
.
.-:A1401:10i; AND DRUG ABUSE IN MEDICAL EDUCATION
cotsupport thisrelationship; -Although the meanuitb Of required hours in substance abuse teach-ng *iis higher for the newest 'medical schoOIs, as
own -in tible-17-tliedifforinceilietween thecups are_notstatestically significant.
TABLE 17.Required hours devoted to substanceabuse: Comparison of schools by age
Date founded'
fore 19001900-1959 -
1960 ind later
Nuinber of Mean requiredschools subatance abuse hours
483024
27.121.629.7
Foondloo Oaa hoot 11175-10 A.414C Illrerioy ofAmeleen Md ice, Siocelkm.
i.older- schools have certain advan-ges that offset the newer schools' freedom of cur-
-riaulitridevelopinent in the area. For example,-older itho011 they* in a better position to obtainGov.einnient_granni designed-to help them expandtheir drug abuse and akoholisin curriculums. They
F .--maY-aladbe more likelfti possess clinical facilitiesBeeessarytosubstance abuse instruction.
Two factors that do appear to affect the amount of;L substance abuse teaching in a medical school are
he PriiienCis:Of a career teacher and the siie of thesChOol.-The,ineen number. of required substanceiibuse:hOurs is significantly higlierfOr career teacher`schools -than for non-career-teacher schools (table.18).
TABLE 18.Required hours devoted to substanceabuse: Comparison of career teacher and
nova- career - teacher schools
N_umber of Mean requiredschools substance abuse hours
Career- teacher schOols 39Nonlareer-teacher .
8),.
unibe 0. of required substance abuseifiCantly greater for :Mailer medical
.greater
ger medical schools. (See table 19.)
63
36.3
19.8
16
TABLE 19,Required hours devoted to substanceabuse: Comparison Of schools by size ; 4,
1st-year enrollment'Number of Mean required
schools substance abuse hours
41 to 120 46 :30A121 to 330 34 22,3
(R.= '.003)Imiamorollmenfisvms frimh4 MA Mk *mai Ripon ofi Malta, ediscratom
to Or WO Stems, 11741-7S.
Findings fOr Career Teacher Schools Only
Since some of the results did not agree with our pre- -.existing impressions, such as relationship betweenage of school and substance abuse hours, werepeated some of the analyses, using only:Careerteacher schools. The findings regarding age ofschool are summarized in table 20. Although there'is a trend in the career teacher group for the newest'schools to have the most required substancehours;the differenCes- between the groups are notstatistically significant.: _ . ...-
TABLE 20,Careerqeacher schools:-required hours devoted to substance abuse: .
Compqrison of schools by age ....
Date founded' Number of-' Mean remilredschools-. substance eon:On-file
Before 19001900-19591960 and later
19
11
9
32.833.447.1
Poondlos doe from 1975.75 AAMC armory of **Maw Molati Educifileit
With the career teacher schools only, the publicly'owned schools have significantly more requiredhours of substance abuse teaching (40.6) than piivats schools (29.3). Another difference Is that idcareer teacher schools only, there is someship to section of- country, with-western schoolsaveraging 49.4 required hours in substincenortheastern 24.1 hours, and southeastern 44.2
Case Examples.
We want to illustrate the general findings. by-.scribing the Curriculum of one school_wit a rieli a
24
full program in substance abuse and one schoolwith a very limited curriculum For each of theseschools, the questionnaire was completed by an
74associatedean.
_
School Afull program_
1. Departments and divisions involved in substanceabuse teaching: medicine, community medicine,psychiatry, pharmacology, pathology, adolescent
2. Affiliated clinical programs in substance abuse:Five hospitals are listed, three with two programseach.3.- The introduction-to-medicine course includes 6hours on substance abuse. _
The pharmacology course includes 10 to 12. hours on substance abtise.-.5...The community medicine course includes about2 hours per week (for the academic year) with onefamily; many of these families have alcohol or drugproblems.
Pathology: includes teaching about substanceabuse.7..-Medicine: includes about 3 hours on substanceabuse8. *Electives: nine separate electives offered by sev-eral departments. They range in duration from a
_---- few hours to 2 months.
----School,B-limited program
1'. Departments and divisions involved in substanceabuse teaching: psychiatry, pharmacology, pa-thology,2. -Affiliated clinical programs in substance a buse:
listed.3. The'pharmacology course includes three lectures,which deal primarily with the pharmacology of
_ _ drugs and alcohol, and a 40-minute film on_
overdose.4.-The sophomore psychiatry course includes Phhoution substance abuse.5. Preventive medicine includes 1 to 4 hours on
. alcohol and drug dependency.
70-''Siit4 Findings for Osteopathy Schools
-nirie of the osteopathy schools in the UnitedStates located .mostly in the Midwest, Texas, and--__ _ -
Oklahoma, replied to the questionnaire..Becausel:there were only nine, it was not feasible to subdividethe osteopathy schools by class size, location, etc.;for correlations and cross-tabulations; Therefore,"osteopathy schools will be described as a, Single... .
group and will be compared to medical schools.
Osteopathy schools compare favorably to medicalschools fa the number of hours and courses in sub-stance abuse. They require an average of 26.8 hoursin substance abuse compared to 25.7 for medicalschools. However, more of the teaching is concen-trated in the basic sciences. Of the 58 undergraduate-courses reported only 9 are in the clinical years (16percent), in contrast to medical schools where 40percent of the undergraduate substaace abusecourses are offered during the clinical years. Only _
one osteopathy school indicated that it had affil-iated clinical programs for the treatment of alco-holism and addiction. Of all 58 courses reported, 1628 percent) offer some hospital clerkship expe-
rience and4 (7 percent) offersome outpatient clerk-ship experience, ln short, while osteopathy students_apparently receive more basicscienceinitru-ctiOn-insubstance abuse than medical students, they seemto have considerably fewer o pponunities for clinicalexperience.
Responses from osteopathy schools were similar tothose from medical schools in several areignki with _.
medical schools, most (74 percent) of the substan. ce .
abuse teaching activities are required, most (68 per-cent) deal with both drug abuse and alcoholism,and most deal with the primary disorder rather thancomplications. Like medical schools, osteopathy .
schools reported lecture as the teaching methodmost frequently used.
Osteopathy schools emphasize much of the samein formatio ndefinitioas and description, medical'complications, poisoning, and overdoseas medi- --
cal schools. However, osteopathy schools seem toplace greater emphasis on pathology than medicalschools: It is taught in 67 percent of the courses thatdeal with alcoholism (compared t042 percent Of themedical school courses dealing with alcoholism);As with medical schools, the skills most frequently_taught are diagnosis and differential diagnosis.::.:-
Osteopathy schools divide substance abuse teach- -ing-more evenly among various departments than
-medical schools. As with medical schools, psychia-_--
.
ry is the department most frequently teaching sub- .
stance a huse. However, in osteopathy schools, only'17 percent of the substance abusecourses are offeredby,Pitychiatry; compared to 40 percent in medicalschools..
. _ . . .
-- ALCOHOL AND DRUO ABUSE IN MEDICAL EDUCATION,
DISCUSSION
Limitations of Data
leCause of the slow rate of return, this report is nota snapshot at one point in time; rather, it represents
'data collected over a period of more than 1 year. If agradual change in medical school curriculums isunderway, such as a tendency to increase the timedevoted to akoholiirn and drugabuse, we may havecaughtdifferent medical schools at different points
-The rate of return was less than 100 percent. It_ misfit be presumed-that those schools that did not
reply had lesstnterest and less teaching in substanceOhne.* owever, three schools that had appointedcareer teachers did not reply, giving career teacherichnOle, which are clearly interested in substanceabuse; only a slightly higher rate of return thanMedical schools as a whole.
'The questionnaire replies vary widely in complete-ness and evidence of care in preparation. Thereforethein- May- bia systematic bias in the data becausethose schools stressing alcohol and drug abuse,such as anew: teacher schools, may tend to identifyand list more completely their substance abuseteaching activities. .
The mainpiipe se of the site visits was to determineif. any- of these limitations had led to systematicdistortions, and it was our conclusion that there wereno serious distortions.
-We hive additional information on most of theschools which have career teachers in the form ofpersonal reports, grant requests, etc. However, wedid not use thesedatain this, report; to provide com- _
parability with Other medical schools, we have usedonly the infoimation sent in response to our ques--
-: :tionnaire:
We had to be arbitrary in classifying certain schoolsas career teacher or norkareeteacher schools. We
. listed as' a came teacher school each school from
18
whiCh anjapplicatiOn had been,sent;10-4 .aPro vOli .0110*'*.ifvi he.thirti**941eFlitiCier.4held an .appointment
former cereee teachers had, movitdft4thtmedical schools, but in such caiee7Onlytitilir(01medical schools were counted as care/4001eschools.,We also chose to inchul e three leinit4thahad faculty members who attended Oiiiikeiditemeetings and functioned in most respects as -careiteachers but who were on some otherlartii-4
_
support. .
Some medical schools received career teach& gran Ivery.early in this prograin, while othershayireceived them only recently. lfsomisystematitexpansion in curriculum results from a careerteacher appointment, it may take 1,2;or 3 years tobecome evident. Thus, we probably Caughtiliiiiv.;era! career-teacher_schools.atclifferent-phases-ofthis development.
Conclusions
It would be of interest to compare, our- findings_concerning the present state of thiaffili-subitinetabuse teaching with the situation at prevbut this is not strictly possiblesince a sUrve-itioix;,tensive as ours has not beenrePaitedthe October '1972 Macy COnferCliCel it waiitated...that only_63 of the 120 schoolsf MedicineUnited States'and Csiiiaa offered electives in some'aspect of drug itinse, and 45 had subjects inthecur-;:riculurndealing with alcoholisti(10).0M4afili41::::cate that 102 of the 105 U.S. medical ichoniiiiiik.-;replied to our questionnaiinOffer atleast some:ub=stance abuse teaching, showing that thelituatibri.:`has clearly improved; The repOrt of the 1970 NCKiConference on Professional Trainingon Ale-ohbl-,ism reported a "survey of _existing_facilitiiimedical school programe'thatand osteopathic schools, but itiOndt-Cliiii WOWsample was selected or obtained.(IWe looked at the reports frOmindividinlOchoOlithe 1970 N CA Co n fere n c
each of theM with the reporttrotu.0.0060.44_141140:44.7i
survey' to see if there had been charigeS:.ThiS_tirn:out to be -extreniely diffiCUlt andble for these reasons:-
I. The 1970 NCA report dealtOnly..,With-110hOlif44_..wheteas ibiale with both alcoholindAtii
. . '
TEACHING DRUG ABUSE AND ALCOHOLISM
abuse, and it was difficult for us to separate thesetwo components.2. The 1970 reports were typically not quantitativein that they did not give the number of hours spenton an activity.3. The 1970 report did not distinguish in mostcases between required teaching and elective teach-ing; much of what was presented appeared to beelective offerings.
About the most we can say from this comparison isthat few schools seem to have regressed in theiramount of teaching, and several schools seem tohave strengthened their alcoholism teaching con-siderably.
Although there evidently has been an overall in-crease in substance abuse teaching, a significantnumber of medical schools still teach very littleabout alcoholism and drug abuse. Three question-naire respondents indicated that their schools teachnothing about substance abuse (or, in one case, no"formal" teaching). It seems unlikely that the sub-ject is never mentioned in their curriculums. How-ever, since the questionnaire was mailed to the deanof each medical school, who could either completeit or ask an interested faculty member to do so, sucha negative reply certainly seems to indicate a lack ofinterest. Twenty-five percent of the respondingschools indicate 5 or fewer required hours in sub-stance abuse; 38 percent offer no electives in thefield; 43 percent offer five or fewer courses dealingwith the subject; and 20 percent have no affiliatedclinical programs for the treatment of drug abusersand alcoholics.
We also reached some conclusions about how bestto assess substance abuse teaching. Three solid indi-cators of the amount of substance abuse teaching ina medical school appear to be the number of re-quired hours devoted to the subject, the number oftotal and/or elective courses that deal with it, andthe presence of affiliated clinical programs for drugabusers and alcoholics. It is important to deal withthe number of courses as well as the number of hoursbecause for some teaching activities, especially theelectives, respondents could not tell us exactly how
_many hours were represented; the best answer theygive us wasuva riable."The existence of treat-
ment programs is important because they provide
19
practical experience in the field; a good, solid, didac-tic, basic science background may be wasted if thestudent never sees an alcoholic or addicted patient:
It appears that although the general situation hasimproved, we still have a long way to go. The stateof the art of substanceabuse education is improvingbut is still only minimally satisfactory.
AUTHORS
Alex Pokorny and Patsy Putnam are affiliated withthe Career Teacher Training Center in the Addic-tions at Baylor College of Medicine. John E. Fryeris with the Temple University School of Medicine.
REFERENCES
I. Sabo', P.A.. and Sutton.J.Y.. eds. Professional training onalcoholism, Annals of the New York Academy of Sciences.178:1439, 1971.
2. Josiah Macy. Jr. Foundation. Medical Education in DrugAbuse.. Report ofa Macy Conference. Philadelphia: WilliamF. Fell, 1973.
3, &instil B. The development of a curriculum in drug de-pendency. Journals,/ Medical Education, 49:155 - 162,1974.
4. American Medical Association Council on Mental Health,Medical education on abuse of alcohol and other psycho-active drugs. Journal ((the American Medical Association.21911746-49. 1972.
5. Webb, A., Jr. Training physicians to treat alcoholics, Prtvote Practice. 6:68, 1974,
6. Kuraman, M.O, Drug Abuse Educative' In PharmacySchools. Bethesda, Md,: American Association of Collegesof Pharinady, 1972.
7, Burkhalter. P. Alcoholism, drug abuse and drug addiction:a study of nursing education. Journal of Nursing Education.14(2)130-36, 1975.
8. Josiah Macy. Jr. Foundation. Medical Education In DrugAbuset Report *fa Macy Cortference. Philadelphia: WilliamF. Fell. 1973, pp. 9. II,
9. Stain brook, E. Range of curricula in established medicalschools, In: Syllabus and Scientific Proceedings: In SUM.,nary Form, 139th Annual Meeting. American Psychiatric
Association, 197d. pp. 227-28.10, Josiah Macy. Jr. Foundation. Medical Education in Drug
Abuse: Report of a Macy Conference. Philadelphia: WilliamF. Fell, 1973, p, 2.
I I, Sikes. F.A., and Sutton, .1 .Y ads. Professional trainingon alcoholism. Annals of the New York Academy of Sciences.
178:109 - 131,1971.
2. Medical Education in AlcOhol and DrugAbuse: The Career Teacher Program
Marc Galway., M.D.
Alcoholism and drug abuse have been slow in gain-ing recognition as legitimate medical illnesses, inlarge part because of the social forces which haveinfluenced their treatment. This introductory sec-tion deals with recent developments in medical edu-cation in these illnesses on a national and locallevel.-They center around a federally funded CareerTeacher Program in Alcohol and Drug Abuse,which to date has established faculty members at 43American medical schools and has led to the devel-opment of a national organization for medical edu-cation and research in substance abuse.
MEDICAL EDUCATION AND THESOCIAL CONTEXT
The issues addressed reflect a consistent tendencyof society to segregate certain of Its members andlabel them as defective and undesirable. This is wellillustrated by Foucault(1) in his history of WesternEuropean attitudes toward the mentally ill. Henotes that after virtual disappearance of leprosyfrom Europe in the early 17th century and the con-sequent close of the leprosaria, attitudes toward thepsychologically disturbed and behaviorally deviantbegan to change. Over several decades, asylums and"ships of fools" were established to assure the iso-lation of these unfortunates, who had been pre-viously allowed to mingle freely among the generalpopulation. As time went on, they were treated withincreasing severity, and it was only some two cen-turies later, with the advent of "moral treatment"for mental illness, that humane attitudes toward thementally ill were widely applied in Europe.The labeling of the rejected, with their consequentinhuman treatment, can also be seen in American
20
attitudes toward the opiate addict. This arose spe-cifically after the use of opiates came to be asso-ciated with the oriental laborers of the PacificNorthwest, a socially rejected group, in the late 19thcentury. The chronic, socially debilitated alcoholichas come to occupy an analogous rejected role, andthe person with alcoholism was similarly presumedto be morally afflicted.
It was therefore not unlikely that these social forceswould serve to define the scope of medical educa-tion in the addictions. Indeed, the sensitivity ofmedical education to social forces is clearly illus-trated by the change In the scope of medical educa-tion in the half century following the Flower reportof 1910. In the late 19th century, medical schoolfaculties in the United States were almost exclu-sively composed of the practicing profession. Whileinfluenced by European scientific rationalism, thisreport began a profound transformation on Ameri-can medicine, leading toward an orientation basedon scientific investigation and biomedical research.Interestingly, this is being modified considerablywith emphasis on a new social Issue of healthcare asa human right. Primary care medicine, as an emerg-ing model for the physician's role, may therebyreturn us to the humanistic physician as a medicalrole model.
ALCOHOL AND DRUG ABUSE GAINRECOGNITION
Social trends are hard to discern in their early stages.It is clear, however, that over recent decades thecountry Is beginning to deal more dispassionatelywith the issues of alcoholism and drug abuse. Thedevelopment of Alcoholics Anonymous has had an
28
CAREER TEACHER PROGRAM
important effect on American attitudes. AA illu-strated that the alcoholic person might regain a con-structive place in society and was therefore notbeyond reclaim. It also showed that the recoveredalcoholic, an upright citizen, was apparently not atainted or incompetent person.
A rather different circumstance influenced publicwillingness to approach the problems of opiateaddiction from a nonjudgmental stance. The heroinepidemic of the late 1960s and the consequent at-tempts to find a large-scale solution led the countryto place some 80,000 Americans in methadonemaintenance treatment programs. We were sur-prised to find out that this medically based approachachieved a considerable measure of success and werewell aware that additional sophisticated approacheswere necessary for other addiction problems.
What changes are coming about in physicians' atti-tudes toward alcohol and drug abuse? It is welldocumented that alcohol and drug abuse are etio-logic or precipitating factors in a large portion ofmedical illnesses. One series of hospital surveys (2)indicated that one-fifth of male medical ward pa-dents are alcoholics. For most of these patientsalcohol was a primary precipitant of their illness. Inpsychiatric services, substance abuse was found tobea major factor involved in two-fifths of inpatientadmissions (3) and one-half of emergency roomvisits (4) in two university teaching hospitals.
Despite these findings, the clinical importance ofsubstance abuse is generally underplayed in medi-cal education. This largely reflects physicians' atti-tudes toward the addictions as issues which holdonly a secondary place in their discipline. TheAmerican Medical Association, however, throughits Council on Mental Health, issued a positionpaper in 1972 on the importance of placing greateremphasis on drug and alcohol abuse in medicaleducation (5). It emphasized that medical educe-tors'efforttshould be directed at correcting prevail-ing stereotypes, and that students should be sensi-tized to the physician's function as a gatekeeper to
_available drugs for the abuser. A literature on pro-fessional training in alcoholism and drug abuse wasbeginning to develop, derived both from actualmedical school curriculum (6) and from nationalconference's, such as one sponsored by the NationalCduncil on Alcoholism (7).
21
THE CAREER TEACHER PROGRAM
In this context, the Federal Government in 1971undertook planning of a program which would sup-port medical school faculty members interested inteaching on substance abuse for a large number ofmedical schools. The fatuity, designated as careerteachers in alcohol and drug abuse, were to besupported in this work by a Federal grant for aperiod of 3 years. Upon the establishment of theNational Institute on Alcohol Abuse and Alcohol-ism and the National Institute on Drug Abuse, thecareer teacher program was undertaken as a Jointendeavor by the new Institutes. At present the pro-gram is operating on 43 campuses across the coun-try, with others soon to be approved. Of the currentcareer teachers, 33 are physicians, primarily psy-chiatrists. Internists, pharmacologists, and special-ists in public health are also participating.
In addition to the individual career teachers, twonational training centers were designated, one atthe State University of New York, Downstate Med-ical Center, and the second at Baylor College ofMedicine. These programs were principally chargedwith providing onsite training in the form of coursework and apprenticeship-type exposure for the newcareer teachers. As it became apparent that many ofthe career teachers were relatively sophisticated inthe area of substance abuse, the training centersundertook additional functions, including prepara-tion of bibliographies on current literature, devel-opment of resource handbooks, and ongoing eval-uation of the program.
One important aspect of the program in which thecenters took part was the development of nationalconferences three times a year, attended by theentire career teacher group. These conferencesserved to develop a common perspective and toallow for exchange of specialized information. Per-haps more important, however, they generated aspirit and feeling of community which allowed thecareer teachers to return to their respective institu-tions and deal with the professional isolation whichcharacterized the role of the specialist in addictiveillness.
As the award period came to an end for manycareerteachers, it became increasingly apparent that therewas a great necessity for assuring continued involve-
29
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
ment in the substance abuse teaching field. Theacademic systems from which teachers came oftenmaintained regressive outlooks on addiction, whichpermeated academic and clinical structures, andwhich could not be transformed over the courseof only3 years. To assure continuation of their work,the career teacher group has established the Asso-ciation for Medical Education and Research inSubstance Abuse. This group, initially synono-mous with the Career Teachers and Training Centerfaculty, is to serve as the nucleus for an organiza-tion directed at augmenting the course of substanceabuse training, research, and treatment on medicalcampuses throughout the country.
On the national level, there have been additionalundertakings, such as presentations at medical andscientific conferences, ranging from the researchconducted over the period of the grant to new teach-ing and clinical techniques. The career teachershave also collaborated with the National Board ofMedical Examiners in formulating questions onsubstance abuse for the national boards. In addi-tion, continuing education courses have been pre-sented at national conferences and conventions,such as the American Psychiatric Association Con-vention and the National Drug Abuse Conference.
ACTIVITY IN THE MEDICAL SCHOOLS
Although much work has been doneon the nationallevel, the principal aim of the career teacher pro-gram is to improve the training in drug abuse andalcoholism in the teachers'respcctive undergraduatemedical schools. Before appointment, teachers gen-erally had an area of expertise within the substanceabuse field and subsequently expanded on theirwork in that area. The initial task for the careerteacher was to evaluate the overall pattern of coursesand to plan a strategy for filling in the needs whichhad not been met. Alternatively, in a school withminimal teaching on thesubject, s/he could initiallydevelop his/ her own "model" curriculum. Thesestrategies involved two possible approaches. Theteacher might expand his/ her work from withinhis/ her own department, building on associationsand curriculum time available there. Alternatively,f I I he might begin by undertaking work on an inter-departmental basis, contacting other departments'
chairpersons and course directors at the outset, soas to negotiate a broader base for development.
Since many career teachers were generally knownfor their expertise in substance abuse at their respec-tive institutions they were often in a position to con-tact members of various departments and discusscurriculum needs. Often other faculty initiated con-tact, hoping to fill gaps in their own training pro-grams. At other times, a teacher's role as clinicalconsultant led to new teaching opportunities.
The curricular exercises themselves often had astrong emphasis on active student participation, inorder to provide the best opportunity forattitudinalchange. Such participatory exercises have beenused in a variety of contexts, such as in care of thedying patient (8). It has also been demonstratedthat medical students report the most meaningfullearning experiences to be those which involved ahigh degree of active participation rather than pas-sive observation (9). In light of the singular impor-lance of attitude change in the area of substanceabuse, this approach appeared to be even moreessential. For example, one approach often under-taken was to have students interview alcoholics andaddicts in the first year of medical school. Thishelped to desensitize anxieties about the nature ofaddiction and to engender a more realistic view ofthe patients as people. Role-playing exercises werefrequently used, and surveys on the alcohol anddrug use of the students themselves were taken.These latter data were then used to provide com-parison for students with other population groupsof t he same age and were used as entree into the im-portant issue of physician alcoholism and drugabuse (10).
FUTURE OPTIONS
Much interest centers around the establishment ofthe Association for Medical Education and Re-search in Substance Abuse. With this organization,with the maturation of the career-teacher group,and with the influx of new career teachers it is hopedthat new educational options will develop. Theprospect of a national network of educators in thisfield would certainly facilitate their implementation.
Advances have already been made: In an initial sur-vey of the earliest group of career teachers, it was %
223Q
CAREER TEACHER PROGRAM
found that curriculum time devoted to substanceabuse increased by a factor of 2.1 in the preclinicaIyears and by 2.8 in the clinical years. This additionaltime should be carrying with it increased sophistica-tion and a less prejudiced perspective regarding bothtreatment options and the humanistic concern forthe abusers.
Much effort, however, must be devoted to the clini-cal programs, because the positive attitudes engen-dered in students are so often disrupted once theybegin work on the hospital wards, where the treat-ment system operates with built-in prejudicesagainst the addictive illnesses (11). Because of this,there is a growing sense of the responsibility of careerteachers to the practicing physicians. This has led tothe development of training packages for graduatephysicians, as well as the liaison necessary withlocal medical societies and hospital staffs. It hasbecome clear that the scope of the program neces-sary for achieving its goals is quite broad.
AUTHOR
Marc Galanter is affiliated with the Albert EinsteinCollege of Medicine.
23
31
REFERENCES
1. Foucault, M. Madness and Cicilizatiox New York: VintageBooks, 1973.
2. Bareha, R.: Stewart, M.A.: and Guze, S. B. The prevalenceof alcoholism arno ng general hospital ward patients. Ameri-can Journal of Psychiatry, 125:133-136, 1968.
3. Crowky, T.J.; Chesluk, D.; Dais, S.; and Hart. R. Drugandalcohol abuse among psychiatric admissions. Archives ofGeneral Psychiatry., 30:13-20, 1974.
4. Atkinson, R.M. Importance of alcohol and drug abuse inpsychiatricemergencies. California Medicine, 118:1-4, 1973.
5. American Medical Associatign Council on Mental Health.Medical school education on abuse of alcohol and otherpsychoactive drugs. Journal of rite American Medical Asso-clarion, 219:1746-1749, 1972.
6. Stimmel,. B. The development of a curriculum in drugdependency. Journal of Medical Education. 49:158-162.1974.
7. Seizes, F.A.. and Sutton, .1.Y.. eds. Professional training onalcoholism. Annals of the New York Academy of Sciences.178:1 -139, 1971.
8. Olin, H.S. A proposed model to teach medical students thecare of the dying patient. Journal of Medical Education,47:564-567, 1972.
9. Ables, B.S., and Brandsena, J. The effectiveness of differentlearning experiences for teaching psychiatry. Comprehen-sive Psychiarry, 14:29-33, 1973.
10. Vaillant, G.E.; Brighton, J.R.; and McArthur, C. Physi..cians'use ofmood-alteringdrugs: a 20-year follow-up report.New England Journal of Medicine. 282:365-370, 1970.
1 I. Galanter, M.; Karasu, T.B.; and Wilder, J.F. Alcohol anddrug abuse consultation in the general hospital. AmericanJournal of Psychlarry. 133:930-934. 1976.
Curriculum Material
3. Physician Education in Substance Abuse:Curriculum Objectives
Donald 1. Davis, M.D.
In recent years, public awareness of the physical,emotional, and social problems associated with theabuse of alcohol and other psychoactive substanceshas increased dramatically. With this trend hascome the awareness that many physicians havebeen inadequately educated regarding the nature,recognition, and treatment of patterns with sub-stance abuse problems. In 1972, there appeared anofficial AMA committee statement on medicalschool education in substance abuse (I). In it, theneed for medical education on the abuse of alcoholand other drugs Is outlined, and a number of keyareas of content are delineated. Shortly thereafter,a report from a conference of prominent medicaleducators, sponsored by the Macy Foundation (2),was issued. This report presented a strong case forthe need to improve medical education in substanceabuse. In his editorial on needs in future medicaleducation (3), E. Gray Diamond, past president ofthe American College of Cardiology, also has madea strong statement on the need for increased medi-cal school education in substance abuse.
The question of physician education in substanceabuse goes far beyond the area of curriculum con-tent. Articles have also appeared on such topics asthe attitudinal barriers of phySicians in dealing withpatients who have problems related to drug and alco-hol abuse (4,5),, as well as the high incidence ofaddiction among physicians and the problems ofdenial among their colleagues and themselves (6).
Steps have been taken from outside the professionas well to bring about an upgrading of medicaleducation on substance abuse. One of these wasFederal legialit ion creating the Career Teacher
27
Program in Alcohol and Drug Abuse. The intent ofthe program was to support a medical school facultymember to devote his time to the development andimplementation of curriculum in substance abuse.There are presently career teachers at 43 medicalschools throughout the country. There are, in addi-tion, two medical-school-based training centers toassist the career teachers in their endeavors. Thepresent report is one outgrowth of the program.
Since 1973, members of the career teacher programhave met on a regular basis three times a year. Outof these meetings have evolved small work groupson key topics such as curriculum content, teachingmethods, and the evaluation of teaching in sub-stance abuse. There also evolved an organization,the Association for Medical Education and Re-search in Substance Abuse (AMERSA), which al-lows ex-career teachers to maintain contact withthe program and allows career teachers and othersto share and exchange teaching methods and re-search findings.
The list of objectives that follOws presents the workof the AMERSA Committee on Substance AbuseTeaching Objectives. These are not intended tomandate how all medical schools are to teach aboutsubstance abuse, but they are intended to conveythe opinion of experts as to what should be includedin a medical curriculum on substance abuse. Thegoal has been to make available a broad scope ofobjectives to which schools can turn for guidance,both to maximize their own strengths and to coverareas of relative weakness while maintaining mini-mum standards.
33
ALCOHOL AND DRUG ABUSE IN MEDIC/AL EDUCATION
The objectives are grouped according to subjectareas that the committee found most helpful. Theyare not .ntended to be recommendations for courseor lectu: e headings. Also, it is not felt that the orderin whic k these objectives appear need be their orderin a met; :cal school curriculum. Where the commit-tee has taken a stand is on establishing prioritieswithin subject headings. These priorities are pro-vided solely for the benefit of those curriculumcommittees and teachers who may be relativelynew to the field and who have not yet formulatedtheir own priorities or determined their own best ap-proaches to the teaching of substance abuse. Under
DEFINITIONS
each subject heading, appear first the overall objec-tives. These are sometimes called terminal objec-tives and refer to goals or expectations of studentsonce they have completed their formal education.The overall objectives are followed by a longer andmore detailed set of objectives, often called en-abling objectives, which is intended to provide teach-ers with guidelines as to the content of their teach-ing to accomplish the overall objective. These areguidelines which, through experience, have appearedmost helpful in developingcurriculums in this oftenignored, yet crucial, area.
CURRICULUM OBJECTIVES
Li Deane the following as they relate to substance abuse:a. Abstinenceb. Abusec. Abuse potentialct. Addictione. Antagonismf. Cross-dependenceg. Cross-toleranceh. Dependencei. Enzyme inductionj. Habituationk. Idiosyncratic reactionI. Misusetn. Physical dependencen. PotentiationO. Prevention; primary, secondary. tertiaryp. Psychoactiveq. Psychological dependencer. Synergisms. Tolerance: metabolic. pharrnaeologic, behavioralI. Withdrawal syndrome
2.' Describe various models of substance abuse (e.g., medical model, learning model).3.3 Contrast the alcoholic with the problem drinker.4.' Contrast the addicted to the nonaddicted user.5.2 Differentiate between an objective medical versus a moralistic understanding of "alcoholism" and "drug abuse."b., List common criteria of substance abuse versus use in terms of duration and frequency, social consequences. lick versus illicit.
EP1DEM1OLOGYGENETICS
1.1 Outline various methods available to conduct and evaluate epidemiologic studio of population groups regarding substanceabuse, incorporating incidence, prevalence, mortality, and morbidity.
1Highest priority.i Recommended.
2838
CURRICULUM OBJECTIVES
2.2 Describe evidence about the role of heredity in the development of substance abuse (e.g., Winokur's hypothesis and enzyme poly.morphism).
12 List the incidence/ prevalence rates for use/abuse of various substances for the Nation and for selected populations (defined bydemographic and other characteristics such as associated diseases and inpatient/outpatient).
4.2 Describe the use of epidemiologie data for the development in governmental and program planning of prevention, detection,and treatment.
BASIC SCIENCES (BIOCHEMISTRY, PHYSIOLOGY, PHARMACOLOGY, PATHOLOGY)
1./ Be able to do the following
a. Compare alcoholism as a nutrient with carbohydrates, proteins, and fat.
b. Describe the reasons for nutritional deficits occurring with a high intake of alcohol.
c. Describe the effect of alcohol on vitamin metabolism, particularly: pyridoxal phosphate (vitamin 86), thiamine (vitamin 111),ascorbic acid (vitamin C), and vitamin A.
2.1 Diagram the major metabolic pathways of alcohol degradation (include the major enzymes).
3./ Describe the physiology and biochemistry of dependence and addiction, with special reference to the brain and liver.
4.1 List the types of substances of abuse, as per Goodman and Oilman. List some street names associated with each of these typesof substances.
5.1 For commonly abused drugs, describe or outlinea. Dosage levels and therapeutic rangeb. Common behavioral and physiological effectsc. Common behavioral and physiological side effectsd. The physiology of withdrawale. The absorption, distribution, metabolism, and elimination
6.' Explain drug-drug interactions among commonly abused substances, and between them and prescription drugs of any kind. Useclinically significant examples.
7.1 List the acute and chronic pathologic effects of commonly abused drugs on the following systems:
a. CHS and PHSb. CVSc. GId. Skine. Respiratoryf. Endocrineg. Hematopoietic
8.1 Describe the ways in which detection technology is applicable to diagnosis and treatment of substance abusers.
9.2 Outline the pharmacologie action of disulfiram in the presence of alcohol.
10.2 List various roots of administration and describe the marked differences in the effects mentioned in item 4.
11.2 List the common adulterants of street drugs.
12.2 List the naturally occurring substances in blood that chemically resemble various drugs of abuse.
SOCIOCULTURAL FACTORS
1.1 Compare and contrast substance abuse patterns in ghettos, suburban areas, and among medical school faculty. Outline aprevention program for each. .-
2.1 Evaluate the role of peer pressure in the prevention, development, and maintenance of substance abuse.
3.1 Describe factors which make physicians particularly susceptible to abuse of specific substances.
3r,
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
4.1 Discuss health care es a mechanism for addressing the needs of deviants (not in the negative sense) in our society. Include adiscussion of "correctional theory" versus labeling."
5.2 Describe the ways in which cultural factors influence the use of various substances using ell of the following groups: Italians,Jews, Irish, French, Chinese. and blacks.
6.2 Describe the ways in which the ritual and/ (irreligious use of a substance relates to the development or prevention of abuse anddependence.
7.2 Describe economic and political issues that contribute to the growth and stability of substance abuse.
PSYCHOLOGICAL FACTORS
1.1 Describe the concept of the addictive personality end the controversy surrounding it.
2.1 Describe the concept of substance abuse as a symptom of en underlying emotional disorder.
3.1 Apply learning theory (e.g., classical, operant conditioning. etc.) to the phenomenon of substance dependence.
4.1 Describe how drugs as stress coping mechanisms can affect various phases of the indiv;dual life cycle.
3.1 Deseribe the role of denial as a defense mechanism in the substance abuser.
6.1 Compare and contrast the concepts of suicide, self-destructive behavior, and substance abuse.
7.1 Describe the concept of self-medication of psychiatric symptoms. Include in the description sleep disturbance, depression,anxiety states, psychotic disorder., and personality disorder..
1.1 List noopharmacologic factor. set, setting, and placebo) that contribute to the occurrence of an acute toxic (both positiveand negative toxicity) drug response. Explain the contributions of preexisting psyehosocial pathology and current life andinterpersonal stresses.
9.2 Explain how substance abuse can be a form of coping and edeptational skill development.
10,2 Describe psychodynamic theories (e.g., drive and anxiety reduction) of the phenomenon of substance abuse.
112 Describe how the behavior patterns and lifestyles of substance abuser. predispose them to prevarication.
12.2 In any given patient there is a complex interaction of psychological, social, and pharmacologic factors. Compare and contrastat least four conceptual models, explaining the Milian of these factors to the addiction process.
DIAGNOSIS AND TREATMENT OF OVERDOSE
Ust the expected pathophysiology of overdose from each of the separate substances of abuse.
2.1 Describe the appropriate pharmacologic, piyuhologic, and supportive intervention with overdose from each of the separatesubstances of abuse.
3,1 List expected psychopathologic states with overdose from each of the separate substances of abuse.
4.1 Ust the signs found on physical examination of overdose to each of the substances of abuse. Describe the continuum of signspresent with low versus high doses of the substance.
$,t Outline the differential diagnosis of skull injury, hypoglycemia, diabetes, stroke. etc., and drug overdose or tonicity.
6,2 Outline the specific treatment for recurrent seizures from dreg overdose.
DIAGNOSIS AND TREATMENT OF WITHDRAWAL STATES
1.1 List the expected pethophysiology of withdrawal from each of the separate substances of abuse.
2.1 Describe the appropriate pharmacologic, psychologic, or supportive intervention with withdrawal from each of theseparatesubstances of abuse.
3,1 List the expected psychopathologic states with withdrawal from each of the separate substances of abuse.
4,1 Ust the signs found on physical examination of withdrawal from all of the substances ofabuse. Describe the continuum of signspresent with increasing dosage of the substance.
!Highest PMrluy,tRuommended.,
3o36
CURRICULUM OBJECTIVES
5.1 List several medical complications which may accompany or precipitate withdrawal.
6.1 List the substances of abuse which have no withdrawal syndromes.
7,1 Describe the settings, procedures. and persons necessary to treat withdrawal from the various substances of abuse.
8.2 Outline the specific treatment for recurrent seizures from drug withdrawal.
9.2 Outline the basic steps in the differential diagnosis of recurrent seizures that may be related to use of substances.
DIAGNOSIS AND TREATMENT OF SUBSTANCE ABUSE
1.1 Describe the clinical aspects of substance abusers which might arouse feelings such as anger. fear, and anxiety in the physician,and how these feelings might lead to inhibitions about treatment,
2.1 Describe the phenomenon of relapse in substance abuse and its implications for treatment.
3./ Describe how the concept of Continuity of care applies to the substance-abusing patient.
4.1 Describe the spectrum of effects ,,signs and symptoms) of intoxication with each of the substances of abuse,
S.' Having detected intoxication. outline the extended common course of treatment available irrespective of the substance involved.
6.1 Describe the signs. symptoms, psychopathology, and diagnostic criteria for chronic dependence on each of the major categoriesof substances of abuse. Describe the common factors in chronic dependence.
7.1 Outline a substance abuse history and how it should be taken to include presenting problems. history of dependency, geneticfactors, early developmental experiences, and social factors,
8.1 Given the realities of denial, prevarication, and lack of collaboration in treatment by substance-abusing patients, describe anapproach to supportive, nonrejecting confrontation of patients with substance abuse problems which would facilitate appro-priate treatment intervention.
9,1 Describe approaches of intervention with the physician who has become dysfunctional because of substance abuse.
10.i Describe practices for the safe and efficacious prescription of various psychoactive substances. Include dose and frequency,course of drug, emphasis on nonpharmacologic therapies. and specificity of target symptoms for which drug is used,
11.1 For the emergency treatment of possible drug-related conditions, outline the basic steps in diagnosis and the priorities in treat-ment of comatose patients, emphasizing vital support systems: respiratory, cardiovascular, Ws, urinary output, ete., and specificantidotes, e.g., naloxone.
12.1 List at feast six findings on physical examination that would be either pathognomonie or bighly suggestive of current drug use,intoxication, or withdrawal.
13,1 List specific medical complications of chronic drug abuse which would be detected on a general physical examination.
14.1 Outline what must be covered in ipsychosocial history to rule out adequately the presence of social consequences of substanceabuse, with emphasis on (1) work history, (2) marital difficulties, (3) repeated accidents, (4) kgal problems, and (5) socialdifficulties.
15.1 List at least five treatment referral alternatives for substance-abusing persons. Outline an adequate referral to each of thesefacilities.
16,1 Compare and contrast the positions that recommend the cautious use, versus the avoidance, of psychoactive drugs in thetreatment of substances base, with particular reference to never-addicted, presently addicted, and previously addicted individuals.
17.1 Describe three central points in the course of evaluation and treatment where family involvement can be of benefit.
18.1 Describe how to motivate substance-abusing patients. Include problem areas, appropriate and inappropriate reinforcers,current personality variables. AA referral, religious supports available, etc.
19.1 List at least four criteria of successful treatment of the substance abuser.
20.1 Describe why pharmacologic intervention may frequently be inappropriate in certain cases of intoxication.
2J.1 Deseribe the implications for treatment of the concepts "The patient is a substance abuser" and "The patient has a substanceabuse problem."
22.1 Describe principles of crisis intervention, therapeutic community, and chemotherapeutic approaches for substance abusers.Compare and contrast these approaches, including their applications in outpatient versus inpatient settings.
23:! List three questions that would help determine what substances of abuse an individual might be using.
Ifligbest,Priotity.ltecomatea44.
31
37
ALCOHOL AND DRUG ABUSE 11k1 MEDICAL EDUCATION
34.1 Describe social networks as contributors to substance abuse problems and as positive resources in the treatment strategy forthe substance abusing patient.
25) The therapeutic approaches to the drug using patient are multifaceted and multidisciplinary. The major strategies are soda-therapeutic. psychotherapeutic, and chemotherapeutic. Delineate the modalities and outline factors that would be indicationsfor each of these therapies.
26.2 List special issues which are encountered in the consultative role to other physicians in their work with the substance-abusingpatient.
37.2 Explain the indications and limitations of each of the following three possible outcomes of ptychiatrie consultation for thesubstance abusing patient: (a) improved treatment by primary care physicians and staff, (b) acceptance of the patient fortreatment by the consultant, (c) referral to another treatment agency.
31) Compare and contrast criteria for and outcome of treatment for drug withdrawal: (a) hospitalized. (b) ambulatory.
29.2 Evaluate the relative prognosis of persons who are substance abusers. Include the dimensions of type of drug, age, sex, acutechronic, and different treatment modalities.
30.2 List at least 10 subtle signs (other than drug-taking behaviors) of incipient or recurrent abuse.
31.2 Complete the following table regarding direct and indirect medical complications of each category for the major dross of abuse:
i
--
Organsystem
Medicalcomplication
Treatment
Acutentottication
Acutewithdrawal
Long-termaddiction
33.2 Outline the apparent prenatal end neonatal complications of maternal substance abut*.
33.2 Describe the results of specific diagnostic tests such as urinalyils, breathalyzer. blood-drug levels, and blood chemistries whichwould suggest acute and chronic substance and/or withdrawal.
LEGAL, ETHICAL, HISTORICAL ASPECTS
1.1 Define the current DEA categories of drugsdemonstrating understanding of their development and rationale. Where maya listing be found of these categories?
3.1 List the Federal and State rules for prescription writing in each of the DEA categories.
3.1 Describe the specific laws as they relate to Medical practice for the following:a. Physician patient COMMUlliCationSb. Prescribing practicesC. DWI. public intoxicationd. Commitment and transfer procedurese. "Impaired physician" lawsf. Breathalyzer. blood alcohol level analyses, and urine drug analyses
illisbes. Priority.31teeemainded.
32
38
CURRICULUM OBJECTIVES
4.1 Explain the medical ethics issues involved in the treatment of a substance-dependent patient, e.g.. confidentiality, detection/treatment, and research.
5.1 Outline the historical appearance and progression of use of alcohol. opium. marijuana, tobacco. sedative-hypnoties. ampheta-mines, and hallucinogens, and tha various treatment approaches to treatment of abuse of these substances.
6.1 Describe bow drug and alcohol use by physicians influences their practice.
7.2 Describe the lapl measures that have been used historically to control the abuse of substances. Include the effects they have had.
1.2 Demonstrate an understanding of the impact of the Uniform Alcoholism Act and the Narcotic Addiction Act on health careand research practices.
PREVENTION
1,1 Demonstrate an understanding of primary. secondary, and tertiary prevention in relation to substance abuse(e.g.. legalmeasures,educational methods, environmental manipulations. substitute preparations. technological control),
2.1 Describe the role of various secondary/tertiary prevention models such as industrial programs. court-related programs, and fetalsubstance abuse detection programs on the early detection of substance abuse.
3.1 Lin six ways in which attitudes of and behavior toward patients by house staff physicians influence the development by medicalstudents of sound clinical skills in the treatment of substance abuse patients.
4.2 Demonstrate an understanding of the role of the physician prescribing practice in the prevention of substance abuse.
5.2 Outline a program of substance abuse prevention for the prevention of physician dysfunction from substance abuse.
AUTHOR
Donald I. Davis, Chairman of the Committee on Curriculum Objectives, is affiliated with the GeorgeWashington University.
REFERENCES
I. American Medical Association. Council on Mental Healthand Committee on Alcoholism and Drug Dependence.Medical school education on abuse of alcohol and otherpsychoactive drugs. Journal of the American MedicalAssociation, 219:1746 - 1749.1972.
2. Josiah Many. Jr. Foundation. Medical Education in DrugAbuse Report ofa Macy Conference. Philadelphia: WilliamF. Fell, 1973.
3. Diamond. E.O. The physician and the quality of life. Journalofthe American Medical Association. 2281117-119. 1974.
4. Chappel, J.N. Attitudinal barriers to physician involvementwith drug abusers. Journal of rite American MedicalAssociation, 224:1011-1013. 1973.
S. Fischer. IC.: Mason. R.L.; Keeley. LA.: and Fischer. J.V.Physicians and alcoholics: The effect of medical training onattitudes. Journal of Studies on Alcohol, 30949- 955,1975.
6. Bissell, L., and Jones. R.W. The alcoholic physician: A survey.American Journal of Psychiatry. 133;1 142-1146, 1976.
39
4. A Course on Alcoholism forPrimary Care Physicians
George Jackson, M.D.
A review of medical literature reveals numerousarticles calling for greater knowledge and improvedattitudes for physicians in the field of alcohol use,abuse, and addiction. Other studies make referenceto courses fora variety of health professionals otherthan physicians and investigate the impact of theseon the participants.
Williams, VanLewen, and Breen (1) have studiedthe effect of a 6-day intensive alcoholism course onthe participants as compared to a control group.The group attending Florida School of AlcoholStudies consisted primarily of no nphysician healthprofessionals with enough interest in the field toattend a course. Their paper provides a detailedoutline of the teaching program with topic areasand teaching methods, i.e., lecture, panel discus-sions, question-and-answer periods, and demon-strations. The investigators were able t o demonstratea change in knowledge and attitudes as comparedto a pretest and the control, but a shift in behaviorwas not as readily apparent. One conclusion wasthat the school effected attitude shifts, but thesechanges seemed to bear little or no relationship toany change in behavior.
More and more ed ucatio nal co urses and sessions areprovided for physicians in the field o f alcoholism as
part of the general increase in emphasis on continu-ing medical education. The following curriculum isproposed as a model to provide some standardiza-tion in the educational effort. Additionally, aninvestigation of the effect of this curriculum notonly on physician knowledge and attitudes but onbehavior is urgently needed. To promote participa-tion in an educational effort which results in more.continuing medical ed ucation credits but no changein patient-related behavior is wasteful and promotesa false sense of progress.
AUTHOR
George Jackson is affiliated with the Mount SinaiSchool of Medicine.
REFERENCE
I, Williams. J.H.: vanLetven, A.; and Breen, T. Evaluation of*6-day course in alcoholism education and orientation. Intr.national Journal of the Addictions 9(5):673-99.1974.
3440
A COURSE ON ALCOHOLISM
ovitsg ON ALCOHOLISM FOR PRIMARY CARE PHYSICIANS
Developed by a committee of the Association forMedical Educationand Research in Substance Abuse
Commhtee ChairmanGeorge Jackson; M.D.
Members_Itudy Arredondo, Ed.D.. Joseph Benforido,,M.D., Louis Bozzetti, M.D.,
Charles Buehwald, Ph.D., John E. Fryer, M.D., Benjamin Kissin, M.D.,John 'Morgan. M.D., James O'Brien, Ph.D., Jack Marren Rogers. M.D.,
S'Aney H. SCIU1011, M.D., and Kenneth Hugh Williams, M.D.
INTRODUCTION- ...... . . .
Hil prohleins caused bY incisive use of beverage alcohol make up a large part of the primary care physician's practice. AlthoughFmost physicians feel competent to manage the trauma caused by an alcoholic's driving misbap, many physicians feel unprepared and
kuiayold1cabng with the etiology of the trauma-alcoholism. . .
fiThe-goalatidabjeCtivest and MethOdologie considerations provided will assist in the development of a continuingeducation programof proficiency on thipartof Prirnarycare physicians in detecting, diagnosing, and managing the individual withexcessive alcohol use.
..r IrICIPANTS
. .k',Theis guidelines are designed with emphasis on the role of the primary care physician. Thus the intended participants are physicians
including general practitioners family practitioners, internists,emergency room physicians and industrialPediatricians obstetricians gynecologists, and psychiatrists who act as primary care providers would be included also
FOAL*AND:' OBJECTIVES FOR A 2-DAY CONFERENCE ON ALCOHOUSMIFOWPRIgAItYtiRE:PHYSICIANS
_ .
!, lieprliary care physician should be able toRecdmã patients wit. .43 **Mat riolt.of Alcohol dependence, patients who abuse a leohol, and patients who are dependent on alcohol
taRlaterveaalaPpropriatelY. for treatment . ;
Wel eoittetiablejn the recognition/intervention role.
.. .... .
; P la _..... . .... ...., --.",.,...liicl,f;!::..-. -- : ..tql(civroarxtes%-..5, "viica-n....sha. uld.beibleatof recilicofonili:ewitnhespriastkietnacti whose risk of alcohol abuse or dependence is above average. This
--zidtittl'inay.bCdpfi40.hy.;,PPP pr.Prre,
....
,:: , ;,Availlitjaf tilahltiatO tbeaultvalual.CrilialbirfeiiiiiiCT,biTaigiiittiii.7':........:.
, rand_ Irhil.P?r.Y.,;9(111COOkah*-., :'....: ,..Facts Iiiirtahilit-yldiihiiiiiioni..t:,.. :- ..:. .....:...... . .. ..
,. .
vidttalpsychoilellizaiffactota.c.g...detirepion, anxiety, affective disorders.-Ysiciin,.hoinemalóer, bartender. , .
. . . ._.-. ...
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
- The primary care physician should be able to recognize the patient who is or may be abusing alcohol, Such an individual may beidoStlfled by one or more of the following factors:-Aeuie alcohol intoxication.Alcohol Mt breath.Illaekbuts.-Continuing 'sleep disturbance and use of sleep medications.Driving-while intoxicated.Episodes of loss of control of behavior.PreqUent.Use of psychoactive drugs and drug-seeking behavior.Frequent work absence or tardiness.Liver abnormalities.Multiple JOaline complaints and recurrent GI distress.Peripheral, neuropathy.
. _ .
Riposted accidents (drivjng and other).
The priniary care physician shOuld be able to define and identify the patient who is acutely intoxicated with alcohol with particularattitnfion to-Levels of consciousness associated with excessive alcohol consumption.Differentiation of CNS dysfunction due to alcohol from other causes. (A variety of other drug intoxications and conditions resultin chiages in consciousness and/or behavior similar to that seen in alcohol intosication ,e.g., diabetic coma, psychosis.)
Other abnormalities frequently found in individuals who present with acute alcohol intoxication, e.g., subdural hentatoma, 01:bleeding.
-The primary care physician should be able to define and identifythe patient who is dependent on alcohol. Such an individual may beidentified by one or more of the following:proutnce.of alcohol withdrawal syndrome:Early-mild (tremors, agitation, insomnia).Latisivere (delirium tremens).
-Tolerance to largianseunts of alcohol.Presence of various medical complications. cirrhosis, pancreetitis, macrocytic anemia, organic brain syndrome, malnutrition,.13! Weer/bleeding. - _
Sufficient criteria as deicribed by the National Council on Alcoholism.Sufficient positive responses on the MAST test.
. . . -
Intervention _ .. _
.The primary care physician should be able to efficiently treat the patient with acute intoxication, and to facilitate withdrawal from thedependent state withOUfadverse effect (detoxification),
ACUli intoxication: The f011owing aspects are of particular importance in treatment:Life support for the comatose patient (e.g., intravenous and respiratory support),Calm
. .discourse.Sedative medication, e.g., benzodiazepine derivatives.Possible referral to "sobering up" services.
2. Phisical diOndence: The folloWing aspects are of particular importance in treatment:Sedation:of hyperactive central nervous system, e.g., paraldehyde, benzodiaZepinederivatives.Close observation foir development of delirium tremens after early (mild) withdrawal state.Vitamin therapy.
.
Observation for complications, e.g., infection, aspiration.Observation for other sedative drug withdrawal.Preparation Of patient for long-term treatment.
PsYchoti44Y.Beizodiizetiinideriiitive.maintenanoe in sekcted cases.Referral to other sources of therapy.
.
The physiCian should be a ble to intervene to provide treatment for remission of alcohollorn directly and through referral.,PrImery.phYsieianactivities: . .
c:..Pjaparaticin.ef patient for lOng-term therapy.Ongoing review medicalotatus:
7..,Pittlent.eninageriieniThicludiagiggressive followup and coordination ofoutside services.
Utilization of iiiiMtietY drisgs chlordiazepoxide for short-term maintenance.
36
I....Other:sources of therapy:...Coiiiinunis.Y.
Balfiay bottle:"AA4Al..AOn.Alateen).
...r..PrOfeSSionale"..g.; psychiatrist, psychologist, social worker.
g0iiiceiiiii:PMSMF1-:Mental healtlfiervieei.:Patient's familyLegal inereiroi: - -
iiteripy.
ilen
. ,
attitudes ..
To feel more in the recognition/intervention role the primary care physician should be sash& to the following factors:--13414Miiit6001e.....
: -
Alcoholism is problem .r.,Alenlieditia"briehrenic condition with remission and relapses. . .
'..litenhOlic einpreient"difficult management problems which engender negative feelings in the physician.17-....Ofiem will not be detected without a high level of suspicion on the part of the physician.
Pliklieirini'Merinse of and attitude toward alcohol will affect care of the patient.
A COURSE ON ALCOHOLISM
METHODOLOGIC CONSIDERATIONS
The following suggestions are prepared to facilitate the accomplishment of the learning objectives and program planning.
.. 194! Plan!** committee must be developed to adapt these guidelines to the local situation. Local alcoholism experts glom beinCluried in. plinnina. - . . .
2 The State/city Mental healthdepartment and the area alcoholism education and training program (AAETP) should beconsulted.=Thcse -agoncies may have specific program materials and/or advice. Financial support may be available. (See table I for a list of
r"E. :;t1i'. _ following may be considered for promotion of the program
:Continuing medical education creditthis is essential.10.161$7, as iVitiiliiiing participants ; cheek with AAETP.
ointlpeinisorship (e.g,, county medical society and family practice association).lot,ceof the meeting in newsletter or other county medical society mailing.nearly mailing reinforced by a second followup mailing.
r participant for registration should approximate the going rate in area
...... _...-.. ... . .. .
ifaltradois , .. . ..
op a pretest and posttest of knowledge and 'attitudes.icit.comMents after conference on reaction to presentations.
lAuDing Mnterinti
e)Ocnl'ecirtintittee May develop.a package of learning materials to include the following:ocal eniatireeienPliCit listing for locality
'iilme of teaming
_ .
objectiye)r..".
"tAigt1±X,-.....,7 77 .7
.
. ....... . .
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
TABLE 1. Area alcoholism education and training programs
Area . States/territories served
,:warER,st :
. '.. ,
Dillas-Reed, PLD,, -Director :,-.:-- 1733:East Plumb Lane
:lab. 260'Reno, Nev. 89502702- 786 -3610
Alaska, Arizona, California; Colorado, Hawaii, Idaho, keitiliaa,Nevada, North Dakota, Dragon, South Dakota, UtaL,WaskIniii;Wyoming, Pacific Islands /Trust Territories
.
ZASTERN, ,
.Charles SappDirector ,
, P.O;. limi'Si2:: BlooliEeld, tAmin. 06002*:20:2438326
. . . _ .
Connecticut, Delaware, District of Columbia, Mahn.- Mgryllad,Massachusetts, New Himpshlre, New Jersey, New YOrk, Penniy1.vaais, Puerto Rico, Rhode Island, Vermont, Virgin bland', Vir.ginia, West Virginia
,... ..-40VMERN
Edward AlderetleC4recaoi :7160 30niper Street NE.Atlanta, Ga. 30308
4047873-406
Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana,'Mississippi, New Mexico, North Carolina, Oklahoma, South.Carolina, Tennessee, Texas
MIDWEST. .
William Dutynski, Ph.D.DlieCtor .180 Mirth Michigan Avenue$1.100031 ::: .
CW646;1E:60601312-782 7-0073
Illinois, Indiana, lows, Kansas, Michigan, Minnesota, MissoUri,Nebraska, Ohio, Wisconiin
. Annotated readingscategorically grouped)PrOioSed historical questions which could be used in M.D.'s practice. The physician can Incorporate questions about alcohol
.
into,:theSCittine medical Interview at the same lime questions are asked about smoking and using medication.List'Of. Various agencies from whom more information or resources is available:
,Aleisholies Anisitymouswrite to:General Service Office of Alcoholics AnonymousBox 459..°rand Ceitral Post. OfficeNeei.York; N.Y.: 10017
Artie AlcabOiisin Education and Training Programs
. *09.1)eentersifiticobol StudiesiRutgeritiniversityNeteltiunswick, N,J. 08903
For air iianotarcii Sat of readings. *write to Mom Jackson, M.D.. Dcwtmeol of Community Midi"' roc Moues Sinai Scheel of Medicine, Now Vora, KY, HeatSobkrin" loalti40 :ii xleahiliam diagnoilo: aleohol4aated paolteloslot a i diodes; children of a leoholic piccolo: do Fend' oft mid withdrawal; d rinki0g habitscue ra I; sided>: Mum a leeSOI ;
ap# uc4) son rud, physiology, pievemiosi tole! forces: missiles and demography; aria Owl.
.
38
7.;
A COURSE ON ALCOHOLISM
mice* Clearinghouse for Alcohol Information
Ville, Md.: 201152
ationalCotincil on AlcoholismAvenue
ee;_YO:r1r. N.Y. I0017
. .batings)
NFERENCiPLAN
iniplairfor riCOrrie:rence of 25 to 50 participants.-hie seated around table., in small (8 to 10 persons) groups.
.
the [lead of the..sponsoring organization.
action .whafWill.he daft and how.
ifteigion (part I): Trauma (auto accidentlacerations, semiconscious) brought to hospital emergency room.inidiOisnil,'Written, or oral prftentation.
7 =Objectives 'hitiodnce concept of detection, differentiation of intoxication as traumatic cause of depressed consciousness, need forof suspicion:'
Reaction to case presentationwhat should be done to work up and manage tbecase. Group leader to bring*wile indicatedAbgvo." .
epreseniOtiOn(psii II):.Traumi case found to have blood alcohol level of 300 mg percent and minor fractures; level of conscious-mei improves with conservative management. On second or third day in hospital patient beComes severely agitated with increased
ture. and hallucinations. .
AlftholiddiatiOn, tolerance, withdrawal, detoxification.. .
60 jib Flaibbacks into individuals history, with aspects of problems on job, bome, previous DWI, encounters
****Schiacohoiliii1*es not de*ted ereckliewleddedve :introduce high -risk factors, signs and symptoms of abuse and addiction, concept of early detection:-
fall-=roupdJscuss or,: ResetiOn tothisaspeetif case presentation. Group Iftder to direct discussion to opportunities for detectionOady.interViotion: .
teinsifroloShO4.Of early detection and recognition, barriers to these methods. Description of higiisk groups, signs and symptomsiddiedinfrimendence.
i**Ft..6000Nhen intoxicated:
ott nrieffeft on judgment and performance.testa and /or blood alcohol levels (BAL) after alcohol consumption. Correlation of number
nn oftritiine;is it relatni to PM:sottie:: iMerchiiiisa-and opportunity to observe effect of alcohol on BAL.
Othiditadois and pathology of alcoholism.ftipresentanonk gins trauma case begins therapy for alcoholism, number of failures, short remissions described with final
_ . .. .ufteas at contr.
. . . . .
-- crisre: rview; of.types.of.thempy.for alcoholism,
FTEI:prooK.Oki Miffed by representatives of loCal alcoholism treatment organizations with literature, etc.
am*. ShOrt:0MariptiOnAf boivivariciy of local treatment agencies would handle therapy of presented case.
rtr re==discuuiart ;Medical legal aspects -- physician as problem drinker.
iik.Short'Wrip41P;evainationof course, posttest if used
Career Teacher Resource;i'dbóok
harles Buchwald,-Ph.D.
Medical education in alCoholism and drug abuse: anti across many disciplines, each with its own ex-
tensive literature; special concerns, and jargon. Forthe most Part; these disciplines do not deal with theMaterial relating to substance abuse as an integratedbody ot knowledge Equally true, there is no such0140 anOOrdinited curriculuinin drug and alco-hol abuse at.most Medical schools. At some schoolsWere:: are scattered .1-hour; lectures in as many -aseight
: .
piiiitidePartmenis..At other schools, threer-iniii:154*MiUte or 20-minute segments of larger
lectures substitute the scattered hour lec-',..t4rei.:Theit(15-little question that at most medical
schools the enitictilum. in substance abuse isinadequate
I for reiticone:;such as these that the Careerjaelter Pi;iiiitn:in Alcohol and Drug Abuse was -
established in:10I'to'ettempt to upgrade the cur- .
eknitini..inMediCal schools. Committees of career. teiiiketiandfacUlifirani'the career teacher Centers
began to meet to discuss such matters as inte-giated'inedieitl School Orikultini, It bedinWii-Ppii-
.Meld that the broad range of knowledge re-quired"foricOMPrikensive curriculum necessitated
"f... fmiIiarfty withintxtensive literature, frequentlyfrom disciplines other than one's own. If a career
il_<*;; teacher was to coordinate an interdisciplinary cur- .
ikniiiMin his oWiiMid kill school, s/he would require. . "4 ,---a'.*Veeifie,referencoguide to the drug and alcoholliterature of the several medical school diteiplines: ..
elarier. teacher' needed. a resource that wouldenable him/her toaCqUire-the relevant knowledgeOCOther, disciplines without the time-eonsnningstudy needed iii':becnniiikiteklieit in every field =
Although many career teadterigPrOacliedtheirnOli'"assignments with the aim of personally teachingof the alcohol and drug abuse coursestutim, most became aware that this was not the mostdesirable aPproach instead,:theiSOOn:ifiSeOierethat coordination of substance : bUSece***10within the existing medical school departnintalstructure was more feasible Thus, it apPeareiViliata resource guide should alseifshared with teachers of etlier.:diSeiPlintS..1:.:''
The Career Teacher Resource Handbook staout -as a manual for new Career teachers 't7i lead,therhto the relevant literature of alcohol and**across all disciplines In orderity of the handboOk, -. the cited for eacsubject area was to include the nlnsteprnjrelicii0.and up-to-date reviewartieles;0!*....44i#F1fiwere the basis of ,nrneh-::enitent.,.'-iklie74-dirllresearch, and articles presenting both sidei of rele-vant controversial isSuet?AdtiSeriptiOntaili#21can,-,::.:1an a bstract;was prepared frireaChittieleti.!eneage the reader tosser etitind read:the OittOttlrni,ust the abstract
For the career teacher who wanted exteusiie.
educatiOn in a given content area than thatmerely by reading the seleationnfnqielei;.!:tive list of facilities known for specialization in thaarea was included. wellknown treatment orindi-vidualyid ual experts who. wàuIdbe, worth consulting
.. .. . . .: .. .
.-.. .....
visiting for a protracted period of time in ordiftobtain information in greater. depth.
Therefore, the resource handbook lanned formultiple Usage. For the career teacher who
A..7r-oc.r.A_7'7"
CAREER TEACHER RESOURCE HANDBOOK
..."..feaehinfg.-a;particulariOurse, the references wouldenable him /her to discuss the material knowledge-ablY.,with the actual teacher, and help make him/ her*Warta the latest material pertaining to substance.-
-. abuse:The teacher could also make use of the listedreferefcei as recommended readings for the medi-cal students.
One additional resource that is deemed of value totheCareer teacher is a list of teaching aids. A third
.-Subieetion was added to several chapters -of the re-source handbook listing films, audiotapes and videoapes, Slides,. etc., relevant to a particular content
..area:Only.material appropriate for medicalEach annotated listing also includes
and addresses of the suppliers of theaterial. .
a.reOurce is to be of continuing value, it mustrefieet:ihe latest scientific and treatment literature.lierefore the resource handbook wasdesigned in a
fOrmat so that sections could be updatedretativelkeasily. The initial plan of an annual revi-iii4:.Praved to be too ambitious for such a largetindertaking, so the present plans call for a lessrequatitlietiodic updating.
An editorial committee of present and formercareerteachers has been formed to insure the approPriate:selection of articles for these revisions. Further planscall- for adding an annotated bibliography of the ::major. reference works available in the field to thehandbook. An additional list of teaching aids appro;.priate for professionals other than physiciiiiiS':Will.also be included in order to increase the usefulnessOf the handbook.
The editorial committee will also explore the feasi-bility of coordinating the handbook with the set ofcurriculum objectives so that it will serve more di-rectly as a curriculum guide. This will primarily in-volve changing some chapter headings, dividingsome sections in two, and collapsing others. In thisway, the handbook will serve as a barebones outlinefor an eventual textbook in substance abuse.
Following are the contents and a sample chapterfrom the first revision of the resource handbook.
AUTHOR
Charles Buchwald is affiliated with the State Uni-versity of New YorkDownstate Medical Center.
-AREER. TEACHER RESOURCEANDBOOK OF ALCOHOLISMAND DRUG DEPENDENCE
Contents
4. Physiology
a. Bibliography 27b. Facilities 29c. Teaching aids 31
5. Pharmacology
ctA:kOhOlisni
Definitioni
a. Bibliography 3:b.. Facilities 7c. Teaching aids 9
EpideMiologY
a.. Bibliography 13b. Facilities 17
c. Teaching aids 19
Biochemistry :y
Biblioigraphy: :
21
F acilities 23Teaching aide 25
..
41
a. Bibliography 33b. Facilities 35c. Teaching aids 37
6. Pathology
a. Bibliography 39b. Facilities 41c. Teaching aids
7. Sociocultural factors
a. Bibliography 45b. Facilities 49c. Teaching aids Si
8. Psychological factors
a. Bibliography 5$b. Facilities 57c. Teaching aids
Z74N9 eS.ith ke"... .tiarneat.
mab
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
- 9. Diagnosis and treatment of overdose
. i, Bibliography ....... 65b. Facilities ...... 67c. Teaching aide 69
10. Diagnosis and treatment of withdrawal states
a. Biblioiraphy . 71b. Facilities 75c. Teaching aids 13
11, Diagnosis and treatment of alcohol abuse
a. Bibliography 87b, Facilities . 93c. Teaching aids 101
12, Legal aspects
a. Bibliography 105b. Facilities 107
. 13.- Prevention
a. Bibliography 109b. Facilities 111c. Teaching aids . 113
14. Associations and conferences
b. Facilities 115
Pert D -Drug Abu'
I. Definitions
a. Bibliography ,... 119c, Teaching aids . 121
2. Epidemiology
a. Bibliography .. 125b. Facilities 127c. Teaching aids .. 129
3. Biochemistry
i. Bibliography I311) Facilities . 133
4: Physiology
I,' Bibliography 135b; Facilities ..... 137a. Teaching aids . 139
S. Pharmacology
a. Bibliography 141b.- Facilities 143
Teaching aids 145
6; Clinical pathology.
a, Bibliography 147b. Facilities 149c. Teaching aids 151
. .
Sociocultural factors
Bibilovapby 153b. Faillitice 155
'111014aWi: 157
B. Psychological factors
a. Bibliographyb. Facilitiesc. Teaching aids
9. Diagnosis and treatment of overdose
a. Bibliographyb. Facilities 1
c. Teiching aids 173
10. Diagnosis and treatment of withdrawal states
a. Bibliography 175b. Facilities .. 177 ,c. Teaching aids
11. Diagnosis and treatment of drug abuse
a. Bibliography ' 183b. Facilities 180c. Teaching aids 199
12. Potydrug use
a. Bibliography 203 ;b. Facilities 205c. Teaching aids 204-
13. Legal aspects
a. Bibliography 211b. Facilities 213c. Teaching aids 215
14. Prevention
a. Bibliography 217b. Facilities 219' "';
c. Teaching aids
15. Associations and conferences on drug abuse
b. Facilities
Part CGeneral louts
1. Curriculum planning
a. Bibliographyb. Facilitiesc. Teaching aids 231
2. Teaching methodology
a. Bibliographyb. Facilitiesc. Teaching aids
3. Programed instruction
a. Bibliographyb. Facilities 1,c. Teaching aids 243 :-
4. Health planning
a. Bibliographyb. Facilitiesc. Teaching -aids
9r,
CAREER TEACHER .RESOURCE HANDBOOK.
Social! educational1 vocational services
i. BitiliOgiiPhy 253b Fiteilitki 255
Teaching aids. 257
6.. Administrative issues
a:- Bibliography 259'b. Facilities 261e: Teaching aids 263
7, Treatment personnel
a." Bibliography 267Facilities 271Teaching aids 273
.
Reicareh and evaluation. . .
a:, Bibliography . .... 277b::- Facilities 279
:General resources
b. Facilities .. 281e. Teaching aids . ...287
Sociocultural Factors
Bibliography
1. Bacon, Selden D. The process of addiction to alcohol:social aspects: Quarterly Journal of Studies on Alcohol.
,34:1-27, 1973:
A descriptive study dealing with the process of social...Control and drinking,The develo ping_aleoh °lit reduces
the nurriber and variety of his social activities and drops::Mot of mentbershi pin social groups, joining groups moretolerant ot his drinking and which exercise less control
...over him. Recovery involves a resocialization through
.::rletiming.Controh over:behavior socially defined asintolerable and over expected beitivior. PreventioneabiliChieiferibiqitsbring: dint 'bihiViOr: by others
of deirilit drinking behavior.
._Bailey.;.M.BAlooholism and marriage. A review of re-searchand. professional literaittre:**QuinerliJournal of
Alcohol; . .
Itie.revieViThits abstracted and summarized the majorand:Marriige, a field
'Of reSeitieh4 bleb- hiSeMergedivithinthepait IS years.StatistiCal analysis marital status hiedemonstratedthat the ster4typeCflieitleohOlic.aSamarginal under-
ineither of society,ii no longer tenable. Al-.ersh011i*.hitieit':high rate of broken . marriages, but'Mini.are ivith their spoOses. Case stidiei of the.-"iviVetkof irieOholiciihitiedescrilied the persOnal
these:WOMen and the neurotic: interaction be-The:: hypothesis that ale*
cumulative stress affecting. the family inya.riOns pattenter3Ways has.**been tested to a limited
. .
Mtteit..
cis, controls on excessive drinking,suggested in the etiology of alcoholism, arein review ofthe literature. Examples drawn fromcross-cultUral studies in,which: it was iound that fre-quency of rininkennes.i was pOsitiiely correlated to -frequency or ceremonial drinking.- especially .
alcohol was drunk aboriginally,- demonstrating thatsacred Or ritual use Of alcohol does not necessarily re -,..-sult in controlled drinking. Frequency - of iiiiinkenness.was highest in societies with low eh ildliood.pressure.. -toward complianceaid in those wherelidepen'de*in adulthood was stressed, supponing the hypothesis:of a dependence-independence conflict in alcoholism.:Abstinence as-a social control of alcoholism is dis= . -
cussed in anthropological and historical perspective.Effective social control in present-day society is necessary. Moderation in drinking, once established the -culture, may alleviate the conflicts and anxieties whichmotivate excessive drinking. A -bibliography of-40items is included.
4. Beckman, L.J. Women akoholics; a review of social andpsychological studies. Journal of Studies on Alcohol,36:797 - 824,1975.
Ina review of social and psychological studies on wome nalcoholics published in English since 1950, findingson social history variables,' personality -eharacteris-tics social roles, and sex-role confusion and treatmentmethods are examined. A bibliography of 109 hems isineluded.
S. Wane, Howard T.; and Barry, H. Binh order and alcoholism: A review. Quarterly Journal of Studies on .-Alcohol; 34:837-852, 1973.
In a wide-ranging cross-cultural survey, the investi-gators found an overrepresentation,Of last born in allfamily sizes, increasing progressively larger fami-.lies. Conflict over dependency hasbeensuggetited is amotivational factor which 'aiai..underlie-eireeialie" `_-drinking and which may be overdeveloin0.41:14 lastborn of the family,-especially among men::
6. Edwards, P.; Harvey, C., and Whitehead; WiVeibfalcoholics.' Quarterly Journal .4. Studies on Alcohol,34:112-132, 1973.
The literature on the wives of alcoholics is reviewedunder three headings: the distiorbed personalitj theory, -the Stria theory, and the friVehiii6cill theory.
7. Linsky, A.S. Theories of behavior and the image of the -
alcoholic in popular magazines, 1900-1966: PublicOpinion Quarterly, 34:573 - 581,1970 -71.
A comprehensive review of popular magaithe articlesfinding a shift in the perceived factors in alcoholismcausation and in,the methcid of dealing with alkoholism;''The piittern of changes reflecta_euItural changes in'popular conceptions of man's nature which go far be- -yond the problems of alcohol."
8, Lowe, G. and Ziglin, A.L. Social class and the treat-ment of alcoholic patients: Quarterly Jourridd of Stririier'on Akohol,'34:173.484;
. . .
This survey of white Male voluntary,.firit admissions.(1966-69) to analeohOliSM rehibilhatiOnfacility found,that selection ofclass and that there AvirefeW;itOrial elitit.differenties.in days of. treatment` services:received ofattendance a r t heripigrO ups. TherlifferenceibetWee
SociaCalturalasieets Of aleohoI addiction:h' Ptiblkatlon Of thiotissielitlonqfNervouidisst :
ental. Oiseiisei."46455471. 1960: :
e conflict between nitriVingfOriiideperidenceind aesire::forideiieridenCe; in addition to insufficient so.
43:
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
these and previous Endings in other locations are dia.cussed in term of the differences among the treatmentWilkie.. -
9. McClelland, D., Davis, W., and Wanner, a, A CrestICtilleril study of folk-tak content and drinking. Sodom.soy, 29:308- 333,1966.
A computer correlation of follotale content and drink.: ing yielded -14 significant correlations. It is suggested: that the psychological stale involved is not subsistenceanxiety or need for dependence, as previous authorshave argued, but a feeling of weakness in the face ofheavy demands which hods men to dreani of magicalpotency and seek it by heavy drinking. The degree ofstructural support supplied by the culture is also die.mused in terms of drinking control.
10, ...Straus, R. Alcohol and society. Psychiatric Annals,3:L:107..1973,
...A general article discussing the Ending of the NationalCommission on Marihuana and Drug Abuse and othersurveys which provide unique Insights into drinkingpatterns and alcohol problems. Labeling and resultantperceptions about alcoholism are discussed, as areleisure lime drinking, traffic accidents and alcohol,drinking and alcoholism among youth, and arrest vet.
'mus rehabilitation of public drunkenness offenders.
Saclocultaral Factors
Facilities
I. Addiction Reim rch Foundation33 Russell StreetToronto, Ontario, Canada MSS2SI
Robert E. Popham, MA., Dictator of Research.416-595-6164
`Brown UniversityDepartment of Anthropology79 Waterman Street
..:.ProVideriCa: ILL 02912
Dwight Heath, Ph,13,T.:40l-1163-3251
J....Georg. Washington University.,...:Department of Sociology
Washington, D.C. 30037
ire H. Cis*, PILO,. Professor202-3314706
S...Ratters University...Center. for Alcohol Studies
DePariment of Sociology.NewBrunswitik, N.J. 011901
. .
Saiden.B14014.rb.b.i. Professor of Sociology
UniversityDepartment of SociologyCarbondale,. El, 62901
Ph.D., Professor643.1.0.449.4.
.
6.. University OfCalif Orilla, BerkeleySiniat.Remearelt group.1912 RorkeBerkeley., Calif 94704..
. ....... .
44
DEM Cahalan. Ph.D.415-549-1284
7. University of California at Santa BarbaraDepartment of AnthropologySanta Barbara. Calif. 93106
William Madsen, Ph.D.105-901-2311
8. University of ColoradoDepartment of Psychology1200 University AvenueBoulder, Colo. 80302
Richard Jessor, Ph.D.303-492-0111
. . .
9. University of PittsburghDepartment of PharmacologySchool of Pharmacy1106 Salk HallPittsburgh; Pa. 15261
Herbert Barry III. Ph.D., Professor412-624-3274
10. Washington UniversityDepartments of Psychiatry and SociologySt. Louis, Mo. 63130
David Pittman, Ph.D., Director, Social Science Institute,314 -863 -0100
Sociocultural FactorsTeaching Aids
1. Alcohol .
Film, 1971, 29 minutes, color, mot 16 um; ii041!P:russ its. Title No. 125101. _ ; .
An alcOholic, and tonne bank vice president, describes his.experience on skid row and how he found a newlifeiliiiiigh'the Utah rehabilitation program. From theerro Live Again"
Ordering Section Rent& St2.50National Audiovisual CenterWashingtion, D.C. 20409 Sale: $175202.763.7420
2. Tht Alaoholic WAN Us.Film, 1973. ZI minutes, color, sound, I6mm, _.....
Prams the premise that emotional problems can*excess -d r i n k i n g b y p o r t r a y i n g emotions as i n di v i d u a l s who
one another. The origin and ontogeny of alcoholism is thusprorated.International Tele-Fans Enterprises Rental 12547 I'm.* AvenueToronto, Ontario M6M 2PS . Sala $345416.2414453
3, Can You TokeVAlm 12!4 minutes, color, sound::R. Gordon Bell, RD, noted lacturer.ortmasses tolerance* alcohol Ind kali men vary frOni.ro person. Dr. Bell points out the Physkil, Mu**effects of too much alcohol on- people whose csuch that they 'cant take it."-Rental- ''Association.Stedirm Film.866 Third AvenueNew York, N.Y. 11*2124354210 ".
to
"Association Against41104
-1323:Weet Market Street'Aktitin. Ohici 44313
qs,
eat ,Waii and Romm, black and white, sound.
. A dnuitidiadein Of alcoholism, showing the etiology and:yeatmeut -
:.Andie;iitrandcii. Rental 555. 34 Macquestem Parkway
*Mount .VirriOn;.141.Y. 10550 Sale: not imitable. 91446475051....
CAREER TEACHER RESOURCE HANDBOOK
Sala 5125
S. Zebras. The. WomanFilm', 1971; 118 *mlnuies, color, sound, 16 rm.
A portrayal of an indigent's lifestyle. A iniddle.opdwoman lei shoin seeking shelter, In contact with govern.mental aid private enterprises. In the street and in a psychietr0401111m1.B.B.C.B Film .Sales Rental: 5100135.Maitland MetTarot's°, Ontario M4Y 1ES Sal 5585
-.416425,3891, Telex 06-33577..
.
. .
. 6. The Rai. 410....2714 minutes, sound, color, 16 mm,
krealittie.dnima of a family troubled by Alcoholism The...Verioni tend* ind alliances within the family are explored.P.iirtiehlttily.istrul to camnttosnap groups and counselors.
.
on Ltd. Rental: 535 for pre.West .46th. vie*, deductible from
'Neel York, N.Y..10036 porthaie price.4124574970 Sale:395 (23 percent
discount for nonprofitorganisation)
OrThOrt,inco. Drink:,.37..rolautee, black and white, sound.
MettelVe?.leittirO film Rattirine R. Gordon Bell,' M.D.sinngg. blilltbnird diagrams; Dr. Bell dealt with the physical.
"PlY 41elleoL'alid social *specie of alcohol addiction.peOlillidOigned for - professional mitten, doctors, ace,
wheneccOmpanied by lectures t *alcoholics ander transomin a 00404
L..L.Vininieitia Co,. Rental: 515 1 to 3 days'49 Wen 46th Street 53 eaeh additional day. NewYork; N.Y..10036212- 582 -7873- .
ComdataL. L. Cromlen at Co. Salt 3225S Baseborn CrescentAgincourt, Ontario416-491-437S
8. Sarah TPortrait (IA Teenage Alcoholic -
Film, 1974, 100 minutes, color, sbund.
A realistic depiction of a teenager becomingan alcohollcandcoming to recognize her alcoholism. Statistics quoted arealarming but questionable.
Universal Studios100 Universal City PlazaUniversal City, Calif. 91608313485-4331
9. (The) Sere Low cif S 044 kenFilm, 28 minutes, color, sound.
Dmmatimlly portrays the step.by.nep pros:m*16mila«holism of a wife and mother. Shows how ignorance of the...symptoms of the disease doles her to deceive her friends, her,family, her physician, and herself, until disaster forme. herto seek help.
Loan InformationStanley R. Steenbock, DirectorCounty of Los Angeles Information Services300 West Temple Street .
Los Angeles, Calif, 90013213-423 -3611, extension 64167
SaleHollywood Film Enterprises, Inc. Sala 51506060 Sunset BoulevardLos Angeles, Calif,313-464-3181
10. Minniefor Datrion .
Pilm, 1968, 39 minutes, color, mound. . .
This documentary, produced for the Los s,CountyCommission on Alcoholism. focuses on one farnilYb searchfor help. This search leads the wife to Oldies aleoholiiiiiithformation center where she learns torecognize the sym monisof alcoholism and toecaps her husband% illiieu. Theca...learns Motivadonaltachniqoes and offtienitsieavailableo'finelly tesiliring"that they can find guidanakivek._them* the AlcOholiC may continue to drink, - '-Loin InformationStanley R. Steeribilik, DirectorCounty of Lin Angeles Information Services300 West Temple StreetLos Angeles, Calif. 90012313435-3611, extension 64167
Hollywood Film Enterprises. Inc. Sale: 51506060 Sunset BoulevardHollywood; Calif. 90038313-464-3181
valuation Techniques
- . - . .
dance Abuse Attitudes: Their Rolesegment in Medical Educationa ment
. - -...
K.Clutppeii MD.S...ICtut
ne,afthe early challenges facing`the_Career teacherswas the setting of 'priaritisi in educating medical stu-
linbinitalCohol and drug abuse There was strong-, that attitudes were more Important than:!knoWdge Many of the career teachers had had ii-
,d experiences,withl physicians whose knowledgesadequate 00,010001*. #001j1iffit 41.1 °ugh.;knowledge, ...bti-whoge atti-**WOO negative that they refused to treat alcohol.ordrigaddIcts .
ta; raVenienta Made in manYzother areas of.,"'eltre given alcohol- and drug-
hefts has often been tregineisted,ietopertt..*ni debvety system, and/or of low
th.factoricontz4butlngtoth1s situationinegatheitthiidcs held by physicians toward
nc-dàiidChtpat1enIs and pessimism aboutiffectreness Of treatment for such patients.
Ott that physlclinsin a teaching hospi-avilded the esily diagnosis ofalcuholismand tendedwi1tüntil the ents fit a tereliCt'spreatype.
is !rind eyed the literature and',-iremarked an zthe*, negative, quality of physicians'
4ett4toWirdilColialiOs' anthhe detrimentaltOtiilieieTfielingit**iiiyi on a physician's abil-iridwillIngness to detect and: tmanage the dis7,
lidI4g-A e effect ;a* dietl training onattitutleitoWatCalcohalla patients .:: Fisher and
found slgiificant increases in negative
attitudes from first-year medical students throughhouse Staff iri a teaching hospital (2), Even psychiatrists =
and other physicians in specialized addiction treatment .
settings have been shown to have more negative atti-tudes toward alcohol-and drug-dependent patientsthan have nonmedical staff (3). Pessimism about treat*.ment,bas en pervasive, Knox (4) found: thigtIrth
_. t - .
psYchiatrists and plychologists.considered. treatment .
benefits for alcoholic patients to boyery limitid,andwere: reluctant to participate-personally In Priiiiding.- .---"treatment.
. .
Deciding that attitudes were important itfedutiatingphysicians about alcohol and drugabuse was die easiest .
part of the tisk. Attitudes an difficult to done -arideven mare difficult to teach. O.ur gaal to' prriduci7:Ph ilciani who hid liasitive Mika* towardand drug-abusing patientsind who were siblelo-forineffectiVetreatment relationships with them.. We did notknow exactly what those attitudes were or haw- tomanure changes in them.
. .
Educational attempt i have succeeded in trintimildng..content about substance abuse, but they have had littlesuccess in develaping*or maintaining positive atti--tudes. Reynolds and Bice (5) worked_ withinterns for S months attempting to alter negativeattitudes toward chronic patients Theif.conolt#4.that "despite efforts. t 0 chino. them, these attitudesof the interns appear remarkably stable over theperiod Of time studied" .
. .. . .
. .
49 53
ALCOHOL AND DRUG AiusE IN MEDicAL,
(6):offered a .coorse. to.social workers with the.ezpectetion.that they..would develop. greater comfort
confidence in working with alcoholic patients. She*Ass .discussion of various studies- during the
knowledge, but that greater discom-cart with developed: Reflecting on similar find-
AngSWitliiinterns, residents; and attending physicians,Mendeleonlind associates (7) concluded with referenceo continuing education that "educational programs in
...link:Of:alcoholism should encompass a range ofactivities which would help physicians evaluate their
onalattitudes toward the alcoholic."The Americanedicaf Ailociation Council on Mental Health (8)
Mcommended that "high priority be given to pedagogicalMethods Which will encourage thetmedican students to
r_ t out their experiences and subjective feel-',and attain the goal of professional objectivity."
This paper describes our attempts to understand theroblein, to develop a technique for assessing attitudeshiCh: are relevant to treatment, and to implementiicitional activities which would develop more posi-
five attitudes.
ISTORICAL SOURCES OFEGATIVE ATTITUDES_,
and stereotypes permeate the attitudes of bothdeals 'and physicians. These attitudes interfere with
iciariliatient involvement on least three levels.::patients with drug abuse problems are reluctant
to seek-Medical help: Wheii they do, there is very littletiorihf the full details' of their drug abuse. Bake -
;:and Ewing have commented on the number ofiis"_wives whose undiagnosed illnesses led to
psychiatric 'referral and the discoVeiy of drug depend-ence,,(9): Second,. physicians, including psychiatrists,are reltictsint to' participate personally in the treatmentof drug dependence (4). Physicians report that man-agenient Of alcoholics is difficult, time consuming, andonrewarding;and that drug-dependent patientsare
participate in treatment or to follow adviceFinally, hosPitals often refuse to admit or treat
: recognized cases of drug dependence. We have hadformer Woiii addicts currently receiving methadone
drochloride turned away from hospitals with_ the&tient; "We don't treat junkies.
S:WidesprendoSe of opium and morphine follow-i rig the Civil War iedto. passage of the Harrison Act
*
designed to control the distribu-71 .
Lion and sale of opiates, this 114: was. later'ased,,close medical treatment facilitiei,andla.:00oateand imprison physicians who attempted;'to
-narcotics addicts with opiates: the:large = prisonhospitals at Lexington and Fort bulland the treatment of narcotics addiCiiiih..WasMoved as a responsibility of physicians in practice
In the meantime, medical societies advised physnot to attempt to treat narcotics midi*.narcotics in medical schools vies' often tauthat encouraged a phobic response In the young pliyclan. The talkie of prohibition to control human druse did not deter the development ofabstinence was the treatment of *choice: tarkdi..,dependence. Freedman has described the early learleti . .
in psychiatry "fervent prohibitiOnista.",(11)Unfort*.nately, this attitude often led to the prohibition Of the
individual sea medical patient whens/ he failed to achieve and maintain an alesiiiientstate:-
ATTITUDINAL INFLUENCE ONPATIENT CARE
Although Ueda experimentalwork has been done, t,is an increasing amount of descriptive:evideriieKphysician attitudes have a wide influencenrialmcitaspects of patient care,
Diagnosis
Diagnosis of drug dependence may,be delamissed. Chafetz (1) and others have noted i tphysicians' have a stereotypic piclure aka todependent patient:as derelict; and they-re Ocal symptoms to make-their -diagncisis:- re-!delay until the condition has reached an advancestage. Reversal of this,tendency has: been demostrated in the Department of General-Manchester University, England (12). Then', :tuse of routine questionnaires with at patients=risk of alcohol dependence increased the detectionrate of alcoholism by nine dines in 1 year.
Access to Health Care
Negative attitudes may ekludechemicallypatients from the health care proAsicin sys Ode-for those with acute inedloal problems; Jeh1neli
SUBSTANCE ABUSE ATTITUDES
argued strongly for the disease concept of alcoholdependence, in part to influence physicians and hospi-tals to change admission policies that exclude alcohol-ics. Although official policies have changed, the diag-nosis of chemical dependence still selectively influencesadmission rates. Mayfield and Fowler(14) studiedalcoholics and excessive drinkers referred to a VeteransAdministration hospital service for treatment. Althoughthere were few differences between the two groups, 17percent of the alcoholics were admitted on the firstassessment as compared with 34 percent of the exces-sive drinkers. The authors comment that "excessivedrinkers are accepted fo r treat ment as often as moderate
drinkers. Meanwhile alcoholics are considered uninter-esting and untreatable and are seldom and reluctantlyaccepted for treatment."
Referral
Chafetz et al. (15) studied the effectiveness of refer-rals by emergency room residents to an alcoholismtreatment clinic in the same hospital. They foundthat "the more anxious a doctor's voice was rated tobe, the more successful the referrals he made." Theyalso found a substantial negative correlation betweenan angry tone in the physician's voice and the effec-tiveness of his referral.
Treatment
The place of treatment chosen forchemically depend-ent persons is influenced by physician attitudes.Mendelson and his colleagues (2), studying bothhouse officers and attending physicians at BostonCity Hospital, found a definite relationship be-tween authoritarianism and custodial attitudes.
Physician pessimism about treatment outcome hasthe effect ofa self-fulfilling prophecy. Goldstein (16)has shown that therapist expectancies about out-come have a substantial effect on the results of psy-chotherapy. He recommends that patients be as-signed to a psychotherapist whose expectancies aremost favorable for that patient.
'The patient's expectations also play an importantralii..Mogar.et al. (17) state that the effectiveness of
...:treatment is largely determined by its compatibilityWith the Pat4riis' beliefs and expectations. They be-
51
lieve that the ideal approach to treatment is humanis-tic, strongly optimistic, and psychologically oriented.
Positive attitudes are not easy to maintain, how-ever. when a physician encounters a patient in anintoxicated state. Frustrating experiences combinedwith "failure to effect change in a patient's drinkingbehavior may cause house staff to feel that all al-coholic patients are passive. aimless, and ultimatelyhopeless" (2). These negative attitudes can then betriggered by the smell ofalcohol on a person's breath.Sudnow (18) reports that when a wino is broughtinto the hospital with no respiration or no pulse, heis likely to be pronounced dead, with no attempt atresuscitation, after a stethoscopic examination showsno heartbeat. A child or an apparently well-to-dobusinessman with the same outward signs of deathis more likely to be the subject of dramatic efforts atresuscitation.
He goes on to state that "the alcoholic patient istreated by hospital physicians . . as one for whomthe concern to treat can properly operate somewhatweakly." Haney (19) believes that the crucial de-terminant is the physician's assignment of blame orresponsibility for the patient's condition. "ln gen-eral, more perfunctory examination and more apa-thetic care are the lot of all patients who, accord-ing to public opinion, could have avoided theirpresent condition."
Measurement of Attitudes
Accepting the importance of attitudes in determin-ing the quality of care received by substance abusersis only the beginning. How can attitudes be meas-u red so we can assess changes in response to educa-tional experiences? Various attempts have beenmade. The early efforts of the career teachers in-volved the use of semantic differential scales usingpolar opposite adjectives such as good-bad, wise-foolish, and safe-dangerous (2,20). Positive changesin response to educational efforts were obtained.
There were two problems with this method. First,student and physician acceptability was not high.Many refused to apply these "labels" to generalizedpatient groups such as alcoholics or heroin addicts.Second, although change could be measured in apositive or negative direction we had no idea howrelevant the changes were to patient care.
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
An attempt was then made by career teachers withclinical experience to develop attitudinal state-ments which they considered functional or dysfunc-tional in their influence on good medical care forsubstance abusing patients. Examples of these state-ments are shown in table 1-(21).
TABLE 1.Physician attitudes towardpatients and treatment
Dysfunctional Functional
Alcohol or drug-depend-ent patients are the dregsof society.
Drug or alcohol abuse isa social or legal problem,not a medical one.
I have little in commonwith alcoholics or drugaddicts.
My only role in treat-ment is in managingoverdose, withdrawal, ormedical complications.
Alcoholics or drug ad-dicts cannot be treatedas outpatients. They'll"rip off" me and thecommunity.
Giving an alcohol- ordrug-dependent personmedication is like treat-ing bourbon addictionwith whisky.
Paraprofessionals areeither in competitionwith physicians or so de-fensive that the two cannever work well to-gether.
How can l help alcohol -or drug-dependent pa-tients find a more effec-tive way to live?
Alcohol or drug abuserepresents problems Ican help treat.
1 share much humanexperience with addicts,even though we may dif-fer in our behavior.
Medical treatment isonly one of several im-portant supports analcohol- or drug-de-pendent patient needsduring long-term treat-ment.
Lo ng-t erm outpatienttreatment in a com-munity is necessary if analcoholic or drug addictis ever to live normally.
There is a big differencebetween medicine pre-scribed and controlledby a physician and alco-hol or drugs taken asself-medication.
Paraprofessionals canbe of great help workingwith physicians, espe-cially in controlling be-havior and communicat-ing with alcoholics anddrug addicts.
52
It may soon become evident that, while these state-ments were useful for discussion purposes, they didnot lend themselves to easy measurement. In addi-tion, many of them required a background of expe-rience which most medical students and many phy-sicians did not have.
DEVELOPMENT OF ASTANDARDIZED SURVEY OFATTITUDES
The career teachers then developed a large numberof attitudinal statements pertaining to a wide varietyof abused drugs including alcohol, usage patterns,patients, and treatment approaches.
An instrument of 153 items was developed. The re-sponse options to this questionnaire were a scalefrom I to 5 (strongly disagree (1] to strongly agreeE51)
This STAK (Standardized Test of Attitudes andKnowledge) was administered to 26 career teachersin substance abuse at their quarterly meeting inPortland, Oreg. Each teacher took the questionnairewithout any discussion.
After questionnaire administration, the career teach-ers divided into small groups and discussed Itemsassigned to them. These groups were free to changethe content of an item or to rework the wording ofan item.
These data were then submitted to a principal axesextraction of factors and a varimax rotation of 10extracted factors. Of those 10, 5 were meaningful,and the remaining 5 appeared to be residual factorsof specific persons. It is well understood that ex-tracting this many factors on so many variablesversus so few people is a violation of factor analyticprotocol; however, these data were to be used as away to condense the number of variables intomeaningful subcategories and certainly not toexamine detailed structure.
Data Reduction
After examination of the 5 factors, the total numberof variables was condensed to 106 items with 2 addi-tional varia bles of "bask sciences" versus"clinician"trained; and, "presently working with substanceabusers" or "not presently working with substance
56
SUBSTANCE ABUSE ATTITUDES
abusers" being added, bringing the total number ofvariables to 108. These questionnaires were thenmailed to the career teachers, and 42 persons re-turned them. The data were again analyzed to extractfactors in the same way as before.
Only those items loading at 0.40 or more on at leastone factor were retained. The item pool was thusreduced to 75. This instrument was then given tocliniciansaround the country who are experienced intreating alcohol- and drug-abusing patients. Fromthis pool a reference group will be selected whohave lengthy experience, believe they are successfulin providing treatment, and enjoy working withsubstance-abusing patients. Analysis of the responsesof this reference group will be used to further reducethe item pool to 50 items and to develop a scoringsystem.
At that point we should have an instrument whichcan be used .to :measure attitudes in medical stu-dents and physicians in a way which is relevant tothe attitudinal patterns found in current treatmentproviders.
EDUCATION FORATTITUDINAL CHANGE
Courses which have demonstrated an ability toalter medical students' attitudes have been developedby career teachers. One such course was designedwith the long-term goals of increasing interest inand improving the quality of medicaland psychiat-ric care delivered to substance-dependent patients(20). The immediate objective was to positively in-fluence students' attitudes toward substance-abusingpatients and their treatment.
The substance abuse course was taught at the end ofthe block on the CNS in the second half of the sopho-more year. It followed instruction in pharmacologyand had a heavy clinical emphasis. The course wasdesigned to involve each student in an experientialway with the different aspects of substance abuse.Audiovisual aids, clinical problem solving, andsmall group discussion were used in almost everypart of the course.
Each student v,..s assigned an Alcoholics Anony-mous (AA) sponsor who took him or her to an even-ing AA meeting before the field trips. A syllabus and
53
book of readings, averaging less than five pages perinstructional hour, were given to each student. Thepretests and posttests included questions on content,substance use, and attitudes.
COURSE RESULTS
A mest for correlated means indicated that theknowledge of the entire class, as measured by the50-item pretest and posttest, increased significantly(mean pretest score, 29.43; mean posttest score,36.22; p < .01). Analysis of covariance indicatedthat personal experience with either alcohol ordrugs did not show any effect on knowledge levelsbefore the course was given or influence the acquisi-tion of knowledge during the course.
The students as a whole showed a significant de-crease in feeling disgusted or upset at encounteringall five types of substance-abusing patients (p <.05,1-tests for correlated means).
On the semantic differential scales measuring atti-tudes toward the five groups of substance-abusingpatients, a mest for correlated means indicated thata significant positive shift took place in the overallattitude toward hard-drug users (p < .05).
Attitude changes toward treatment modalities alIoccurred in the direction of increased optimism.The only treatment category showing no significantchange for any substance-abusing category was thatof self-help groups, e.g., AA, Synanon, and WeightWatchers. These were rated highest in both the pre-test and the posttest. Job counseling showed thegreatest shift in rank ordering and was the onlymodality seen as less important than the physician'srole in the pretest but more important in the post-test.
The physician's role in treatment, both generallyand personally, was viewed with greater optimismin the posttest for alcohol- and drug-dependentpatients. In all cases the class as a whole rankedtheir personal roles as more important than otherphysicians' roles in both pretest and posttest. Therank ordering of treatment modalities, when com-bined for all five areas of substance abuse (with theexception of job counseling), was the same in thepretest and posttest and was as follows: (1) self-helpgroups, (2) family involvement, (3) counseling (psy-chotherapy), (4) my personal role asa physician, (5)
57
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
the role of the physician, (6) drug substitute orantagonist (chemotherapy), and (7) institutionaltreatment.
Student evaluations of the substance abuse coursewere highly positive in comparison with their evalua-tions of other courses they had-taken. They alsorated their medical school experience as having amore important role (p <.01, r-test for correlateddata) in the attitudes expressed on the posttest ascompared with the pretest.
The highest rating was given to the visit to an AAmeeting and the field trips to treatment programs.These visits provided direct contact with people inhelping settings. The second highest ratings weregiven equally to the sessions on management of over-dose and withdrawal and the review session. Bothof these experiences had a heavy clinical emphasis,the first dealing with a series of clinical problemsthe students worked on in small groups, and thesecond providing direct contact with a physicianwho had extensive clinical experience with sub-stance-abusing patients.
Evaluations obtained from the students give someclues as to those parts of the course which may havebeen most effective in influencing their attitudes.Altrocchiand Eisdorfer (22) reported a similar pos-itive impact of clinical experience on attitudes to-ward mental health. In the area of substance abuse,the course described in this paper may have repli-cated in a medical school setting the experience ofMogar and associates (17), They found that clinicalexperience with alcoholic patients resulted insignif-icantly less pessimism in psychiatrists and otherphysicians about the effectiveness of treatment.
The increased optimism about treatment shown atthe posttest by our students is quite important inpotentially influencing theeffectiveness of treatmentE y by these students in the future. Goldstein's(10) recommendation that patients be assigned totherapists whose expectations are most favorablefor the patients is relevant in this context. Theconverse is that many substance-dependent patientslive up to the negative expectations of the people.frequently physicians. who are trying to help them.Mogar (17) made the point that "treatment out-come with the alcoholic patient is a function of staffattitudes, patientattitudes, and, perhaps most impor-tantly, the degree of congruence between them."
54
CONCLUSION
The physician is a key person in the treatment of al-cohol or drug abusing patients, Whether in privatepractice, serving as a consultant, or working fulltime in a treatment program his/her attitudes willbe influential in determining the quality of caredelivered.
S/ he is obviously needed to provide the chemo-therapeutic aspects of treatment. Of particular valueis the physician's clinical judgment when the teammakes decisions that may involve some element ofrisk for the clinic member. In addition, the physi-cian provides important support and education forboth the nurses and counselors who are often undergreat stress from clink members.
Relatively few physicians will choose to becomedirectly involved in the treatment of drug depend-ence. An equally important role remains for thephysician in practice. S/he may have the firstopportunity to make an early diagnosis and referthe drug-dependent person for management. Prep-aration of the patient, communication of hope, andthe provision of emotional and chemotherapeuticsupport may be critical in getting the patient into atreatment program. Physicians will continue to becalled on to manage drug overdoses, severe drugwithdrawal, and drug-related emergencies. Drug-dependent individuals will continue to get pregnant,have accidents, and suffer from any of the humanrace's Illnesses.
Changes in attitude are necessary at both physicianand institutional levels if drug dependence is to beadequately treated. Such a change in attitude ispossible. The history of mental illness showsa gradualshift from medieval rejection and punishment toincreasingly effective treatment which is more andmore being incorporated into the mainstream ofmedical care.
Each of us must be aware of our own attitudesbefore we can change them. The Standardized Testof Attitudesand Knowledge can be used to developthat awareness. The test, which is presented at theend of this chapter, will have many uses in undergraduate, postgraduate, and continuing medicaleducation. It is our hope that it will contribute ina measurable way to improved treatment of suii-stance abusing patients.
58
SUBSTANCE ABUSE ATTITUDES
AUTHORS
John N. Chappel is affiliated with the University ofNevada School of Medical Sciences, and Ronald S.Krug, with the University of Oklahoma HealthSciences Center.
REFERENCESI, Chafe% M.E. Research in the alcohol clinic and around-
the-clock psychiatric service of the Massachusetts GeneralHospital. American Journal of Psychiatry, 124:1674-1679,1968,
2. Fisher, J.C.; Mason. R.L...; Keeley. K. A.; et al. Physicians andalcoholics: the effect of med icalt mining on attitudes towardalcoholics. Journal of Studies on Alcohol. 36:949-955, 1975.
3. Sows. P.N.. and Cutter. H.S. Attitudes of hospital staff to-ward alcoholics and drug addicts. Quarterly Journal of Studieson Alcohol. 31:210-214, 1974.
4. Knox, W.J. Attitudes of psychiatrists and psychologists to-ward alcoholism. American Journal of Psychiatry. 127 :1675 -
1679, 1971.S. Reynolds. R.E..and Bice, T.W. Attitudes of medical interns
toward patientsand health professionals. Journal of Healthand Social Behavior. 12:307-311. 1971.
6, Bailey, M.D. Attitudes toward alcoholism before and after atraining program for social caseworkers. Quarterly Journalof Studies on Alcohol. 31:669 -683. 1970.
7. Mendelson. J. Wexler. D.; Kubransky. P. E.: et al. Physi-sicians'attitudcstoward alcoholic patients. Archives of Gen-eral Psychiatry. II:392-399, 1964.
8, American Medical Association, Council on Mental Health.Medical school education on abuse of alcohol and other
psychoactive drugs. Journal of the A merkan Medical Asia-clarion. 219:1746-1749, 1972.
9. Bakcwell. W.E., and Ewing, J.A. Therapy of non-narcoticpsychoactive drug dependence. Current Psychiatric Thera-pies. 9:136-143, 1969.
10. Gray. R.M. it al. Physician authoritarianism and the treat-ment of alcoholics. Quarterly Journal of Studies on Alcohol,30:981-983, 1969.
11. Freeman. D.X. Implications for research. Journal of theAmerican Medical Association, 206:1280-1284, 1968.
12. Wilkins, R.H,"Thr detection ol alcoholiant IVA noli'llsscial*ist."Paper presented at the First international Medical Con-ference on Alcoholism, London. September 10, 1973.
13, Jellinek, E.M. The Disease Concept of Alcoholism. NewHaven, Conn.: Hillhouse Press, 1960.
14. Mayfield. D.,and Fowler, D.R. Diagnosed and undersignedalcoholism. Southern Medical Journal, 63:593-696, 1970.
11, Chafetz. M,E.: Blanc. H.T.,and Hill, M.J.: eds. Frontiers ofAlcoholism, New York: Science House, 1970. pp. 136 -144.
16. Goldstein. A.P. Therapist- Patient Expectancies in Psycho-therapy. New York: Macmillan, 1962,
17. Mogar. R.E.: Helm,. S.T.: Snaleker, KR.: et al. Staff atti-tudes toward them leoholic patient. Archives of General PO'.chicory. 21:449-454, 1969.
18. Sudnow. D. Dead on arrival. Transaction. 5:36- 43,1967,19. Haney. C.A. Psychosocial factors involvt ,1 in medical de-
cision making. In: Coombs, R., and Vincent, C., eds. Psy-chosocial Aspects of Medical Training, Springfield, III.:Charles C Thomas, 1971.
20. Chappel. J.N,; Jordan, R. D.; Treadway, SI; and Miller,Substance abuse attitude changes in medical students. Oman.ran Journal a/ Psychiatry, 134:379-384,1977.
21. Chappel.J.N and Wino% S.H. Physician attitudes: effecton the treatment of chemically dependant patients. Journal°Me American Medical Association, 237:2318 - 2319,1977.
22. Altrocchi.J and Eisdorfar, C. Changes in altitudes sowirdmental illness. Mental Hygiene, 45:563-570, 1961,
STAN L. ARDIZED TEST OF ATTITUDES AND KNOWLEDGE 111{STAKE
Attitudinal Statementsinstructions:
Pleate.answer each item by Indicating your degree of agreement or disagreement using she following format:
DStragglydissent
dDisagree Uncertain
a
AgreeA
Stronglyagree
Please circle only one answer for each item and complete all items. Remember that your answer should reflect your altitude and not
whether you think the statement is factually correct.
Odom A I. Alcohol is an effective social relaxant.D d is a A 2.. Marijuana use leads to mental illness.DduaA 3. All heroin use leads to addiction.Ddue A 4. Alcohol use is all right if it is not excessive.
55
59
ALCOHOL AND DRUG ABUSE 1N MEDICAL EDUCATION
O d u a AStrongly Disagree Uncertain Agree Stronglydisagree aweDd us* 5. Alcohol is a food, not a drug.Dd u a A 6. Stimulant use leads to mental deterioration.Ddua A 7. Sedatives are more frequently abused drugs than narcotics,OduaA 8. Marijuana should be legalized.DduaA 9. People should realize that the caffeine in coffee and beverages is a drug.Odom A 10, Using any herd drug shortens one's lifespan,D d u a A I I. Any drug can be safely used by a person who is mentally healthy.Ddua A 12, Alcohol is so dangerous that it could destroy the youth of our country if it wasn't controlled by law,Ddua A 13. Heroin is so addicting that no one can really recover once s/he becomes an addict.DduaA 14, Akohofistn is familial in origin.Odom A 15. Almost anyone would turn to drugs if her/her problems were great enough.D d ua A 16, Smoking leads to marijuana use, which in turn leads to hard drugs,Dd us)* 17. Street pushers are the inklal source of drugs for young people.Dd us A HI. Children leans about drug use from their parents' behavior.DduaA 19. Alcoholism is a learned disorder.Odor* V. A disproportionately high number of addicts are born to mothers on welfare.DdueA 21. Physicians are an important source of drugs for most users.DduaA 22. Drug abuse is a character disorder.Odom A 23. Being raised in a slum leads to drug abuse.OduaA 24. Daily use of one marijuana cigarette is not necessarily harmful.oduaA 25. Clergymen should not drink in public.D d Da* 26. Physicians should not smoke tobacco in public.D d um A 27. Tobacco should not be smoked in the rooms where nonsmokers are present.
d on A 28. People should only get drunk at home.D des A 29, People who use marijuana usually do not respect authority.
d is a A 30. People who use psychedelic drugs have emotional problems.DduaA 31, A physician who has been addicted to narcotics should not be allowed to practice medicine spin.D d is a A 32. The laws governing the use of marijuana and heroin should be the same.Dd as A 33. Weekend users of drugs will progress to drug abuse.D d usA 34. Tobacco smoking should be allowed in high schools.D diseA 35, Personal use of drugs should be legal in the confines of one's own home.Dot on* 36. An individual Who does not engage in the social use of drugs isa bore.Dd is a A 37. Teachers mad other role models for young people should not use alcohol and other drugs in public.D dor A 38. Anybody who is clean shaved and has short hair probably doesn't use illegal drugs.Dd on A 39. Recreational drug use precedes drug abuse.D d oe A 40. The majority of alcoholics can recover with treatment.Dd us A 41. People who dress in hippiestyle clothing usually use psychedelic drugs.Dd us w'42. People who use drugs are sexually promiscuous.D doaA 43. It is normal for a teenager to experiment with drugs.Ddua A 44. Marijuana use among teenagers can be.healthy experitneutalion.Dd us* 45. Lifelong abstinence is a necessary goal in the treatment of alcoholism.DdonA 46. A hospital is the best place to treat an alcoholic or drug addict.Dd u A 41. Once a person Becomes drug-free through treatment s/he can never become a social user.
d is A 48. Alcoholism is associated with a weak will.D d us A 49. Drug addiction is a treatable illness.Dd is a A 50. Persons convicted of sale of Illicit drugs should not be eligible for parole.
d is A $1. Paraprofessional counselors can provide effee6e treatment for alcohol or drug abusers.DO ts a A 52. Methadone is a very useful treatment for heroin addiction.Dd o a A 53. Urine drug screening is an important part of drug abuse treatment.Ddoa A 54. Antabusa is a very useful treatment of alcoholism.Ddua A 55. Oroup therapy is very important in the treatment of alcoholism or drug addiction.
dun A 56. Long-term outpatient treatment is necessary for the treatment of drug addiction,Odom A 57. Angry confrontation is necessary in the treatment of alcoholics or drug addicts.DdUn A 58. Family Involvement is a very Important part of the treatment of alcoholism or drug addiction.
dna A 59. Alcoholism is a treatable illness.D d u IsA 60, Chronic alcOholiel who refuse treatment should be legally committed to long-term treatment.Odom* 61. AA is a very useful treatment for alcoholism.
56
60
SUBSTANCE ABUSE ATTITUDES
D d u a A
Strongly Disagree Agree StronglyUncertaindisagree
Ddue A 62. Mentally healthy doctors will have nothing to do with alcohol- and drug-dependent persons.D d u a A 63. Physicians who diagnose alcoholism early improve the chance of treatment success.D d ua A 64. Most alcohol- and drug-dependent persons are unpleasant to work with se patients.D d us A 6S. There is probably some hereditary factor that causes people to become addicts.D d ea A 66. An alcohol- or drug-dependent person cannot be helped until s/he has hit "rock bottom."D d us A 67. An alcohol-or drug-dependent person who has relapsed several times probably cannot be treated.
D d us A 68. There is an addictive personality.D d ea A 0. A physician who treats alcohol- or drug-dependent patients will lose many of his/ her other patients.
Dolga A 70. Alcohol and drug abusers should be treated only by specialists in that field.OduaA 71. The best way for a physician to treat alcohol- or drug-dependent patients is to refer that patient to a good treatment
program.D duo A 72, Once an alcohol- or drug-dependent patient is abstinent and off all medication, no further contact with a physician
is necessary.1111duaA 73. Before an alcoholic is able to stop drinking s/he needs to gain some insight into the reasons for his/her drinking.
DduaA 74. Parents should teach thei.- children how to use alcohol.11) duaA 75. Regular, heavy drinking is not a problem for the who can hold their liquor.
57
7. Evaluation of Knowledge in SubstanceAbuse
History of the Task Force on Evaluation Alex Pokorny, M.D.
When Dr. John Griffin was appointed a careerteacher, he already had an active interest in physicianevaluation. For example, he had contributed a chap-ter on the structured oral examination for the vol-ume, Evaluation Methods in Psychiatric Education,edited by 'Muslin, Thu rnbiad, Templeton, andMcGuire, and published by the American Psychiat-ric Association in 1974. Dr. Griffin had also spenttime in the Research in Medical Education Unit atthe University of Illinois and had been an activemember of the Written Test Sub-Committee of theChild Psychiatry Section of the American Board ofPsychiatry and Neurology.
As a career teacher, Dr. Griffin came for a period tothe Baylor Career Teacher Training Center in July1974. At that time he indicated that one of his objec-tives was the drafting of approximately 500 questionsin the area of drug abuse and alcoholism, and hedevoted a significant part of his stay at Baylor to thiseffort, using part of his time with each instructor toformulate questions on that topic. Dr. Griffin thenbegan talking with other career teachers about help-ing him to field test these questions.
After the career teacher program had been under-way for over a year, the National Institute on DrugAbuse appointed a task force to look more broadlyat.the entire field of physician education and alliedhealth education in the area of substance abuse.There was therefore set up a NI DA Task Force onPhysician and Allied Health Education Objectives,which had its preliminary meeting in Rockville, Md.,
_ in January 1975, and had its first formal meeting inHouston on February 13,1975. In a series of meet-
- ings, this task force adopted a list of eight objectives
58
in the area of physician education. These were thenassigned to specific individuals, agencies, or com-mittees. Objective III was stated as "Secure Inclu-sion on National and Specialty Board Exams ofQuestions on Alcoholand Drug Abuse. "This objec-tive was assigned to a task force chaired by Dr. Griffin,and initially Dr. Richard Phillipson and Dr. AlyceGullattee were to assist him. Later a task force wascreated including those three members plus Dr. AlexPokorny, codirector of the Baylor Career TeacherTraining Center, and career teachers Kenneth Rus-sell, Ronald Krug, and Kim Keeley. The task forcehad 12 meetings from 1975 to 1977.
During the first year, the committee worked almostexclusively on the development of a pool of ques-tions on substance abuse for use by career teachers.The committee started with Dr. Griffin's c onsiderablepool of items. Each task force member then submitted .
about 30 additional items which led to an initial poolof over 300 items. Individual career teachers whowere not members of the task force also providedsome items. During this year the committee workedon individual items during meetings and also betweenmeetings, During this period task force memberslearned a great deal about question-writing tech-niques and approaches to evaluation.
Since one of the original goals was to increase thenumber of questions on drug and alcohol abuse inthe national board and specialty board examinations,the task force set up some discussions with the Na-tional Board of Medical Examiners. The eventualresult of this was that the task force submitted 25 ofits best questions to the secure-item pool of the na-tional board and also set aside 25 00er high*.cluslitY
62
KNOWLEDGE IN SUBSTANCE ABUSE
questions for submission 1 year later to this pool.Since the mechanism by which the national boardselects questions involves choices of a series of dis-ciplinary test committees, it is not possible to man-date or specify how many items willbe asked per dis-order or technique. However, the presence of highquality items in the pool should facilitate the betterrepresentation of alcohol and drug abuse in examinations in the future.
The task force then selected approximately 201items for inclusion in a lengthy examination whichwas field tested with the group of career teachers atthe Portland, Oreg., meeting in 1976.
The Baylor Career Teacher Training Center hasgradually taken on the role of supporting and coordinating the examination processing. The plan is thatthe center will offer to grade examinations and alsoreceive copies of results of examinations so that thisfurther experience with each item can be added tothe information available on each item in the question pool.
An important new development with respect to thistask force was the beginning of discussions with theNational Board of Medical Examiners, initiallyabout adding items to their question pool. At thistime, the national board was making plans for de-velopment of a comprehensive qualifying examina-tion, to be given to physicians after or near comple-tion of medical school as a requirement to beginninggraduate medical education (internship or resi-dency). It occurred to the representatives of the Na-tional Board of Medical Examiners and the NIDAtask force that this might be an excellent spot for col-laboration, and after several planning discussionssuch an agreement was entered into. The nationalboard submitted a grant proposal which was fundedby NIDA, and the evaluation task force also becamea research project examination committee or taskforce of the National Board of Medical Examinersto develop a proportion of the comprehensive quali-fying examination. During the past year this hasbecome the pritzipal activity of this evaluation taskforce. Because of the felt need to broaden the expertiseand competence of this committee, Dr. KennethWilliams, an internist and career teacher from Pitts-burgh, and Dr. Sidney Cohen, a pharmacologistand an established authority In the field of drugabuse, have been added as members (see listing).The work with the National Board of Medical Exa-
59
miners has involved a prominent shift to writing ofpatient management problems and of multiple choicequestions around particular themes and case histories.
RESEARCH PROJECTTEST COMMITTEE
National Institute on Drug AbuseNational Board of Medical Examiners
Chairman,John Griffin. M.D.IAssociate Professor of Child PsychiatryDepartment of PsychiatryEmory University School of MedicineAtlanta, Ga.
Sidney Cohen, M.D.Adjunct Professor of PsychiatryUniversity of California At Los AngelesLos Angeles, Calif,
Alyce Gullattee, M.D.'Associate Professor of PsychiatryDepartment of PsychiatryHoward University HospitalWashington, D.C.
Kim A. Keeley, M.D., M.S.H.IDeputy Commissioner for Medical ServicesNo. 2 World Trade Center67th floorState Office of Drug Abuse ServicesNew York, N.Y.
Ronald S. Krug, Ph.D.'Professor of PsychiatryDepartment of Psychiatry and Behavioral SciencesUniversity of Oklahoma Health Sciences CenterOklahoma City, Okla.
Richard v. Phillipson, M,D.ISpecial Assistant for Scientific and Medical AffairsDivision of Resource DevelopmentNational Institute on Drug AbuseRockville. Md,
Alex D. Pokorny, M.D.IProfessor, ViceChairman, Department of PsychiatryBaylor coil's' of MedicineHouston, Tex.
Kenneth S. Russell, Bd. D.,Assistant Professor of Family and Community MedicineAssistant Professor of PharmacologyDirector of Addiction StudiesDepartment of PharmacologyUniversity of Arizona Medical CenterTucson, Ariz.
Kenneth Williams, M.D.Assistant ProfessorPsychiatry and Internal MedicineUniversity of Pittsburgh School of MedicinePittsburgh. Pa.
'Member of oiling NIDA evilostioo task force.
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
Development of a Grid for Examination In Substance Abuse Alex Pokorny, M.D.
One oft he prime considerations in the developmentof an examination is to make it proportionatelyrepresentative; that is, the number of questionsasked on a topic should be approximately propor-tional to the importance and teaching time allo-cated to the topic. If a topic could be subdividedalong only one dimension, then it would be simpleto allocate the questions in the same proportion. Ifa topic needs to be divided in two dimensions, thenone needs to construct a "grid" or two-dimensionaltable with corresponding cells. If there were threedimensions which were important to consider, thenone would need to construct a three-dimensionalsolid figure. In our task force, we decided that oneimportant dimension would be substances of in-terest such as opioids, stimulants, hallucinogens,and alcohol.It was decided that a second major dimension wouldbe subject areas such as psychological aspects, phar-macology, clinical diagnosis, treatment and reha-bilitation, and prevention. Eventually the committeedecided to have 10 groupings for each of these 2dimensions. These are shown in table 1, with thesubject areas listed down the left-hand side of thepage. After some initial experimentation with sucha grid, it was decided that there was a need fora sub-stance column called"multiple d rug comparisons,"because a great many questions involved two ormore of the substances and comparisons betweenthem. Such questions could not accurately he classi-fied in only one column. Similarly, the subject arearequired a category called "miscellaneous and mul-tiple subject comparisons" for these same generalreasons.
The task force also set up a third dimension, andeach item was classified into whether it representedinformation, skills, or attitudes. After a meeting ortwo it became clear that virtually all of our originalquestions fell into the information category, andtherefore this classification was not stressed asmuch later (alt hough some of this same attempt totest skills and altitudes reappeared later in classi-fications used in the National Board of MedicalExaminers activity),
The initial questions submitted by the task forceturned out to be quite irregularly distributed overthe two-dimensional grid. Such a lopsided distribu-
60
tion is not desirable in an examination. On theother hand, it is also undesirable to strive for aperfectly even distribution on grounds that somecategories are simply more important than others.For example, questions on alcohol should certainlybe more frequent than questions on cannabinoidsor volatiles. Similarly, questions in the areas of phar-macology, clinical diagnosis, and treatment shouldbe more frequent than historical or legal aspects.
The question therefore arose: What percentage ofquestions should be asked regarding each cell of thegrid? Drs. Griffin and Pokorny therefore arbi-trarily chose percentages on an a priori, "expertjudgment" basis and adopted the percentages shownat the tops of the columns of table 1.
Next, for each substance column separately, theydecided what percentage of the questions should beallocated to each of the 10 subject areas, and thesefinal choices, expressed as percentages, are shownas the upper figure of each cell of table 1. These per-centages add up to 100 percent in each column.
When these two sets of percentages were multiplied,it yielded the figures shown at the lower -half ofeach cell in table 1. These lower figures in each celladd up to 100 percent counting the entire table, andtherefore represent what percentage of the totalexamination should be devoted to that cell. As canbe seen, some of these percentages are quite small,less than 1 percent, which makes it obvious that notevery cell can have a question if an examination isof usual length.
Table 2 brings out how the distributions arrived atin table 1 were translated into a 150-question exami-nation. The numbers in the cells are the numbers ofquestions. The reader should see table 1 for thenames of the categories.
A general conclusion from this is that there may bea need to collapse categories. On the other hand, itis likely that one does not have to ask about everytopic in every examination, and all that one needsto be concerned with is that there is a fairly evendistribution.
Furthermore, it may not even be possible to gen-erate items for each and every cell, since in someinstances a combination is logically implausible, ornot much is known in that area.
64
TABLE 1.-Arbitrary, a priori allocation ofexamination to columns and cells of the grid (Griffin and Pokorny, Jan. 13, 1976)
15%
3 92096
07%1 2
5%
3
591
4
5%
5
295
6
30%
7
Opioids StimulantsHypnotics
andsedatives
Minor
tranquilizersHalluelnageni Cannabinoids Volatiles Alcohol
(a) Socimultural10.95
10
2.00
HI
0.70
HI
0.80
10
0.50
15
0.75
20
1.00
30
0.40
10
300
(b) Pathology 5 2 2 2 2 10 S 8
4,80 1.00 0.14 0.16 0.10 0.10 0.50 0.10 2.40
(a) Payeltalogical aspects 5 10 8 8 12 S 10 4
6.09 1.00 0.70 0.64 0.40 0.65 0.25 0.20 1.20
(d) Research and theory 5. 5. 2 2 10 IS 5 5
4.91 1.00 0.35 0.16 0.10 0.50 0.75 0.10 1.50
(1) 11111 lepl, ethical 5 3 3 3 3 10 5 3starlet1.00 0.21 0.24 0.15 0.15 0,50 0,10 0.90
(f) Pharmacology 20 20 10 10 17 10 20 15
19.40 4.00 1.40 0.80 Cop 0.85 0.50 0,40 4.50
HO Clinical diagnosis 20 20 25 25 17 10 10 20
19.35 4.00 1.40 2.00 1.25 0.85 0.30 0.20 6.00
(h) Treatment and rehabilitation 20 20 25 25 13 10 15 20
1895 4.00 1.40 2.00 1.25 065 030 0.30 6.00
(i) Negation 5 5 10 10 5 5 5 10
6.40 L03 0.35 0.80 0.50 025 0.25 0.10 3.00
1) Miscellaneous and multiple
subject comparisons 5 5 5 5 5 5 5 5
5.00 1.00 0.35 0.40 0.25 0,25 0,25 0.10 1.50
100.00 20.00 7.00 8.00 5.00 5.00 SAO 2.00 30.00
01 the percompu Is ;be retentions du top odd op to 1(0 percent; Owego permutes Awed touch subsuming".in Ma epu lipuni vdtbe cub colt sty petootttges of dui anima; nub column MU "tel.:Imam these tae lbe prelf41111nItetud In ad MOO pupIP, b. e, etc pro, dut 'Alum
(1) TM Inver Ilium Aitken& all upturn peourdspes oithe whole table; Winne Apace in don attire ;able add opts IN pineal.
Muitipk drug Misallaneouscomparisons
10 10
1.50 030
0 10
0,00 0.30
S 10
0.75 0.30
0 15
0.00 0.45
5 5
0.75 0.15
40 15
6.00 0.45
20 5
300 0.15
IS 20
2.25 0.60
0. 5
0.00 0.15
5 5
0.75 0.15
15.00 3.00
fig 66
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
TABLE 2.Now distributions arrived at in table 1 would translate into a ISO- question examination[The numbers in the cells are numbers of questions]
2 3 4 5 6 7 8 9 Total
a 3 I 1 1 1 2 1 3 2 0 17
b 2 0 0 0 0 1 0 4 0 1 8
c I I 1 1 1 0 0 2 1 0 8
d 2 1 0 0 1 1 0 2 0 I 8
e 1 0 0 0 0 I 0 1 I 0 4
f 6 2 I 1 2 1 1 7 9 I 31
It 6 2 3 2 1 1 0 9 3 0 29
lt 6 2 3 2 1 1 1 9 3 1 29
1 2 1 I 1 1 0 0 4 0 0 toj I I I 0 0 0 0 2 1 0 6
Total 30 11 11 8 8 8 3 45 22 4 130
TABLE 3.Psychological factors in substance abuse
Knowsbasicterms
Under-standsconceptand prin.ciples
Appliesprin.ciples
Drugs as stress coping mechanisms can affect various phases,of the individual life cycle.
The concepts of self-medication of emotional behavioralpathological symptoms, e.g., sleep disturbance, depression,anxiety states, psychotic disorders, and personality disordersthrough substance abuse.
Substance abuse as a form of coping and adaptational skilldevelopment.
Psychodynamic theories (e.g., drive and anxiety reduction)and the phenomenon of substance abuse.
The concept of the addictive personality and the controversysurrounding it.
The concept of substance abuse as a symptom of an under-lying emotional disorder.
The concepts of suicide, self-destructive behavior, and sub-stance abuse.
Nonpharmacologic factors (e.g., set, setting, and placebo) ascontributing to the occurrence of an acute toxic (both positiveand negative toxicity) drug response.
The role of denial as a defense mechanism in the substanceabuser.
67
KNOWLEDGE IN SUBSTANCE ABUSE
Guidelines for Question Construction Ronald S. Krug, Ph.D.
The following commentary is a synopsis of generaldirections for constructing questions on given ma-terial over which students will be examined. Thefocus of this discussion will be directed toward ob-jective examinations such as multiple choice ques-dons, matching. and multiple true/ false items. Thepresentation will be organized around seven stepsas follows:
Organizational focus of item writingSpecifications buildingInitial item writing processReview process for itemsField test of itemsFinal editingAnalysis of performance
Organizational Focus of Item Writing
Before one begins to write questions, the purposefor which the items are to be used should be clearlyspecified. That is, are items to be written for certifi-cation that the individual is basically competent;are items oriented toward some external criterion(e.g., behavioral objectives); are items to ascertain aminimum performance level: or are items to assessgeneral mastery of a given content area fora givengroup of students? Any one focus may summarilyexclude writing items for another purpose. For in-stance, if a minimum performance level of each stu-dent is to be ascertained, then it is clear that a certainpercent of a group of items dealing with core issuesmust be answered correctly. However, if one simplywishes to ascertain how well a group of students wastaught givencontent material, then the items shouldbe writtent o equally represent all subsections of theteaching area.
Specifications Building
In order to insure the representative nature of itemsto the material presented, a two-dimensional con-tent grid should be prepared. The reader is referredto anexampie of the content grid in table 3. The ver-tic.al items outline the subsections of the materialpresented by content areas. The horizontal items
represent three general areas: the first being knowl-edge of basic terms and concepts; the second, un-derstanding the concepts and principles; and third,appropriate application of the principles and terms.It should be noted that some authors include atti-tude assessment as an additional column of the hor-izontal dimension; however, attitude assessment isa separate area unto itself and'always raises the spe-cific problem, "What is the correct attitude?"
With regard to the vertical items dealing with con-tent, the total test content (and therefore items builton content) should reinforce why an item is in-cluded. That is, do the test items focus on criticalpoints that all students should master? Should it bemandatory that the student pass the item? Is thecontent and test item less essential to certification orminimum performance level? Is the item simply a"filler" to bring the total item count to a givennumber?
Initial Item Writing Process
There are essentially three basic item types follow-ing national boards format which are used for ques-tion construction. These are one best answer, multi-ple true/ false, and matching. While other formatsare used (for example, simple true/ false questions),these three item types appear to have the best valid-ity and reliability over time.
In general, all questions should have file alterna-tives from which the student must select the one"best" response. With five good alternatives; theprobability of getting the correct answer by guessingis reduced to 20 percent (one out of five).
The one-best-answer type of question sets forth anincomplete statement or a question which can beanswered by one of five alternatives which follow it.Usually in writing instructions for the -one bestanswer (particularly in those disciplines where dif-ferent approaches or answers may be correct, butone action or answer is the best) the instructions foranswering those items indicate that perhaps none ofthe five responses are clearly incorrect; however,the student's task is to select the one which is mostcorrect.
63
69
AL,C01401. AND DRUG ABUSE IN MEDICAL, EDUCATION
t rue/ false format has the advantage of01111141M student's knOwledge aboin multiple
*AS of a.pirticularphenometion through the usenequesti oni.Typicaliy: there is a -question or in-
-*V tetii(nieritiwhiCh isifellowed by fourPossible..0411.4:bi.c, and 0)...-The student must read all
Ia`fpirneeiand' olah of them are true state-atitatind jiliiehaiffelse..Theri by using a particu-
S.;1011.'ith*:1-644itif items s /heseltetithe number 1 ifresiPonses a,
care correct; 2 ifa and c are -correct; 3 if b--are correct; 4 if.only d iscorrect; and S if all
re cOrreCtIt.shOuld.be noted that it is inappropri-o,OWihe:forrnat "all Of:the following are true.efint he multiple true 414 Girmat because it44'donble negative and Seriouslytonfuses the
e third format is the matching format. Typicallyn index Hit of items (no more than five) is given inCoolumn and then questions are asked aboutta which can be answered by selecting one of theilioisibk_ responses. The instructions should
..ach of. the following items may be usedce ino re than once, or not at all"; and, in fact thatoUld be the case.
eyliw -Procne fin Items
er-itimi hay, been written to cover a given con-enttriiLitheri ate consecutive;steps, through which_neiriiisi-ito in Order_to insure the item is a "good".
eiween.* initial, item writing and the first reviewcwriter,4a. time interval should elapse so the
101.0.41etiOce from the hem itself. ThismeitherAillideta increased objectivity abOut the
410.'.ik'ifeM.-teCOndly, with a time interval,r1:0iiikiiiii,j0( 647(i-wit-answer types; the item
ay,*reWrittaii frOm a complete-statement ques-teto anincoMPlete-Statement question, which isNallicloatrar.
feview mno0ankattaryour
initial item writ-4.-O0110agUeOan. review your items s/he can
uantl.y.:cietept obvious ,problems in questionshViiielfitiii-ireegO4Vested and have not seen a
m c011eagike may be able to moreeieitirlICeSiiiii.4ethar.nieardnifel data are beingexamined Ofyilethar,the,torrict.answer Whalegm _,, "*hoc riviai-aspects, most importantly, a col-
league can frequently helpyou understand Whethe. you are asking what you intended to ask.--
:-
After the author's review and hopefully a peer review, the items are assembled in one test. The test ata whole needs to be reviewed to ascertain that:thtstem of one question does not supply the answer tcanother question. Likewise it is important that anincorrect response to one question does not forcethe student to select an incorrect response on tub;sequent question.
To circumvent the problem of a student getting ananswer correct simply because the student knowsyour particular pattern of placing thecorrect answerin a given position (e.g., correct answer alivays inthe a orb alternative), a review of the test as a whole
r.should determine whethe there is a tenden0forthe test writer to select the first alternative as thecorrect response more frequently than s/ he ,,doesthe fifth. Assigning the position of correct alterna-tives by a random number table Is good insuranceagainst this common tendency.-
If one incorporates matching items into a test andthe list of queitions which are to be-matched withthe five index items is lengthy, it helps to alphabetizethe matching list so the student does not waste time, :hunting for a particular item or losing his/ her placeOnthe test booklet.
Perhaps the most important portion of threviewprocess for items is to review all items to eaten*that the alternatives are plausible. A Coin.mon errorthat item writers make is to use the alterna0i."111'..-of the above/none of the above." These alternativetare appropriate if they :plausible; however',-.1fthat alternative is simply a filler, then it is better tohave for plausible alternathies than to-insert thefiller simply to bring the number of choices to atotal of five. izext, many item.writers (even experkenced writers) will insert into one of the alternativesthe words "all," "none," "always," or "never." UsU-ally, if any of these wordsoccur in the item or in thealternatives, the student who Is test wise will, -
that alternative because few things:in the worldalways occur or never occur. Another commonproblem in test writing which occurs for all itemwriters is to "unconsciously" make a verbal IISSO'Cia'tion between the stem and correct.foil. Thai-Verbs(association may be in terms of the tense of a verb, anidentical word,Orother keys t o associating betweerthe stem and the correct alternative. Laitly; in the- -
nibelt alternative type question one avoide,,ttae.40posite.aiteinaiive since this really in-
creasesthe probability that the student can get the-eStionSeisirrplY..bygtiesting.
eOniiitencyis a mandatory aspect of. . .
ern:writint...11.afternatives for a given:questionbe-OfieqUal length. Item' authors frequently
...F1101Cligc9roe..ego4nvolved with the correct state -
ment -to :its being longer or selectively.
shorter the ineorreet alternatives. There is alsot erealitythattitith is more complex than fiction, re-
"auliing' in alternatives frequently beinglonger than alternatiVes. The test-wise studentktiOWS.this partiCular fault in test-item writers, and
. hive -.nOlother -data on which to base their.-....resp.onierthey.. an frequently gain scores they
don't .deterve by selecting that alternative which is4iii4a1Y-shorter -or longer than the others. Next,he:.alternativermust be consistent with the stem.
at icthey.M.U.st all be plurals, the same tense, andmilel
......, .
f all doses given in milligrams orubic,centimeters). Further, in terms of consistency,
alWitys _ use the proper names or theiminatt "tamer:in the alternatives, but not mix
nt..*e;'Onei:Shoultnot mix subject material such asaMeritates, and definitions (in other words use
hOMOgenecius sets); and One should use the similarWordiriiii:eaCh.Of the Regarding the'iiSt;.Paint;:the-teit-wise student Vows that if, -forinstance,: fOti rtings are giVen,by_t he it trade name,nt.Iilie.firti4giVen by the generic name, it is more
likelythat.the.generic name is the correct responsetliei than any Of the four trade names, The last
:;iitemainder..graMmaticil consistency to which theiteitiWriter.tritist attend is the appearance of nega-iVerinither-the stem or the alternatives; Double'e--tiVer'..'eitjier Within' an alternative or impliedetWein:the .Siern and an alternative should be
aVOidecl-tince negative- thinking is more complex
..... ..thinking..POsiti.ve And as a related point, if instem or "not" are to
.1. .be:tiseckitAs.:imp.ortant to underline and capitalize
theitilitce most test takers tend to select theone one which is most incorrect.
The final Point under the review process for items iso.reword lterns.to comply. with common rules for
writing testquestions. These.inehideiriot using text-oo........,orjeettire.-._quotes, the use of facts, not opin-
leiratilipinion-or -contrOVersiafilibel
. . . - .
:KNOWLEDDE IN SUBSTANCE -ABUSE
source); no sweeping generalizations ("in the-general case"); no guarded statenienti (Maybe, fre-quently); no relative words ("significant;" '"com-**m only"); only one idea per statement sinee one part
of the statement may be correct and the of herinior-rect; a test for main points and, not trivia (particiilaxly where a single insignificant word is the-key tothe correct answer); the alternatives as short 'as .
possible; and, most importantly, the removal of allirrelevant statements and words from the questions..
Field Test of Items
After a test has been assembled, it is important tohave some type of peer review (colleagues; research
assistant, student test cOmmittee, a previous test-ing) to insure that everyoneInd particularly the
expertsagrees on the correct answer. in many'disciplines in the field of medicine, there is contro-versy over what hi the most correct proced ute;and
at least a large percentage of experts need to agree'
that a particular alfernative is the best.inswer.Next, the directions for the test need to, be clear. Donot hesitate to make directions as specific as possi
ble so as to not leave anything to the student's con-
jecture. An eiaminationofthe-student's knowledge. -,,
and skills is not thrapPrnpriateplace for projective;testing. A local field. iest also will circumvent theproblem ofthe miskeying of an item. Nothing is
more frustrating to students than to spend a great
deal of time answering inked' and then-finding thlit
on their feedback they have-missed that'item when.in fact they got incorrect. Frequently they cailintel-lectually excuse such a mistake;but..eniotionalky-they are set up to challenge all further tests.-ieldtesting also helps to establish the amount softime.,required to complete the examination. -Typicallyone should alldw between '4$ and 90 seconds per- .
item. Most test constructors dO not wash- to Make
their tests a test of speed, but rather a test of knowl-edge acquisition and skill.
Final Editing
'One should review the test in the light of all of theabove steps to correct difficulties (rim the peer rel..view, the local field test, or from previous adtration of the examination._Additionallyin Or;
-final editing thrlength.of thetest tan.beyrriectilit,-:
ii_touncithat more time is necessary to complete theentire liathination than was initially estimated.
els of Performance
terthetest has bein administered to a group of-stiiiiiiiisfOr:the first time, it is important to look at
hem to ascertain if it has per-for#iedns was predicted or expected. That is, eachalternative for each item should be .analyzed toOlitain'thi:"PeiCent of students who responded toeael:LatteinatiVe.:- This assists in -.examination oftaiiiiMgeffeetiVeheas as well as design of your test.
e following are some common distributions ofitem performance and possible interpretations.
examinees select one particularalieniitive and; i percent select another alternativewith tickle selecting the Other three, then in fact the
tie:1460d minimum performance1eValiteitiiiif that it is something that all studentsappeèr to he able: to accomplish; however, it is auseless iterato discriminate between students' isle-
leVeta.of Partormance:.lt may be also.* very-.:a_ile,question that anyone could answer using
"ininionsense." Cheek the (tern out for possible_"giveaways -in the other alterliatiVes.
06 percent e the students seleceone alternative'ari'd SO percent Select a second alternative, but again
.
none of the students select any of the other,three;2,:,then most likely the two alternatives selected at the:._
50-percent rate may reprise ent contrOveraitilStaikeion the item, or Soniething about the kith-Style ofwriting may have confused students.
:
If 25 percent selected the correct answer and 275,percent Ideated another 'alternative with 'mine" .3selecting the _other three, then probably either 11.7teaching failure has occurred or perhaps there wasincorrect keying of the item. Reevaluate the item'before using it again: .
. .
If the distribution is: 5.5 percent of the stUdente gel,,the correct answer, 25 percent get a secondalterna-tive, 15 percent set another alternative, 3 percentget another alternative, and 2 percent get the lastalternative, this and similar items, if used in *.col-'lective test, will generate a normal, distribution inthe overall performance of a group of students.Such-itern performance allows for maximum . .
crimination between differentialperformance Wen.of the persons taking the examination. -
. .If all five alternatives are selected by an equal percentage of students (that is, 26 percent, 20 percent,20-percent, 20 percent, 20 percent) than bvlouslythere is a failure inteaching or Item constructiOn:such.that studentaaresuessingestact answer is. The Rein needs either to be dilated Orrewritten to get around the difficulties being experienced by the students in responding to the
NalionalBoardProlect David Smith, M.D.
. . _...---- .:--,.-:The task force on evaluation of the National Insti-:J:- tine on Drug Abuse proposed a collaborative proj-
-CO with the NationalBoard of Medical'Examinerstithe fall of 1975; The national board, in responsetOlienitaily perceived need for medical graduates
id eiiiiinstrate:their-preParednese to assume re..... .._
sponsibility for patient care under supervision'asthey enter graduate medical education, had begundevelopment of an appropriatacomPrehensiveiluai7.ifyiligromination, It was readily recognizable thatthe goal of the task force to'cicyelop,imi,y181uitOe,.1715
curricular interest coin-
KNOWLEDGE IN SUBSTANCE ABUSE
edWithosignificant segment of the program ofeoationaFbeard. The two groups joined theiri0.044init:;.ohtained support from the National
ntiiiiitenn-Oriii Abuse for a project that began ine.suMMer:Of1976.--
-ipropased-model for a prototype comprehensiveualifying examination had been previously evolved
an advisory" committee that had formulated .objectivet-a4reviewed various studies of compe.,tency Criteria.. A:compilation of such criteria had
in tieveloPed -and -a concept and strategy for the:test design proposed. The latter emphasized evalua-tion on behaVioral roles more than the customaryemphasis .00knOwledge of subject content.
..ProtitypeOXam.... [nation was envisioned as being:composed of several modules built around different
ririCipn)::.PrOblein situations in medical science.uiteObvioUtly,Ithe area of drug and alcohol abuse
contains problem situations that are suitable topicsOr. such modules.
e`taslc force and the national board decided toevellip'..teVeral,. such test - modules . in their area ofiiiiCidar:*000..interest. Each module is based
orttl**4ical.: problem- situation 'concerned withabite,Or both, and contains some
1:0:stiti180'scOreiiiiitits...A test booklet containingmodule 'constitutes an examination of rea.
iiiiiie164.11,..ribiiiitlhours, capable of producingnumber that should be
tit i'.o.ftitiall'grOiiPt if not for individual students.elliediciii.nrcibleMliitOations generally have the
history, but they can be built aroundOthel..plObiCnis'in health care delivery, researchSitiiiiiiiinSiOrthOlabOratory. The problem situation
1401i4ociirfri*Oillita bate for theihodule; h ow-,May,.he'..M6r/ified expanded at various
points as the module is developed..
JItittelid of emphasis onparticular subject contents,as been customary in so many knowledgebased
examinations Afted:in the medical curriculum, the..-VolOotiOn.sciught...in these test modules is of sixrOles .eXpeeted :Of the young physician as he entersgra tiate.'medicatedUCation. These roles are
J..c011ection of.data; . . .
iliiiiiitit of data and definition ofproblems; , .
id046CM deciding. upon and idopting ap-ropnatephytician intervention;
Judgment and skill in implementing treatmentby appropriate surgical, counseling, and other:_techniques;
- Acceptance of responsibility for health main.'tenance; and .Professional attitudes appropriate to individual -=-
and community roles and responsibilities as a'_. physician.
The efficiency with which subscores relevant toeach of these roles can be developed is yet to bedetermined.
The domain of medical competence to be Sampled_in evaluating the six fundamental roles has been de-scribed in three dimensions: underlying conceptsand vocabulary, medical problems, and competencycomponents.. _ _ .
A graphic representation of this concept of the total'domain to be evaluated is reprelentedn figure 1.Underlying concepts are presented in terms of thecustomary basic science subjects. The dimensionOfmedical problems is described in categorical termsrather than in the usual clinical subject tides, It isreadily recognized that this list is not totally cornprehensive and is subject to expansion or mOdifica-don as individual tests are developed.
. .
The competency components diminsion contains_titles that resemble those of the performance roles
- -for-which evaluation is sought, but..they.. differ-. -;,slightly in their subjeCt, in that they are to be applied'to the qualities of an individual test kern rather thinthe performance of the examinee iti.thosituatiOninto which s/he is being projected. This list is alioless than fully comprehensive:
It is proposed that for most events in the data bate,i.e., a particular observation or measurement, testitems can be constructed, that are rooted in in ..underlying concept, are relevant to the medicalproblem of which the observation P.1 part,-and canbe directed* to reveal some aspect of a competencycomponent. It is to be recognized that noonedotabase is expected to be 'sufficient for completi.ek-,
. ploration of all possible components of the three..dimensions of the.domain of medical competence;but by the utilization of several data_ bases and in = -.genoity in recognizing situations within "the'rlata%base, as well at the development of nuitiefouiscor.intiferit, it is anticipated hat"iiitilificant-fcoreS4117'7be reached.
nc":-'.:,
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
FIGURE 1
0$00).-00
ciot
NCYC
04,0,41.0
e ap0Cific 'eXimination modules are constructed'about a MediCal or social problem concerned with&it or alcohol abuse. The features of the problem.represented as a 'data base and test items that
miii4.00 knowledge and problem solving abilitieswll;be utilised to-derive performance scores. FOurSUCii:ratidiiies are Underainstruction. EaCh moduleconstitutes in itselfan examination capable of yield
-ins content score Combinations of.. °modules will yield composite Acores and subscores010."*004.0rittaiiiernles.
presently 'up-der construction,'Fr4tr7,-tfirst a situation acute toxic- .
15:41.* and several drags. The second -is
. . .
related particularly to heroin abuse and methadonemanagement, the third is based on id oleinentd ruabuse with attendant ,coinplications in the familsituation; and the fourth is based upen the Matoof a Orlon. With. chronic alcoholism aii(Ormedical complications. .
Each test begins with a definition of theprOblemsituation, the site and envirorimeminteWhickthephysician examinee is to project_himiliertielf; andspecific cieicription of the mediciiiable. This is accompanied by such inforntatiOntilist of normal laborat OrY values and
. more precisely define thebackground of (tie.c.ent...medical problem developed in the testiOdu.- -
KNOWLEDGE IN SUBSTANCE ABUSE
-is ..followed by one or more :patient managementprobleMs derived from the general information ofthe tati base.
!oh patient management problem consists of aninitial paragraph.containing introductory informs--
44thOut the patient and two or more problems,each:Coritaining a:series of scorable options. TheintrodUction may be lengthy or brief, dependingupOnthe evaluation objectivesand usually contains
-at- least. some initial- historical information anditysiaal- findings. Each problem that follows is
usually introduced by another short paragraph that-Mak: incorporate additional information:and pa r-icidarly..defines the setting of that problem. Each
Option is a choice for the examinee to make regard-ing some form of information to be Sought, an
,f-.iniellifilatiori;-or a -prOpoSal for action. -When anexaminee chooses one of the options s/he indi-cates this by developing an area next to the optionprinted in invisible ink. Additional information re-garding the option is thereby given the examinee.
er Projects John B. Griffin, M.D.
ecure Item Pool
The- work of the task force on evaluation has re-stilted in production of a large question pool nownumbering nearly 400 items. These questions have
n.diyided into two parts. One part constitutes asecUre;item pool. The questions in this group have
en kept confidential and are made available onlynder- restricted conditions which maintain theirorifidOiltiality: At the present time the secure itemobl hasheen used primarily as a source for yearly
s4htnisSiOn of quelltions to the National Board ofMedical EXaMinerS. These questions are distrib-titi4to appropriate test committees for consideration
lieissit*incltiiiciri in partil or II of the Nationaltxaminers'exaMinat ion for.med-
stiidetits.The national board, of co urse, cannot
Following the patient management problems; themodule contains groups of multiple;choiie ques-tions. These are :arranged in relation to- topics -orevents within the general data base.or the stem ofthe patient management problem: They are essenti-ally knowledge-baled items in the customary Multi- ._ple-choice formatsand may explore rather remotely .
suggested correlates as well as specific conceptsunderlying decisionmaking in the problem situa-tion..lt is in this area that the opportunity is pre-sented to evaluate the examinee's knowledge ofunderlying concepts and basic sciences. .
. When the four different tests or modules are allavailable, it is proposed that they might be utilized..as pretests and posttests in a given institution andcould form the basis for some comparative studiesbetween programs at different institutions, the per-formance of certain groups of students or individu-als, and student performance in the area of drugand alcohol abuse as compared to performance inother areas of the medical curriculum.
guarantee inclusion of these questions. However, theregular submission of carefully' constructed ques-tions can reasonably be expected over the years toresult in inclusion of a larger number of substanceabuse questions than has been the case in the past'on the national board examinations.
Nonsecure Item Pool
The remainder of the items in the question pool (atthe present time about half of the items are in--eluded in the secure pool and about half are in:thenonsecure pool) constitutes the nonsecure itempool. These questions are used.to provide assistanceto educators in the field of, substance abuse
-teaching-programs.. For exiinpie,: career, leicherilhave frequently requested questions which could be
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
use to test general knowledge of their students.Items' from the nonsecure pool can also be used tocreate pretest and posttest questions for specificcourses In discussing: the best way to utilize thensotiSeenreitems, the-evaluation task force finallysdecided.upon the construction of a general releaseexamination. The questions in the nottsecure itempool are not 'regarded as confidential because theyhavelieen released for use in situations over whichthe eValuation task force does not -have directcontrol:
eneral Release Examination. .
The first general release examination (GR-77) wasprepared in the following manner: Two hundred
:questions were administered to a group of 21 careerteachers in substance abuse. Two nonmedical per-s6fis also took theexamination to serve as controlsThus, the career teacher group was used to establish7oireitilivaliditY of the examination. An item analysiswas done on the responses of the career teachers
the controls to be certain that there was generalagreement about 'correct answers to the questionsiini.tO:sPOt questions that were overly difficult' or
--,too easy: The reer teachers and controls were alsoMike narrative comments about the ques-
-: as they completed the examination. Thesei-.comments were used to eliminate ambiguity and toimprove the construction of the test questIons.
rorn -.the original 200 questions, 150 questionswere found to perform satisfactorily. One hundredOtt heie Items were selected to constitute the general
_'..ieleaSeeituninatiOn for 1977.The subject areas and'abusabLeiubstances covered in the test were plotted
on -the grid discussed earlier to insure adequatedistribution of items.
This examination was then released to 30 of thecareer teachers who wished to use it in theirgrams. The career teachers accepted the examina-lion with the understanding that they would reportto the evaluation task force the ways in which thequestions were used, the scores made by their stu-
dents on the test questions, and the items whichwere found most useful. The career teachers weregiven the option of using the examination in itsentirety or parts of it as theysaw fit.'In addition, the".,-general release examination has been made avail:able to non-career-teacher schools. .
If the responses from the schools utilizing thisexamination indicate sufficient usefulness, con-:sideration will be given to the preparation of such ageneral release examination on a regular basii, per-haps releasing a new examination annually oreveryother year.
Knowledge Portion of STAK
The remaining 50 items which werefound accept-able for use after the validation studies described -.above have been submitted to the committee whichis preparing the StandardizedTest of Attitudes andKnowledge. This test is described in detail, in thepreceding chapter. The 50 items selected *will beused for the knowledge portion, which will exist in along form constituting 50 items, and shorter formconstituting 25 items. The form used will-dependupon the amount,of time available for administra-tion of the Standardized" Test of Attitudes and '-Knowledge.
At this point it appears that the existenceof a -
carefully constructed pool of examination items insubstance abuse has many uses. However, defini-tiVe data concerning the usefulness of these hemsshould be available with completion of the nationalboard project and responses from schools using thegeneral release examination.
With the use of the first general release examinationand the national board project; no obligations havebeen placed upon those using the items except thatthey cooperate in the evaluation procedures. It isanticipated, however, that schools utilizing the itempool in the future will be asked to contribute to theitem pool each time a general release examination isprepared.
70 75
KNOWLEDGE IN SUBSTANCE ABUSE
libation of Test Instruments bycators In Substance Abuse
Kenneth S. Russell, Ed.D.
e.evaluation- committee hopes to continue the-/L..-.-,-,..development and refinement of the general item
for questions Su bstanceabuse. Any medicaleducator who would like to contribute to this devel-
. opment:and:hive -access to the -resulting pool ofquestions may"do.so by contributing five or more
5 original test items to the general item pool. In re-: tOrn,.the eilicator's name will be placed on a list
and.he-or."She will subsequently receive the currentissue: of the general release examination in sub-
._ _stance abuse.
The procedure for contribUiing test items is simplytend such items to John B. Griffin, M.D., Direc-
;for's-- Medical Student Training, Woodruff MedicalEmory ..University School of Medicine,
yiPepartment of Psychiatry, Atlanta, Ga. 30322.
,individuals who use items from the general release.-:. examination will be asked to report the wayi. in
WhichtheY.,have used the examination and to reportthe responses of their students Usti item analysis of
:777titiiderit-ittpdrists it available, this should be sent. If
_noi, copies of the student answer sheets can be sent.
. .... .
1.**
71
to Dr. Pokorny and an item analysis can be done.Contact: Alex Pokorny, M.D., Program Codirec-tor, Career Teacher Training Center, Baylor College.of Medicine, Texas Medical Center; 1200 Mour-sund, Houston, Tex. 7702$ ..
This information will be used to further refine anddevelop the test items. Participation and coopera-tion in the further development of the general itempool is both welcomed and encouraged by the eval-uation committee.
AUTHORS
Alex D. Pokorny is affiliated with the Baylor Col-lege of Medicine; Ronald S. Krug, with the Univer-sity of Oklahoma Health Sciences Center; David- --
Smith, with the National Board of Medical Exa-miners, John B. Griffin, with the EmorY.UniversitySchool of Medicine; and Kenneth & Russells withthe University of Arizona Medical Center.
Proceedings of the
ional Conference onical Education in
I and Drug Abuseovember 5-6, 1977
Washington, D.C.
-
Opening Remarks
Marc Galanter, M.D.
On behalf of the membership of the Association for Medical Education and Research inSubstance Abuse (AMERSA) and the career teacher program, I would like to extend avery warm welcome to our invited guests. It is a pleasure to come together on this occa-sion, the National Conference on Medical Education in Alcohol and Drug Abuse.
We have an important challenge before us. By drawing together on this occasion, we can- have a major impact on American medical education. Within this room are enough
.
-medical faculty; if we continue to work together, to move the issue of substance abuseinto the position of prominence it must have in the education of our physicians.
_ -.,--: I will now make some brief remarks on the history of our group. These are directed in
particular to the majority of the 200 participants in this conference who are not Yet Mem--: ber's-Of our association, and to the majority of our own membership, who have been asso-ciated with us fok a. relatively short time
We began with the Career Teacher Program in Alcohol and Drug Abuse. That program ..
': -' ViiisPlanned.C011abOratively by a number of leading figures in American substance abusetreatment, education and researCh. Planning was conducted at the National Institute of
Tkiiial.::8616;beginnint in 1969, where the decision had been -made. that America:- needed to rethink how it was educating its physicians to deal with the problems of
. addictivedisease.
The separate alcohol and drug Institutes were established shortly thereafter, and thecareer teacher program was undertaken as one of the first and the largest joint programsof the two Institutes. It served as a valuable bridge between the Institutes in the area of
. .tramong. This collaboration assured that efforts would not be duplicated and that thethrust of the undertaking would not be muted by overlapping activities.
- The program was similar in structure to a number of others in different medical special-..". ties. Perhaps the one most familiar is the career teacher program in psychiatry, which,
over the Course of a few decades, made an important contribution in establishingpsychi7,atric"education as part of the basic medical curriculum throughout the United States.
.I.t Was also decided to establish career teichinttraining centers, and Downstate Medi-cal
- _
. enter and Baylor College were as theSites. These served as a.focui-. . _
foorientibgnew Career teachers, kir disseMinatinginfOrmation, and,for cocirditiating edY-. . .
.
-.catidnal.meetings fOiihe.caieer.teachers and others involved in the program In fact,neither Government representatives, career:" teaChers, ,nor training centet..,.periOrineli. :.!..;
were eritireli:cliai'iliout where this endeavor lead:. ..
As it turned Out, this served as an interesting lesson in the social PiichOlOgy ofprganiza-tions, The "young recruits" were bit dissatisfied with what their_ 'seniors", had set up for, then-1-.00e were unrest and complaints and insistence that the career teachers ihoUldbe able to plan' their own program better than would others. At that time and at ensuing_
meetings, a steering committee was elected for the career teacher group. The group,meeting three times a year, began to develop a sense of organization. Given theconflict '
: between our goals and the structure of established medical curriculum, we might havepromoted iivOlition. Instead, we have become somewhat institutionalized, with the
LOP
hope of constructively influencing established medical institutions. Webegan to Strugglefor-the opportunity to establisfran-organizatiOnal.basithlt wuld havibedibitity. . .
D'! 7
As we meet today, that evolution does_not seem surprising, but many of us here have metbefore under less auspicious 'circumstances, I recall well one meeting 'at GeorgetownMedical School. We were not surethere was a clear hope for our organized group. After,other Options for support foi this national conference gave outat that time, we decidedto organize ourselves, to do our own work, to rely on our own resources, and to dependon theelliancesthat we had develoPed over time, The Association for Medical Educationand Research in Substance AbuseAMERSA--was now an independent organization.
. .
There has been an excellent rapport and a shared sense of commitment arnongmembersof the group:It:has certainly been a pleasure-to serve as the first president of theorganization:It became possible over this time to go ahead and plan curriculums,continuing education programs, examination programs, a national conference, and.other elaborate and carefully developed work. I think we did things that larger, istab.....lished organizations had not yet done.
W,edecided to limit membership to the career teachers for the first year. Our plan Was.tohold &nation al, conference which would allow for development of the identity of theorganization and to provide a reason why others who share our interests might join We
.invited physicians and allied professionals teaching in medical schools.Now, we ask youto join us, and anticipate a positiveresponsebecainewe've all stood very Isolated in our:medical centers. On a local level, unfortunately, our colleagues have expressed limited1,1 interest in education in substance abuse. I imaginethit Many ofus have felt this way. Now
17- we may join together.
AUTHOR
Marc Galanter is affiliated with the Albert Einstein College of Medicine.
76 7 9
note Address
rneSt Noble, M.D., Ph.D.
Thelate.Billy Rose, one of the world's greatestshowmen; once said, "Never invest your money-in.anYthing that eats or needs repainting." Billy;never:took his own advice, and we have onlylikenhaltof it In the case of the career teachersialcdhol and drug abuse.
.onettieless, you have been a very good invest-ment: In ttie past 5 years that the career teacher.fogiar6 has existed, 42 of you have been work
..1tiOur Nation's' medical schools; represent.g ,th, ird.ofthese important institutions.
:recent-survey-based .on-about:.half- of theseplacer ents- Indicates.that about 10,000 medical
physicians, and 10,000 other_tii-alth..relatedworkers,have been influenced byn.yopigefforts. They,- In turn, can be-expected Co
ive.,.:better:direCt alcohol_and drug services toarte:itirnbers'of patients and Indirect service to
countless more patients throUgh their catalytic16110:Once on other health* professionals.
any of YOubecaine career teacher's, ttie.er of curriculum hours devoted to alcohol
:and.drygibuse.education averaged a mere 12.4..T,O0,#_;thataverage approaches 74 hours, That's asixfol0:inCrease. Allsof this is being achieved at....±-arinual= per placement Cost of approximately.-
,e.:SOlarY of an assistant_ professor in a medicalol.
ant congratulate you on these achieve=and on the high 'quality and impressive
umber, of teaChing materials ybu-have pro-.044dTheysir!k alribute tCtyour abilities and
tosli.Will,boCkfintl*Ways to get these mate-rintol e-hands:of -others-who:will
good use of them. There is no doubt in mythat the career teacher. program Is working andworking well. I can testify personally to the valueof such programsbe_causeAke you, I began myinterest_in alcoholism through a Federal grantoffered by the National Instituteof MentalHealth; the research career development prosgram.. it has turned into a' lifelontcOmmitmentfor me. Perhaps you too %Will findle lifelongcommitment, and perhaps one Of You.will-be atthis lectern someday.
I have said you are agOod InVeitmentd* purPoie'noW is to YeZ caneven better investment. Let me begin.bY,..tpoting:::another impresario.of the 'enteitainrriOnt...WOrlthe lateSamuel Goldwyn. He'onceja.makes the star; God gives them the talentilt"SUto the -.producer to-recognize that.:,01.06t.:aridevelop ft." When.Yciu return to yourand your community, I Warn you to be.the-prci...:,:.ducers. I warn you to recognize the:'talents:inyour university and your .corrirrainity-and-di...velop in those talents a 'sensitivity and involve.ment in the alcohol and drug abuse problemswe all face. Opportunities for doing this, He allaround, You can offer to give a Coriti6uirig edu?
. _ cation course_on alcohol and drug :abuse for.your local medical sOdiety. You can-contact yourpublic health officer to discuss how you can help .
him to develop a prevention or early interven=.ton -program in alcohol and drugsabuse..Per-
._ haps you have in-Old friend in a nearby rriediCarschool 'where little is being done *.to Piovide'_learning experiencei in alcohol and-drug abuse.Why not contact -that old friend and ie.e if.you.can interest him -or- her in 'getting .soiriettillifstarted there..
_ - .-
7.17,777,-
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
.yoU are looking for other ideas you have onlyto call-and -chat with the person who serves asyou r State alcoholism or drug abuse authority. Aregular liaison. with that person could generatesome poWerful ideas. That person has control of
-.the purse strings in ybur State and can helOut-into action any ideas you have for bringing alco-hol and drug concerns into the mainstream. You
= are-a Unique intellectual reiource to these au-thorities. With similar goals in mind, the two ofyou need to get together.
Someof.you have been doing the very things 1have been suggesting, and more power to you.Others may pick up on these ideas as well and, ifso, more power to you, too. I know you cannotdo everything. There are only so many hours in aday. It is much more important that you impartyour own style and talents to the mission.
Some Of you will influence the field throughresearch that attracts the interest and admirationOf your colleagues. Others of you will becomegood at- curriculum development, Still otherswill express their talents by helping to organizeheir community's health care systems.
..
t;whativer you are doing, you will do it evenetter whenyou reach out into new directions.Y6i)..ere 660d at research, you become better
irissearch for having spent some time in theIii,oing- laboratory of your community. Giving a:Coiltli(uing education course for practicing phy-SICiens may spark some teaching ideas that you`caii'pUt to use with your medical students.
Ithink of your work as an effort to shape andinfluence two dimensions of time: the presentand the future. The program is embodied inyour work with our existing health care net-
'Work. The future is embodied in your work withmedical students, tomorrow's practitioners. ByinflUincing both of these dimensions you dou-ble the value of the American people's invest -ment in you:, Within your universities you have
to extend the awareness of alco-.0..F14.c.ir46:prObleMs into other departmentsdiscipline's:- internal medicine, anesthesiol-
,..CerdiolOgY,OhCology, gynecology, nursing,...s.6041:*Oritt Quite a few. here are psychia-
tristfrAsill$YChlatrist;11m"proad of thataMe ifiiii*We ill know that the psychiatrist is not- .:
often the first person to see a patient withdrinking problem. If we are to reach the large.mass of people who need help; we have to gethe primary.care practitioners and other special-ists involved, too.
.
That is why I'm so pleased that a group of youhave been the moving force in getting questionsabout alcohol and drugs included on the uall=lying examination of the National Board of Med;ical Examiners. This legitimizes alcohol, and drugproblems in the world of medicine. It puts everymedical school and medical student on. noticethat the treatment of persons with alcohol anddrug problems is now an integral part of what anaspiring physician must know in order to prac-tice medicine.
I regard the inclusion of these questions on theboard examination as a landmark step in bring- :-ins alcohol and drug treatment into the mainstream of medical practice. And I'm very proud -'Indeed of the career teachers. who made- ithappen.
I am also pleased with the career teachers whodeveloped a manual, on alcohol.and,drugs for._emergency room physicians. It is important ehatthese physicians know how to manage detoxifi,
-cation: it lieqUallY important that they learn torecognize alcohol and 'drugs as the cause of.many an accident, physical abuse, or cither vio-lent injury that they treat. Unless patients with.these injuries are referred for treatment of theiralcoholism or drug problem, many will be return-ing at a later date -with injuries, and some willnever return, because they will die ,in,somefuture mishap, fire, or crime of violence.I am glad to know that some of you have beengoing on grand rounds. That is an excellentopportunity to sensitize your colleagues to theproblems and complications they will encoun-ter among patients with alcohol or drug condk.dons.
I am also delighted that the-career teachers atthe Mount Sinai Medical Center in New YorkandoNorthwestern University in Chicago havebeen instrumental in establishing occupationalalcoholism programs. at -thigt_schooki'f,Thelke___..progairis`are highly cost effective.the Rochester Institute of Technology began a*Prograii.
78.
CONIERENCE PROCEEDINGS
50. In a single year, 51 employees were helped,saVing,the Institute 5363,000. These Savings wereaChieVed in IPWer employee- turnover, fewerMe.CHOI...claims. and workman's compensation,
abienteeism; and a drop in life insurance!death benefits. Offhand, I do not know of any-thingthat would give your mission more favora-ble-attention than 0 you were to promote such acoit.-.effective program at your own university.
fiefOre I conclude, I want to give you my view ofwhat is happening at the National Institute onAlcohol Abuse and Alcoholism and In whatdirection we are headed. The most immediate
:item-Of interest is a national plan for combatingalcoholism that we initially drafted at the Insti-cute. It is now circulating among the Nation'salcoholism-concerned community for reaction.A dominant theme of that plan is what we call"Operation Mainstream," which proposes toget alCoholism out of the closet and into the
. limelight of concern and commitment amongthe public, the social and health care fields, thehealth insurance industry, government, and thebusiness and industrial communities. Alcoholic.perions are still stigmatized and neglected. Fam-illes- hide-them; -employers will not give themjobs; .health insurers do not cover alcoholics;courts_cOnsign_thern to the drunk. tank; andhospitals refuse to confront alcoholism as amajor health problem that needs their attention.
-Alio, as you know, many practicing physicianssimply avoid handling them as patients. We haveto change all this. Our national plan lists goalsthat. will help to bring about this change. Webelieve these goals are within t he Nation's reachwithin the next 5 years, and I want to cite them.
1. We want to see 60 percent coverage ofhealth care costs for alcoholism treatment
. by third-party insurance payers. We alsowant to see that at least half the insured pop-
_ ulation .has broadly based coverage for al-cohollsrn services. When this goal is reached,
-.there will be an economic incentive to treatalcOhOliclieriOns, rat her than the economicdisincentive there is now.
.** .2. We :want ,to,see-ocCupational alcoholism
-.programs, exPanded to take in half of ,theWork' force, There are powerful emotional
and economic reasons why peopleWill k,cept treatment that has been suggeitell-a
'their workplace, and we want to take. _ (age of those reasons. We 'also kn,*:.t.
employed persons accept treatment iOon_and that early treatment -significantly .inv=::proves their prospects for rehabilitation.
3. We want to double the Nation's researcKcapability in alcOholism and focui-on fledings that can be directly applied to preven,tion and treatment. We need to understandmuch more about the etiology of alCoh011im,the social factors and trends that affethexesand age groups. We need to developphar«macologic agents useful in treatment. We-need a good mass screening test. Not least ofall, we need to understand the biological,-metabolic, and life situation risk factories-sociated with alcoholism. Somewhere downthe line we want to be where the cardiovas-cular field is now, and be able to help phy-sicians and people assess their own risks withalcohol use based on age, sex,..personal.,.habits, emotions, life role,- and the corninan:..situation factors they encounter....
4. We want to reduce the heavyldrinkingthat_characterizes 11 percent of the Nation's:adult population by bringing into treatment;existing problem drinkers and by helPing"others avoid ever reaching this stageln, a.
sense, this fourth goal is a measure of What-ever success we achieve with the firit three.One measure of success of this gOal isNation's annual per capita consumptiOn.,.of:ethanol. It is now 2.7 gallons. Heavy. drinkera account for a large share of that:- Onesurvey we commissioned shows that front 10to 15 percent of the adult population drinks65 to 80 percent of the beverage alcohol.
Now I would like to tell-you some of the things: -_-we are doing and plan to do in order to achieve ;'-the four goals that I have cited. Seven yeais ago,only a handful of people wereworkIng-to. getemployers to establish occuptionalikoholiprograms. Today, FederallundS have-iiikatiek1,125 occupational program consultantsand the number.Of occupational_: programs `hatincreasedfrom 300isiabOUi 1,000; Wproviding grant
79
ALCOHOL, AND DRUG ABUSE IN MEDICAL EDUCATION
organizations so that they can develop ways toestablish joint labor-management approachesto look into the establishment of more suchprograms. Once an employee is brought toaccept treatment through a program, the financ-ing mechanism must be in place. Currently weface the problem that health insurers do notoffer broadly based coverage for alcoholismservices. One reason for this is that they lack theactuarial experience for setting rates. They alsolack the marketing know-how. That is why theNational Institute is trying to develop a modelbenefit package for alcoholism services amonghealth insurers.
Prepaid health plans and HMO's need to bebrought into the alcoholism picture. We havefunded a project by the Rhode Island GroupHealth Association which has succeeded in get-ting 150 employers to establish occupationalalcohol programs. They t hen refer their employ-ees to the group's medical facility for treatment.Thus far, 750 employees a year are being referredfor treatment, and 70 percent of them are stay-ing abstinent afterward.
We also want to look into the question of theavailability of alcohol. For one thing we want tolook at the alcoholic beverage control laws ofthe States. When President Roosevelt signed thebill repealing prohibition he said: "I ask thewhole hearted cooperation of all our citizens tothe end that this return of Individual freedomshall not be accompanied by the repugnantconditions that obtained prior to the adoptionof the 18th Amendment, and those that haveexisted since its adoption ... I trust in the goodsense of the American people that they wouldnot bring upon themselves the curse of exces-sive use of intoxicating liquors to the detrimentof health, morals, and social integrity . . . Theobjective wesee through a national policy is theeducation of every citizen toward a greatertemperance throughout the nation."
The ABC laws of the States were an effort toabide with the spirit of F.D.R.'s words. No onecan say what results these laws have achieved.Our guess is that the present ABC laws are notmeeting the purposes for which they wereintended in any coherent way. We want to study
these laws and perhaps come up with somerecommendations for change.
We also want to look at the price of beveragealcohol. It appears to be inexpensive today inrelation to disposable income. We want to findout whether alcohol consumption is related tochange in price, and if it is, at what point, amongwhich groups in the population, and to whatpurpose. Some people call this approach neopro-hibitionist, whatever that means. One thing Ican tell youit does not mean that we are tryingto bring the Nation around to another experi-ment with prohibition. However, we do have torecognize that the magnitude of our problemswith alcohol may well be related to its availabil-ity. We would be remiss in our responsibilitywere we to ignore this possibility.
We are going to look at alcohol both from theconsumption perspective and from the humanattitude perspective, and when our studies comeup with useful findings we are going to tell theNation what those findings are and let the chipsfall where they may.
That is a brief look at what we are doing at theNational Institute. I wanted to give you the fla-vor of our thinking and some idea of our plans.You career teachers figure largely In those plans.We view the physician as a central figure in thechain we are trying to build through the goals of"Operation Mainstream." Only when physiciansacquire the know-how and accept the commit-ment to treat alcoholic persons will we begincutting sizably into the problem. You teachersare the key to that. You are few in number, butpowerful in your influence. You are t he cat alystsof change and you occupy the high ground ofthe medical school for exerting that change.Your students look up to you. That means youare influencing tomorrow's medical practice.Your associates in medicine respect and listen toyou in the collegial spirt of the profession.Through them you are also infitiencing today'smedical practice. As you influence both thesegroups you also influence the entire health carefield and its allied professions. And as physiciansput alcohol and drug problems into mainstreammedical practice, they in turn will influence puib-lic attitudes as well.
CONFERENCE PROCEEDINGS
Your work is like a pebble cast in a pond. Theripples travel outward in all directions and theyreach distant shores. Your impact is beyondmeasure. Keep up the excellent work you havebeen doing. Do not lose that fine edge of dedi-
cation that brought you to this work, and remem-ber always that we are depending on you.
AUTHOR
Ernest Noble is affiliated with the National Insti-tute on Alcohol Abuse and Alcoholism.
Si
847. r:71L .r:
Debating the Issues I:The Role of the Physicianin Substance AbuseTreatment
Moderator: Frank Seixas, M.D.
This conference is like a deja vu phenomenon for me. Nine years ago I convened aconference called Professional Training in Alcoholism. The representatives of 30 medicalschools who arrived were full of hope and ideas and enthusiasm. Fragments of teachingon alcoholism could be fot:nd in many courses, but they were not integrated, and themedical students themselves felt on graduation they knew little of how to handle analcoholic.
How excited we were when the career teachers program was established. It meant thatparticipating schools would have a designated faculty member around whom instructionon alcoholism and drug addiction could center. The first six career teachers were pre-sented with copies of the proceedings of Professional Training in Alcoholism, publishedby the New York Academy of Sciences. Subsequent meetings of the NCA NationalAlcoholism Forum have provided a platform for the presentation of pedagogical papersby career teachers. indeed, Dr. Kissin and I independently proposed regular meetings ofthe career teachers with the object of sharing techniques and building an "espirit decorps." It was a pleasure for me to represent NCA in preparing one such meetingdevoted to alcoholism with the National institute on Alcohol Abuse and Alcoholism. TheNCA Journal, Alcoholism: Clinkat and Experimental Research, contains a regular column,
8
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
"With the Career Teachers," which Joel Solomon writes where we try to keep peopleinformed on this group and AMERSA,
The exercise this morning, "The Role of the Physician in Substance Abuse Treatment," isan important one. I think the two sides are clear: Should there be a physician specialist inalcoholism and drug abuse? Alternatively, should we concentrate on making everyphysician as able as we can to deal with alcoholic patients in his practice?
There are subsidiary questions in this debate. Do we really consider alcoholism and drugabuse diseases? Must we consider behavior alone? Should we relegate behavior to theposition of a symptom reflecting preexisting or induced changes in neurobiologicatfunctioning? Should the physician remain in the background entireiy, merely referringto and consulting with lay counselors on demand?
Unless the debate brings in an unexpected, unassailable argument proving that eitherthe education of specialistsor the instruction of all physicians is futile, one might hope toremain firmly devoted to both thrusts. We can expect each to be buttressed with newincisive arguments.
84 86
Should All Physicians Be Trained ToTreat Alcohol and Drug Abuse?
in Favor: Benjamin Kissin, M.D.
The position I will take in this discussion hasbeen developed more completely in chapter 2,volume S, of The Biology of Alcoholism, whichHenri Beg leiter and I edited. It's called "TheMedical Management of the Alcoholic Patient."The question to be addressed is: Should all phy-sicians be trained to treat alcohol and drugabuse?
We speak of substance abuse treatment asthough it were a single operational phenom-enon which it obviously is not. I'd like to dividethe issue into several categories. First of all, wecan categorize it into alcoholism and addictionto other drugs. Drug addiction, in turn, can bedivided into opiate addiction, a species untoitself, and other types of drug dependencies toso-called soft drugs and hallucinogens. It's clearthat the role of the physician in the treatment ofalcoholism may be different than in the treat-ment of other drug addictions, particularly nar-cotic addiction. The very fact that narcotic addic-tion is illegal and has very strict legal sanctionsattached to its treatment immediately makes therole of the physician in the treatment of narcoticaddiction quite different from that in alcoholism.
Similarly, it's equally Important to separatestagesof acute intoxication and acute withdrawal syn-dromes in both alcoholism and drug addictionfrom long-term rehabilitation. These withdrawalphenomena may take a week, sometimes 2, oreven as tong as 3 weeks to be treated. The long-term rehabilitation of the alcoholic and the drugaddict should never be discussed in terms of less
than years. The role of the physician in the acutephases, i.e., In the diagnosis and treatment ofacute episodes of alcoholism and drug addiction,is obviously different from his role in the longsterm rehabilitation of the chronic alcoholicor drug-addicted individual.
All physicians must have some familiarity with atleast certain aspects of alcoholism and drug ad-diction. Every physician, whether a psychiatrist,internist, surgeon, ophthalmologist, or obste-trician, should know about the diagnosis and treat-ment of the acute withdrawal syndromes in alcoholism or drug addiction because inevitably, atsome point in his career, he is going to haveexperience with it. If he does not know how torecognize it, whether in the pregnant woman oran infant in heroin withdrawal, he will not evenbegin to know how to deal with the problem.
It is perfectly apparent that every physician musthave a basic knowledge of alcohol and drug de-pendence upon which adequate diagnosis canbe made. The necessity for educating medicalstudents in this fundamental aspect is evidentand, from my point of view, hardly open to arguemerit. More significant questions are: Whoshould the physician treat and who should henot treat; should the average phytiCian, the psy-chiatrist, the internist, the family physician inprivate practice undertake the long-term reha-bilitation of chronic alcoholics and chronicdrug-dependent Individuals?
As I have indicated, every physician must havethe ability to diagnose and treat the acute sole
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
sodes. if, for example, he unsuspectingly deliversan infant who goes into withdrawal, or if he isdoing surgery and the patient is in withdrawal, inaddition to calling in a consultant, he should alsohave some concept of the complications of with-drawal and of the approach to treating thosecomplications. Therefore, it appears to be be-yond disputation that every physician shouldknow the basic principles of how to recognizeand treat the acute syndromes in alcoholism anddrug dependence.
Concerningthe major question of whether phy-sicians, particularly the primary practitioners inprivate practice, should undertake the long-term rehabilitation of chronic alcoholics andchronically drug-addicted patients, I feel that allphysicians in three categoriesinternists, familyphysicians, and psychiatriitsshould be ableand willing to undertake such treatment in cer-tain kinds of alcoholic and certain kinds of otherdrug-dependent individuals. Certainly not thetreatment of narcotic addicts. That is legally toocomplicated for physicians to undertake in theirown offices. But I do believe that for certaintypes of alcoholics, the physician can be a veryimportant resource. The 85,000 private phy-sicians who fall into these three categoriesinternists, psychiatrists, and family physiciansrepresent one of the greatest and best resourcesfor treating alcoholics that we have Even now,while this whole question is in dispute, these85,000 physicians in private practice are alreadytreating alcoholics, a fact that is not well known.
Three studies have been done in this area: oneby Bailey, another by Jones and Helridge, andthe third by Giasscote. Without going into thedetails, they found that the average physician inthese three categories has under treatment atany given time. about three alcoholics. If youmultiply three times 85,000, you come up with afigure of about 260,000, of whom about 75 per-cent are in active treatment. So, there are pres-ently about 200,000 alcoholics in the UnitedStates who are being treated by family physicians,internists, and psychiatrists. Whether they arebeing treated well or not is another issue, butthey are being treated. This figure of 200,000compares favorably with the total number ofpatients that are being treated in AA. Leach and
86
Norris indicate that in the year 1970 there wereabout 200,000 people with alcohol problems inthe United States actively in AA. That 200,000figure comes up again as an estimate of the num-ber of patients in all federally funded, State, andlocally funded alcoholism programs.
Unquestionably, there is a certain amount ofredundancy there and I'm sure that about halfthe patients in the alcoholism programs are alsoin AA. Hence, there are probably about 500,000patients who are in active treatment in theUnited States. and physicians constitute a sig-nificant portion of those providing treatment.
What, then, is the history of success of physicianstreating alcoholics, as opposed to psychiatristsand social workers? Interestingly enough, therehas only been one study that even tries to com-pare these three groups on their overall effec-tiveness. In that comparison, the internists did _.
best, the social workers did next best, and thepsychiatrists did most poorly. That conclusionwas reached by Gerard and Saenger in theirexcellent study on outpatient clinics. Apparently,in the structured situation of an alcoholism pro-gram, medical physicians can be effective pri-mary therapists. That may or may not be the casein private practice, but certainly they are actingas primary therapists there also.
Under these circumstances, it seems that as lead-ers in this field we have a responsibility to teachthose physicians in private practice how theycan treat patients most effectively. if there hasbeen any fault in this area, I don't believe thefault has been with the private physicians, forthey have undertaken to treat these patients. Ithink the fault rather has been with us. We havenever told them what types of patients _dryought to work with and what to do with thesepatients. We have never told them how theyshould treat certain patients and how theyshouldn't attempt to treat others.
The criteria for diagnosis of alcoholism whichFrank Seixas' group at the National Council onAlcoholism has developed has begun to showphysicians how to diagnose alcoholism. I thinkwe now have to go a step further. Now that theyknow how to diagnose alcoholics, we have to setup criteria on how they can differentiate be-
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tween different types of alcoholics so they maylearn which alcoholics can be treated success-fully in the private office and which alcoholicscannot. For example, the family physician or in-ternist who tries to treat the patient with severepsychopathology is obviously heading fortrouble, both for himself and the patient. Butthis is only one example. it seems to me thatthere has to be an attempt to set up criteria toadequately select and appropriately treat pa.tients In private practice.
We do attempt to do that in The Medical Man-agement of the Alcoholic Patient," and we comeup with some very rough recommendations. Thefamily physician and internist can do very wellwith the socially stable patient with relativelyminor psychopathology, particularly if he knowsthe family well. He knows the husband and wifeand can talk to them. He can suggest, for exam-ple, the use of Antabuse to the husband. If thehusband is really willing to go along with it, wehave found that having the husband take theAntabuse in the presence of the wife at dinner ismutually supportive.
I treated many such patients as part of a largepractice in internal medicine. I did not specializein alcoholism per se, but I always had 20 or 30patients who did very well with no psychother-apy and no social supports other than bringingin the families and talking to them for a halfhour. I never did an actual statistical account,but 70 to 80 percent of the patients did absolutelyfine. These were socially stable people, verymuch like the group that Griffith Edwards re-cently reported on. His paper suggests that theymight have done just as well if they had notcome to my office at all, but the point is that thepatient who is socially stable, whose alcoholismhas not yet disrupted his family life or employ-ment, can with relatively minor support from thephysician, be greatly helped by the family phy-sician or internist. On the other hand, the morepsychiatrically ill patient can certainly be treatedIn the office of the psychiatrist.
In my experience, the patient whose life hasalready been disrupted, whose family is brokenup, who does not have these external resources,and who has lost his job, does not do well under
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the auspices of a family physician but does bet-ter in a public program.
In all of this, I am not for one moment suggestingthat this become an alternative to AA. CertainlyAA has been the major source of improvementand rehabilitation for alcoholics throughout theworld. But this type of treatment can be seen asan adjunct to AA or if you prefer, AA as anadjunct to this form of treatment. In summary, Ifeel that the family physician, the internist, andthe psychiatrist can do a great deal in the long-term treatment of the alcoholic.
I also think this is fine for certain types of drugaddiction. For example, the 16-year-old kidwho's getting very high on marijuana can oftenbe brought to the family physician who can talkto him like a Dutch uncle and often get him tostraighten out. This is particularly true where thedrug use isn't accompanied by severe psychopa-thology. If it is, then the patient should be re-ferred to a psychiatrist.
I think that most of us are in pretty close agree-ment on this issue and the question appears tobe not so much should private physicians treatalcoholics, but rather, under what circumstancesand which private physicians. Dr. Pattison men-tions the socioeconomic factors. I think it'strue that the family physician, internist, or psy-chiatrist are all very busy and if they get an alco-holic who is socially disrupted and can't pay hisbills, this turns out to be very frustrating. It's acruel and harsh thing to say but the private phy-sician is probably better off not treating that typeof patient, because he is not going to be success.ful with that type of patient and it will just lowerhis tolerance for other alcoholic patients. Thistype of patient needs an extended psychosocialsupport system. The private physician does nothave these resources available, and the alco-holism treatment program does. So, for the sakeof the physician and the patient as well, thephysicianshould not undertake treatment of thesocially disrupted patient.
The question of delineating which physicianshould treat what kind of patient with an alco-holism or drug problem and under what circum-stances is a critical one. Certain physicians relatebest to certain kinds of patients.
8.9.
ALCOHOL AND DRUG ABUSE tN MEDICAL EDLC Al ION
Not all physicians are psychologically or sociallyoriented. However, in some cases, z. totally bio-logically oriented physician can be very effectivewith a field-dependent, externally oriented pa-tient. With such a patient, who usually has tre-mendous respect for the physician, the physi-cian may say. "I find that your liver is down 6inches." This has a great impact on this type ofperson. What I used to do with that type ofpatient was to take a pen and mark a line at theliver edge. Each month I showed him how theliver was becoming progressively smaller withabstinence.
However, this approach can also be dangerous ifyou have a self-destructive patient who is reallyout to kill himself with alcoholism. To tell a de-pressed, self-destructive alcoholic that his heavydrinking is killing him, is to say just what he wants tohear. So he continues to drink more heavily. When
Against: E. Mansell Pattison, M.D.
Alcoholism is said to be the No. 3 health prob-lem in the United States. Alcoholism is wellknown in the medical community, it has beenwell discussed, and most physicians see alcohol-ics all the time. It is no great news if you go to anymedical school and talk with medical studentsorfaculty and state that alcoholism is a medicalproblem. They will all agree. We don't have toargue the point that alcoholism is a major healthconcern.
Ardent proponents of the so-called disease con-cept of alcoholism propagandize that physiciansshould have a primary role in the treatment ofalcoholism, on the other hand, skeptics point tothe traditional disinterest and noninvolvementof the medical profession, dysfunctional involve-ment, and mismanagement by the medical pro-fession as evidence that physicians have a pe-
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you find yourself dealing with that kind of patient.the family physician or internist should quickly gethim to a psychiatrist. The first things to recognizeare your own limitations, which kinds of patientsyou can do well with, and those for which yourtreatment could be disastrous.
Finally, I think the idea of having physicians treatthe socially stable patient with an intact familymay be the most effective means of primary andsecondary prevention of alcoholism. There wecan pick up alcoholism in its earliest stages, sincethe private physician is usually the first profes-sional to really see the alcoholic. By the timepa-tients come to alcoholism treatment programsthey are far along the road. The alcoholic withminor problems is the ideal kind of patient forthe gamily physician to treat. The physician cancontribute in a major way to the early detectionand early treatment of the early alcoholic.
ripheral or even a nuisance role. I suggest thatboth extremist positions are untenable. (1)
In point of fact, physicians have a great deal todo with alcoholism. But the question is, how arethey involved? What are they doing with alco-holics and what is the result? The problem weface is that physicians do not see people com-ing in saying. "Dear doctor, cure me of my alco-holism." Rather, patients usually present them-selves in one of three disguised situations.
First, they present themselves with complaints ofcomplications of alcohol abuse. These includehepatic, cardiac, hematologic, and- neurologiccomplaints. These people do not consciously linktheir medical illness with their alcohol use andabuse. As a matter of fact, their problem is verymuch like many other patients who have psy-
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chophysiological illnesses in which one has todo a job of reinterpretation. We do not trainphysicians adequately, or even at all, how to linkin the patient's mind the complications they suf-fer with the antecedent causes, e.g., alcohol use.
The second group presents with the con-sequences of alcoholism, such as fractures, headtrauma. and burns. These patients may recog-nize that their medical problems are directlytied to their drinking but are not likely to com-plain of their alcoholism.
The third group recognizes their alcoholism andmay seek medical help for it but disguise theirsituation with a somatic complaint such as insomnia,nervousness, and anxiety. These patients will say,"Yes, I went to my physician hoping he would catchme at it, but I tricked him." We have a very nicegame in which physicians learn h w to trick alco-holics, and the alcoholics are there trying tofigure out how to trick their doctor. When the Jigis up and the trick is exposed, both are deflatedbecause it is no fun playing the game anymoreand no treatment occurs.
We have to look beyond just the fact that doc-tors see alcoholics, for of course they do. Theymay even correctly identify an alcoholic. It is notthat doctors are ignorant or do not see what is infront of them. The critical issue is what do theydo after having made their medical observations.
In medical school education we often ignore theprofound impact on young physicians who areexposed to stereotyped alcoholics. Medical stu-dents say, "Oh, yes, we know about drunks."They are referring to those people who are so-cially unacceptable, who are disheveled, andwho show up in the emergency room. We donot show them any other people who have al-cohol problems. Therefore, their initial andoften only formal definition of the alcoholic is interms of skid-row stereotypes. This is dysfunc-tional because the first exposure is a permanentimprint.
Alcoholics do show up in the caseload of com-munity physicians. The Jones and Helrich study(2) of 3,376 internists found that only 3 percentsaw no alcoholics, whereas 16 percent saw over20 alcoholics per month. Interestingly, half ofthese alcoholics were women. It is estimated
that 70 percent of physicians in private practicesee at least 10 alcoholics a month (3). Dunn andClay (4) state that 10 percent of physician inter-nist caseload outpatients are alcoholics. The samestudy indicates that only 40 percent of generalhospital staff referred alcoholics for treatment.Sixty-five percent of the referring staff weregeneral physicians; 21 percent, internists.Among the nonreferrers, 61 percent were sur-geons. So we need to examine the influence ofspecialty practice on the physician's manage-ment of the identified alcoholics.
In an unpublished study, I reviewed the actualcaseloads of 25 physicians in the community andfound that identified alcoholics are quite willingto accept referral. Among 25 physicians' case-loads of alcoholics, the most that any 1 alcoholicwas seen was for 3 visits, and in no instance wasany referral for continuing treatment made bythe physicians (5).
If we look at hospital statistics, the problem iseven more amazing. The incidence of hospital-ized patients who can be identified as havingmoderate to severe alcoholism ranges from 27 to60 percent of general hospital populations. Bar-cha et al. (6) found the highest incidence ofalcoholism is associated with respiratory, cardiac,endocrine, and neurologic illness. McCusker etal. (7) state that alcoholism was found in 100percent of patients with seizures, 67 percent ofthose with respiratory disease, 53 percent withliver disease, and 25 percent with cardiovasculardisease. Eighty percent of individuals with tuber-culosis in one study were alcoholics. Among theaging, the prevalence of alcoholic symptoms is35 per 1,000on routine examination. Gaitz and Baer(8) found 44 alcoholics per 100 in a psychiatricscreening study.
Of all alcoholics in the hospital that were identi-fied in McCusker's study (7), only 55 percent hadbeen diagnosed by the attending physicians atadmission; at discharge, only 45 percent main-tained the diagnosis. Apparently. alcoholics getundiagnosed very rapidly! A study by Dorschand Talley (9) showed that of identified alcohol-ics in an emergency service, only 16 percent werereferred for alcoholism treatment, and 20 per-cent were hospitalized; thus, 64 percent wereidentifieddiagnosed, but received no referral.
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ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
What happens with outpatient services? TheJones and Fielrich study (2) reported that treat-ment given to alcoholics by 90 percent of theinternists reviewed was the prescription of drugsand nothing further; 83 percent of the physi-cians in the sample prescribed tranquilizers andantipsychotic drugs. The questions raised bysuch treatment include: Is it efficacious? Does itreinforce symptoms? Does it produce mixed ad-dictions? Does it produce crossed addictions?Does it produce alternate addictions?
It is obvious that physicians are treating alcohol-ics all over the place all the time. The question isnot how do we teach physicians how to treatalcoholicsthat is not the problem. The realquestion is to change how physicians are treat-ing alcoholics. The issue for education about alco-holism in medical school and residencies is howto uneducate or disabuse physicians of fallaciousand perhaps destructive treatment methods aswell as to educate for appropriate and effica-cious management of the alcoholic.
Medical education and alcohol education as dis-cussed here tend to focus primarily on the med-ical student. Yet the major socialization of physi-cians and the carving out of attitudes, values,and patterns of practice occur during the resi-dency period, not in medical school. The realchallenge for us in medical education is how tointroduce alcohol and drug abuse educationinto the residency portion of medical education.
Medical education is still organ and disease ori-ented, whereas alcoholism (not the conse-quences or complications of alcoholism) is a per-son problem. But medical education is not per-son oriented. Most physicians today know how todeal with fetal drug syndromes, fetal alcoholsyndromes, etc., because these are organ prob-lems. Alcoholics who enter into the medical sys-tem get reasonably decent treatment for theirorgan pathology. They get no treatment for theiralcoholism, which is a person problem, any morethan any other medical patient with a personproblem in medicine gets good treatment; thepatient with chronic back pain, the patient withchronic heart trouble, the patient with chronicprostatitis, the patient who has a prosthesis, thehemiplegic, the person with a stroke. These arechronic syndromes that involve multiple agen-
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cies of care. These are the people who don't getgood treatment in our system, and the alcoholicis not alone in that. Everybody who has chroniccomplicated, rnultisystem, multimodality sortsof medical syndrome problems gets poor treat-ment in our medical system. We are fooling our-selves if we attempt to solve the problem ofperson-oriented treatment in alcoholism with-out regard to the lack of a person-oriented med-ical education.
There are very few modell of continuity of carethat are whole person and family oriented Inmedical education. I call your attention toGeorge Reader's paper (10) in which he reviewsthe failure of comprehensive medical care edu-cation .in the United States of the last 30 years.Reader points out that we know how to educatestudents in comprehensive health care, we knowhow to educate stu dents in total person care, weknow how to educate medical students in con-tinuity care, except we can't do it unless we havea medical delivery system which is comprehen-sive, person oriented and continuity oriented.These do not exist in most of our medical schoolcomplexes.
The system of delivery Is critical, We tend toignore the influence of the location of the phy-sician and the type of delivery system in whichhe practices. The study by Gerard and Saenger(11) shows that internists were effective workingin an alcoholism treatment delivery system. TheKissin et al. study, "Social and Psychological Fac-tors in the Treatment of Chronic Alcoholism,"(12) showed that in the sample from the alcohol-Ism delivery system there was a subgroup ofalcohOlics who were positive responders to phy-sicians. These people score high on social desira-bility; have high, stable ego defenses, are notinternally oriented, but are externally oriented,and they respond well to authority figures. Theseare the people who do respond If you wag yourfinger and say, "Don't you know you're killingyourself? You know you are going to die if youdon't stop drinking." These people will do wellwhether 'n a private system, in the public sys-tem, or in an alcoholism system.
What is the problem with the private practi-tioner, the 8S,000t hat Kissin mentions? We havenot studied en important sociological parameter
CONFERENCE PROCEEDINGS
of the patient-doctor interaction, because oneof the critical factors that influences how theprivate physician acts with the alcoholic is the"getting and keeping" syndrome: "How do I getpatients, and once 1 have them, how do I keepthem?" What are the sociological parametersthat influence how the private physician inter-acts in such a way that will not threaten thepatient/physician relationship? We often teachphysicians how to interact with patients in waysthat may arouse patient resentment, patient hos-tility, patient suspicion, patient frustration. Nowonder we then run up against brick walls, be-cause we are not really up against just the per-sonal attitude of the private physician, but alsoagainst a sociological, political, and economicreality. The economics of keeping patients be-comes more important than provision of appro-priate treatment. We have not addressed thatissue.
Rather than recommend that physicians treat allalcoholics or treat no alcoholics, we ought totalk about what kind of physicians can treatwhich alcoholics in which contexts. Certain phy-sicians who are interested can learn to treat alco-holism effectively. Some physicians will not wishto treat alcoholics, but can learn how to refersuch patients for alcoholism treatment. And allphysicians should learn acute management ofalcoholics presenting with medical syndromes.
I want to make three additional comments. First,I am not sanguine about referral to psychiatrists.Just 2 days ago, a friend of mine called up fromanother city and asked, "Will you see an alco-holic patient of mine for evaluation?" I said, "Ican't; I'm here for just a brief visit." "Well, whois a good psychiatrist in my city?" In this city ofabout 500,000, it turns out that the 1 psychiatristwho is an alcohol expert is not taking any morepatients. Another psychiatrist is out of townevery other week and prescribes nothing buttranquilizers to all the alcoholics who are re-ferred to him. There were no other psychiatristsI could identify in that city of 500,000 who wouldaccept alcoholics for treatment. Those of us whoare psychiatrists have some housekeeping to do.
My second comment is in regard to education.Often, the only exposure to alcoholism treat-ment that medical students and house staff re-
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ceive is an AA pitch. The problem is that thereare often people who belong to AA who comein and give a very strong ideological antimedi-cine, antitherapeutic, antiestablishment pitch,and the medical students are turned off. Theysay. "Well, if that's the treatment for alcoholism,fine; let them go treat the drunks; I don't wantto have a thing to do with it."
Third, if we're going to talk about referral, wewill have to teach medical students and residentshow to use community resources. A study byElaine Cumming, (13) entitled Systems of SocialRegulation, describes utilization of communityhealth agency resources in the city of Rochester.She found that private physicians never usedpublic resources or agencies for their privatepatients, even when their patients needed theseservices. In other words, what we have is an en-capsulation of the private health delivery systemand the public health delivery system, and thetwain do not meet. I find it effective to takemedical students around to every different typeof alcoholism agency in the community, to talkwith the administrators and the treatment per-sonnel in order to expose them to the existenceand function of relevant social agencies (14, 15).
One final thing about self-attitudes. A favoriteanecdote relates to the diagnosis of alcoholism.A salesman comes in and says, "My wife says I'mdrinking too much." The doctor asks, "Well,how much are you drinking?" and he says, "Acouple of martinis for lunch and two or threeafter supper." The doctor says, "That's not analcoholism problem, I drink twice as many asthat myself!" We know that alcoholism is a majorproblem in the medical profession.'We knowthat physicians have lots of unexamined atti-tudes about their own drinking. A debateis al-ways raised with students when they discuss thedefinition of normal and abnormal alcohol use.How can we expect physicians, who have notlooked at their own attitudes, to be able to assistthe alcoholic client? (16)
In sum, we have focused our medical educa-tional effort primarily on medical students andhave ignored resident education. We have giveninsufficient attention to the specialty contextswithin which medical treatment of alcoholicsoccurs. We have focused more on the general
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
aspects of alcoholism and neglected the practi-cal issue of physician management. We havefrequently overlooked education about utiliza-tion of community resources. And we need toemphasize appropriate definitions of normaland abnormal alcohol use.
AUTHORS
frank Seixas is affiliated with the National Coun-cil on Alcoholism; Benjamin Kissin, with theState University of New YorkDownstate Med-ical Center; and E. Mansell Pattison, with theUniversity of California at Irvine.
REFERENCES
'1. Chafetz, M.E. Management of alcoholism in medicalpractice. Medical Clinics of North America, 61:797-809,1977.
2. tones, R.W., and Helrich, A.R. Treatment of alcoholismby physicians in private practice. Quarterly Journal ofStudies of Alcohol, 33:117 - 131,1972.
3. Rat hod, N.H. An enquiry into general practitioner'sopinions about alcoholism. British Journal of Addiction,62 :103 - 111,1967.
4. Dunn, J.H., and Clay, M.L. Physicians look at a generalhospital alcoholism service. Quart erly)ournal of Studieson Alcohol, 32:162-167, 1971.
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S. Pattison, E.M. Rehabilitation of the chronic alcoholic.In: Kissin, B.. and Begleiter, H., eds. Biology of Alco-holism. Vol. 3. Clinical Pathology. New York: PlenumPress, 1974.
6. Barcha, R.; Stewart, M.A.; and Guze, S.B. The prev-alence of alcoholism among generarhospital ward pa-tients.American journalof Psychiatry,125:681-684,1968.
7, McCusker, J.; Cherubin, C.f.; and Zimberg, S. Prev-alence of alcoholism in a general municipal hospitalpopulation. New York State Medkaljournal, 71:751-756,1971.
8. Gaitz, C.M., and Baer, P.E. Characteristics of elderly pa-tients with alcoholism. Archives of General Psychiatry,24 :372 - 378,1971.
9. Dorsch, G., and Talley, R. R espouses to alcoholics by t hehelping professions in Denver: a three-year follow-upstudy. Quarterly Journal of Studies on Alcohol, 34:165-172, 19T3.
10. Reader, G.G., and Soave, R. Comprehensive care re-visited. Health and Society, 54:391-414, 1976.
11. Gerard, DI., and Saenger, G. Out-Patient Treatment ofAlcoholism. Toronto: University of Toronto Press, 1966.
12. Kissin, B.; Platz, A.; and Su, W.H. Social and psycholog-ical factors in the treatment of chronic alcoholism.journal of Psychiatric Research, 8;13-27, 1970.
13. Cumming, E. Systems of Social Regulation. New York:Atherton, 1968.
14. Cumming, E.A conceptual approach to alcoholism treat-ment goals. Addictive Behaviors, 1:177- 192,1976.
15. Cumming, I Ten years of change in alcoholism treat-ment and delivery systems. American journal of Psychi-atry, 134:261-266, 1977.
16, Cumming, E.; Sobell, M.B.; and Sobell, LC, EmergingConcepts of Alcohol Dependence. New York: Springer,1977.
.9 4
Debating the Issues 2:Physicians' Use of Alcohol andDrugs: Implications forMedical Education
Moderator: Sidney Cohen, M.D.
l am not going to make any introductory remarks because I want to give as much time aspossible to the speakers. We have a fascinating topic: "Has Medical Education FocusedToo Much on the Adverse Consequences of the Nonmedical Use of PsychoactiveAgents?" Some of us may say, "What else can we do besides focus on this; this is themedical model." Still, we have to be open to the possibility of alternatives, and we aregoing to hear an alternative presentation.
I do hope we develop an adversary position between the two contestants. I don't want tosee blood on the carpet, but anything short of that will be all right. I think that we learnbest under conditions of stress.
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Has Medical Education FocusedToo Much on the Adverse Conse-quences of the Nonmedical Useof Psychoactive Agents?
In Favor: Norman Zinberg, M.D.
This is a subject dear to my heart. Potentially, itrepresents ideas which are central to medicine,and to what extent medicine should encompassa certain amount of social psychology versus a"hard, computerized" science. I do not thinkthat medicine need be that kind of dichotomy,and I think part of the reason that it seems adichotomy is that so often it is presented in veryextreme ways.
It seems to me that most physicians really dostruggle toward some kind of balance. Most ofmy professional life has been devoted to teach-ing nonpsychiatric medicine, and it has longbeen my feeling that one must not try to turn agood internist or a good surgeon into a bad psy-chiatrist. Rather, we should help them to thinkthrough what would make them good internists,e.g., how they could use their knowledge as in-ternists to be socially and psychologically aware.
In no area of medicine is the teaching limitedsolely to illness. We always try to establish a base-line when we think about pathology. We knowthe difference between what is "usual," "nor-mative," "moderate," or whatever word oneuses, and what really represents the disease. Butthat notion has been avoided in the area of drugusage.
.., For the doctor to be able to discuss these things= : with a patient one way or another, he must be
771.-n:":
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taught about the differences between "normal"and "abusive" drug usage. In medical schools,we must teach addiction, alcoholism, and toxicresponses to all kinds of substances. That is abso-lutely essential, and I am not suggesting for asecond that that teaching should be abandoned.But in no other area of medicine do we teachonly the pathology without indicating the base-line from which that pathology springs. So Iwould not accept the argument that we do nothave enough curriculum time to discuss "nor-mative" drug usage. I don't think that time is theissue; the issue is the point of view from whichpeople think about these things.
As an example, I recently consulted on an earlyversion of the new Diagnostic and Statistica!Manual (DSM-Ill) of the American PsychiatricAssociation. It treats alcohol and other drugsvery differently. For instance, its definition ofbaseline alcohol use was 10 drinks over a4 -hourperiod producing no effect. That is an enormousamount of whisky; the definition suggests thenotion that one must drink a lot of alcohol be-fore behavior is labeled as psychiatric illness(which is what the diagnostic manual is about).
The definition for "marijuana abuse" was"twice a week for a month." Cocaine was fourtimes in a 3-month period. I tried to explain tothe authors of DSM-I II that a very fair percentage
96,7*
ALL n IUL Nt) DRit, 1,6(.!.i to s.tt OR. Erit A,110\
of the populatio, . ald have -psychiatric dis-eases." using thes,...,,finitions.
They said that I was concerned with the false pos-itives, with those people who would be labeled"il!" who were not ill, while the authors wereconcerned with the fake negatives. They wereconcerned with the psychiatrist who would missdrug abuse when it was there. And they werewilling to go too far, so to speAk , in order toavoid those false negatives.
It has been my experience that with drugs (otherthan alcohol) their concern was absolutely ridic-ulous. The physicians of my acquaintance, andthe people I've taught with. are scared to deathof drugs: Their tendency to find false positives isenormous. The a that physicians would missfalse negatives in this area struck me as veryunusual, If physicians know that a patient uses adrug, their tendency to think that the patientmight be in trouble with this drug is quick andsharp and very direct: physicians terrified ofdrugs! I feel that rather strongly
I oppose the notion that there is no normative.or relatively normative, drug use. Consider mari-juana for example. To use President Carter's fig-ures of August 2. 1977, 45 million people wereusing marijuana with some regularity in theUnited States. And the further point was madethat most of these people use it very occasion-allysomething like once or twice a week.Fewer than 1 percent use marijuana daily. So thisis moderate. relatively controlled use. But somephysicians do not know this, have a lot troublelearning this. and have not really taken this intoaccount. When they see patients who use thisdrug. they tend to get very frightened about it.
Recently I looked at medical school courses witha panel of teachers. There was nothing but pa-thology in any of the curriculums presented.There was nothing that showed a baseline fromwhich to differentiate pathological from difficultexperiences.
Physicians are faced with patients who ask themquestions. Whether physicians like it or not, theirrole as givers of information around drugs andmedical conditions isvery important. A lot of pa-tients ask their doctors about things that thedoctors don't know very much about, where the
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information is sparse or filledvith mystification,misconceptions. and so on. Physicians find itvery hard to answer these questions and mayanswer by providing a lot of scare material. Forinstance. a recent patient of mine did what Ie. ou Id regard as moderate. controlled drinking.but he was concerned about the drinking of oneof his children. So he saw his doctor. The phy-sician showed him pictures of liver cirrhosis andesophageal varices, with a very terrifying lecturewhich created a lot of anxiety in the patient. Thatmade it much more difficult for the patient todeal with his teenage child's drinking than if hehad been talked with in a more reasonablefashion.
One of the things that i, as a psychiatrist, try tosay is that the really primitive superego is not thedoctor's friend. To beat people out of things, toscare them out of things, to tell them horrorstories, real! y doesn't work very well. In psychi-atric parlance. the doctor's friend is the ego.One may ask of people. "Well how does thisbehavior work for you? Is it scary or unpleasant?What's your impression of the general patternthat you and your friends follow?" One may askof patients, "Do you know anybody who is introuble with drugs, and how do people lookwhen they are in trouble?"
Thus, there are many ways of finding out easilyfrom patients, without the investment of a greatdeal of time. whether drug use works for themor against them. Quantity is only one of theissues, albeit an important one, because socialpatterns differ. What a Madison Avenue adver-tising executive is able to manage as"controlleduse" might be very different from that of a Bap-tist minister in a small town in Georgia.
The physician has to know all of this because itgives him the capacity to deal with patients rea-sonably, without terrifying them. And thisknowledge permits the physician to remain cred-ible. Fora doctor to talk with people about trou-ble, the doctor must know what trouble really is.I have seen physicians lose credibility in talkingto youngpeople and to their parents. Those phy-sicians bring what they've gotten from theirmedical education, which is only addiction,severe pathology, alcoholism, and so on, whichwean terrifying things, They know no normative
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CONFERENCE PROCEEDINGS
base, and they turn peopie off, Then when theyhave valid warnings to give, they are not listenedto. Thus, the physician's retention of credibilityis crucial,
Physicians also need the capacity to serve ascontrolling figures. By that I mean that prescrip-tions describe a reasonable way to use drugsunder certain conditions. in playing that role,physicians have been very important sources ofcontrol, particularly with psychoactive drugs andillicit substances.
I am very concerned about physicians losing thecapacity to act as a source of social sanctions, toprovide reasonable rules, regulations, and waysof thinking about things. If they lose that capac-ity, it will be a tremendous loss not only in theirrelationships with patients, but in the power (andI mean this in the best sense of the word) of themedical profession to operate as a brake in socialsituations. Control in drug usage is achieved bythe application of reasonable sanctions. Its notachieved by abstinence.
1 recently got together all the definitions of drugabuse that had been promulgated over the years:legal, medical. and so on (1. 2). I want to citethree of the medical definitions. American Med-ical Association, 1966: "Abuse refers to self-administration of these drugs without medicalsupervision" (3). American Psychiatric Associa-tion, 1972: "The term drug abuse [is) to apply to
Against: LeClair Bissell, M.D.
First off, I was promised that this does not haveto be a debate so i am allowed to agree with Dr.Zin berg on some of his points and not get into afight,
However, I'd like to start by making a point, per-haps at his expense, and that is that the title of
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the illegal nonmedical use of a limited numberof substances" (a). Another definition: "For thesake of clarity and at the risk of simplification.misuse will be viewed as a nonmedical use ofpsychoactive drugs" (5). Medical students aretaught that any nonmedical drug use is abuse.That is nonsense! Physicians who have beentaught that have not learned any base of reason-able drug-use behavior, nor what behavior canbe sanctioned, They haven't learned how differ-ent populations use different drugs. Physicianswill have to know more than that.
REFERENCES
1, zinberg. NI.; Harding. W.M.: and Apster, R. "What isdrug abuse?" Journal of Drug 'slues. 8:9-35,1978.
2. Zinberg,N.E.; Jacobson, R.C.: and Harding, W.M. "Socialsanctions and rituals as a basis of drug abuse prevention.-Arnertcartiournal of Drug and Alcohol Abuse. 2: 165 -782.1975,
3. American Medical Association. Committee on Alcohol-ism and Art-tiction and Council on Mental Health. "De-pendence on amphetarmnes and other stimulant drugs."Journal of the .American Medical As,ociation, 197:593-197, 1566.
4. Giasscote, R.M.: Sussex, l.N.: Jaffe, 1.11.; Bait, ;.; andBrill, t, The Treatment of Drug Abuse: Programs. Prob-lems. Propoch. )Aashingion. D,C.: Ioint Information-.er vice of the American Psychiatric Associaion and theNational Association for Mental Health, 1672.
5. Lipinski. E. "Motivation in drug misuse: some commentson agent. environment. host." Journal cif the AmericanMedical Association. 2191171-175,1972.
what wewere to talk about was"Physicians' Useof Alcohol and Drugs: Implications for MedicalEducation." Interesting, we haven't even men-tinned it.
The next part of it is, has medical educationfocused too much on the adverse effects of
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drugs? That is what I believe we are supposed toaddress within the context, perhaps. of our ow nuse of chemicals. Incidentally. that is one placewhere I do quibble. I do think that alcohol isa drug, and I get very uncomfortable when wetalk about drugs and alcohol as if they are differ-ent beasts. To me there are simply legal drugsand illegal drugs, or prescribed drugs and self-prescribed drugs.
As teachers facing a group of medical studentsand as teachers who have made certain deci-sions about the use or non use of drugs. t thinkwe have to ask. "What are we going to do?"
First, I think we art' our brothers' keepers. Howwe play that out, of course. is open to a tot ofpersonal choice. What I owe the medical stu-dent is as high a level of competence as 1 canpossibly deliverthat means accurate facts, notopinions.
I'm not going to decide what the individual stu-dent is going to do about his own drug use. He'sgoing to decide that And for a couple of youwho have been patients at Smithers and some ofyou who have heard us lecture there, you'veheard me say over and over again to the patient;there, "You're chairman of yourself, you're re-sponsible for your own addiction; I'm just a doc-tor; the only thing I can do is tell you the truth asbest I see it today."
Drugs have always been with us, but we're in aninteresting kind of phase with drugs these days. Ibelieve that medicine has changed from a con-cept of removing the bad from people to puttingin some type of good. Remember we used tobleed and purge people; we used to make themsweat and we put leaches on them, exorcisedthem, and got all those bad things out.
Instead of taking something out, row the doctor/patient transaction is frequently deemed incom-plete unless we give the patient something to fixhim up. to make him either mote energetic orless energetic.
An important area to discuss is physician pre-scribing practices for alcoholics. Most physiciansseem to try to avoid prescribing Antabuse forfear of killing someone. By the way, we haven'tseen any Antabuse/alcohol reaction causing
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death in many years. But ,,n't it interesting thatphysicians will prescribe minor tranquilizers orsoporifics to alcoholics even though the deathrate is infinitely higher? I think this gels to a kindof popularity issue.11 you giN. e Antabuse it meansthe patient has to stop drinking: but it you giveValium. Seconal. Tuinal. or Quaalude, nothinghas to change.
We have a number of pressures to resist, andone of these pressures is that it becomes increas-ingly difficult for any one of us to be unpopular.Unfortunately. dealing with medical students aswell as dealing with addicted patients, we fre-quently find ourselves in the position of havingto say "No." You can't accept buying temporarysolutions to human problems with chemicals.Unfortunately, I didn't stay for the him today.but my guess is that we saw once again whatKates had shown in 1974: Sleeping pills are effec-tive for 2 weeks but no more, and then there areproblems.
What about our own attitudes if we're going tohave to say "no" to a student or ask that studentto say "no" to a patient? I think it's pretty self-evident that if ,ve cannot say "no" to ourselvesabout drugs our voices are going to have a dif-ferent ring when we ask somebodyelse to do it. Ijust find it hard to ask somebody to do some-thing I cannot do or am not doing.
I was interested in what Dr. Noble said aboutprohibition. It fascinates me that "prohibition"has become such a terrible word. Frankly, I thinkthe worst thing about prohibition is that it can-not possibly work because it cannot be enforced.But it interests me that nobody seems to getupset over the idea of prohibiting cigarettes. Infact, the righteousness of some of my fellowex-smokers absolutely drives me bananas, Theydo not for 1 minute apologize for making lifemiserable for people who still smoke. Crowdingthem into the backs of airplanes, sealing themoff in various parts of restaurantsthese are thekinds of things that the alcoholism communitywould never do in a million years. We are bend-ing over backwards to have open bars at themeetings of national alcoholism organizationsfor fear that somebody might call us prohibition-ists. Fascinating!
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We are worried about prohibition, but we donot worry about prohibiting cigarettes. we areworried about prohibitive. but we are still notcoming to grips with prohibiting illegal drugs inspite of those kids still in jail in New York forsmoking a few joints or peddling a few ounces ormarijuana. Look at the furor that Dr, Noble raninto when he simply said he would like to lowerper-capita consumption as a goal for NIAAA.Suddenly, people forgot that rates of cirrhosishad fallen in Europe when per-capita alcoholconsumption went down. This might be a goodthing to do for the health of the Nation. Sud-denly there was a great squawk that this was"neoprohibitionist."We have a kind of de facto prohibition going onin New York State. People on welfare or receiv-ing SSI, if suspected of being alcoholic, areforced into treatment: an interesting require-ment to put on one segment of the population.Why is this not termed "neoprohibitionist"? Iwonder about some of the organizations whoare being so hypercritical of drinking practicesand accept a good deal of money from the dis-tilled-beverage industry.
We have all of these rather interesting debatesgoing on about should we or should we not setup a return to social drinking as the goal for thealcoholic, Should we also be trying to get smok-ers back to social smoxing or to get mainlinersback to a little Saturday night chippy habit? Whyis it just booze? Whv not social drug use orcontrolled drug use? Is it really that one sub-stance is legal and another is not? After all cig-arettes are perfectly legal. As a recovered aIco-holic.sober 24 years, I have been badgered,' donot know how many times, by people who weredetermined that I was going to go back to socialdrinking to prove one theory or another. Butsince I stopped smoking 3 years ago, virtuallynobody has been pushing me to have two cig-arettes after dinner. Why not? I doubt that I amgoing to develop emphysema or come downwith squamous cell carcinoma on two cigarettes.Cigarettes are not even going to alter my think-ing and judgment. I ought to be able to make anintelligent choice about cigarette No, 3 in a waythat I probably couldn't about drink No. 3, andyet there is no such pressure, What's that allabout? I don't have an answer.
Let's assume for the sake of argument that a thirdof all alcohoiics, clearly alcoholic. could in factgo back to :ncial drinking. I don't think anybodyhas claimed atei.hing that exorbitant. but let'sassume they caul& Suppose one-third of thepeople who hav had a reaction to penicillincould go back to talking penicillin safely. Look atthe behavior of the physician faced with thosetwo situations. The person with the penicillinreaction gets extensive skin testing and everypossible antibiotic is used except penicillin. Fre-quently, the same person is recommending con-trolled drinking for all alcoholics, it doesn'tmake sens 2.
What about our medical students? I think weneed to tell them they are at extremely high risk.We don't know what the actual prevalence ofalcoholism and drug abuse is in the medicalpopulation: all we know is, it's pretty high. Injust about every study that's been done, themedical student and the doctor are at greaterriskat least for the legal drugs. narcotics, minortranquilizers, et ceterathan the general pub-lic. We know that health professionals in generalare at risk. although in our studies we had only 2percent of dentists addicted to narcotics as op-posed to 18 percent of our physicians, and itlooks like it's going to come out about 12 per-cent on the nurses. Availability does make adiff !fence!
I think there is a tremendous denial of where weare with our own addictions, As soon as we starttrying to set up sick-doctor committees in ourown States or hospitals, we will begin to sensethis. When we started trying to do something inthe State of New York we discovered that ourgroup health insurance policy (sold by the Statemedical society) had no coverage whatsoever foralcoholism.
It was just pointed out to me that the Federalhealth insurance which covers VA hospital em-ployees (like other hospital employees) does notcover their treatment for alcoholism, in spite ofthe VA system's great current interest in alco-holism, the health care industry taken as a wholeis the largest single industry in the Nation, andyet very few programs, very few hospitals, havedone anything about providing adequate cov-erage for their alcoholic employees.
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How are we going to do things that might make aslight difference? I would like to mention two orthree possibilities. One thing I think we mightdo to alert ourselves to our on use of chemi-cals, and also as a way of getting to people whoare hard to reach, will be to do something aboutsick-doctor programs within our own hospitals.ICAH is now requiring us to attest to the physicaland mental well-being of each member of themedical staff. That means that the buck is nowgoing to stop somewhere. The individual depart-ment is going to have to attest to the good healthand competence of its own staff. This meansguidelines will have to `,. developed in hospitalsto deal with the imp Aysician. One thingwe might try is to ospital privileges forsick physicians con .. Jai on accepting treat-ment. This type of approach has worked verywell in industry where threat of job loss is a greatmotivator to get people into treatment.
Guidelines are now available from a variety ofState and county medical societies. The countysociety of New York has a fairly good set which,with a little bit of adaptation, can work in mostsituations. Once you have an impaired-physiciancommittee together, those doctors on your hos-pital staff are going to have to face the fact thatthey are now going to have to deal with some oftheir colleagues who are sick with addictive dis-eases. That is quite different from taking refugein enzymes. It no longer makes a difference ifthe urinary amylase is more accurate than serumamylase; they are now stuck with the fact that acertain doctor drinks too much, and somebodyis going to have to do something. Teaching phy-sicians how to deal with an addiction problem ina colleague is a great entree into teaching themhow to deal with addiction problems with all oftheir patients.
The best way to teach physicians about addic-tion is to start in medical school. However, if youget a course into the curriculum, don't expectthe students to beat down your doors, Of thestudents who sign up for our elective, we dis-covered that, with the exception of two, everysingle one of those students had an alcoholicparent or an early alcoholism problem, Therewas a hidden agenda in every case except two. I
think this suggests something: 1's e have the sonsand daughters of alcoholic parents in our medi-cal school classes and in our nursing schools. Ipersonally feel that this has some influence oncareer choice. If sou are the nurturing, caretak-ing child in an alcoholic home, very likely youwill go into a profession where you can continuethis lifestyle I am fairly convinced this is true innursing; with medicine nobody has studied it. Ithink t he way into the minds of these students isto give them what they want to learn. and whatthey want to learn is what are they going to doabout the old man. or what are they going to doabout the old lady.
I learned something a few years ago that Ithink is important but indirectly related to thetopic. I used to think that if we taught medicalstudents about addiction, they would carry thatinformation with them for the rest of their ca-reers. However, this is not the case. After theyleave medical school they go through internshipand residency where they are again students andhave to follow the examples of their new teach-ers. if these new teachers are ignorant of addic-tion, then much of what we have taught thestudents will be lost. That is why I think it is moreimportant to teach the peacticing physician. Heis no longer a student and, therefore, can imple-ment his teaching without worrying about su-periors. He also can pass what has been taughthim on to his students. When we teach medicalstudents, we are role models. It is not so muchwhat we say, but what we do.
And that brings me back to thetopic. If I can getthrough my life and enjoy it and obviously havefun and be productive and have a grand, goodtime without chemicals, then i think I am givingthat message to the medical students, If I can'tstand my friends without being half bombed, if Ican't get through the day without tranquilizersand pep pills, I don't think it matters a great dealwhat I say to the student. They are pretty astuteand they have a pretty good idea of who's stonedand who isn't. I think a lot of them have a prettygood idea of the difference between an occa-sional joint now and then, an occasional amphet-amine perhaps to cram for an exam and a prob-lem of real dependency.
CONFERENCE PROCEEDINGS
Sidne> is affiliated with the Uniyersio.. of Harvard U ilk ersit; and LeClair Bissell. Co lum-Ca Mar os Angeles: Norman Zinberitz. with bia University's Roosevelt Hospital.
American Medical Educationin Alcohol and Drug Abuse:The State of the Art
Report on a National Survey
Results of the Survey Alex Pokorny, M.D.
I am going to present the results of a survey ofU.S. medical and osteopathic schools regardingtheir substance abuse curriculums. There havebeen several previous surveys: the 1970 co nfer-encesponsored by the National Council on Alco-holism and the 1972 Macy Conference dealingwith substance abuse, which included a consid-eration of alcoholism. I commend these two toyou as excellent discussions of the general issuesinvolved. However, these two reports area littlelight on the specifics. We have tried to compareour results with theirs, and this is hard o do.
There was also an important position paper putout in 1972 by the AMA Council on MentalHealth. A survey of drug abuse education inpharmacy schools was done in 1972; largely be-cause of the availability of that report, we de-cided to omit pharmacy schools from the presentsurvey.
The background of this survey Includes the startof the career teacher program in 1972. In 1974, atask force was set up, largely by NIDA, to recon-sider theoriginal objectives of the career teacherprogram, to seed there were other ways in whichwe could approach the same goals. This taskforce chose eight additional activities and one ofthem was to do a survey of current teaching. Wedecided to survey schools of medicine, osteop-athy, and dentistry; physicians' assistantsschools; and nurse practitioner schools regard-ing their alcoholism and drug abuse curriculums.These seemed to be the drug-handling healthprofessions. Pharmacy should have been added,but was omitted because of the previously men-tioned recent survey. in the survey we would
seek to determine the amount of teaching, thetype, where done, by what methods, et cetera.
We decided on the following samples: 100 per-cent of medical schools and osteopathy schools,a 25-percent sample of dental schools, and a50-percent sample of PA and generalist nursepractitioner training programs. The last threewill not be dealt with further; from now on I'mgoing to be talking about the survey of medicaland osteopathy schools. In fact. the great bulk ofthis report will deal with medical schools; towardthe end I will comment on the similarities anddifferences for osteopathy schools.
We first developed a questionnaire using largelythe ideas and issues in the Macy Conference andthe NCA Conference. We field tested this firstversion by sending it to three Texas medicalschools (not ours); after these were completed,we conferred with the schools, visited them, anddetermined what the problems were, how trueor false a picture this might give, et cetera. Wenext refined the survey instrument and sent it tothedean of every medical and osteopattrochoolin the USA. We decided to send it it) If dean ofeach school, to make the procedure cumparable,even though we had career teachers in many ofthe medical schools who could have handled itgracefully.
We decided not to i dentify the individual schoolsin our report and just to report totals and aver-ages. By contrast, the pharmacy school surveydid identify individual schools; in fact, theyprinted the individual school replies verbatim intheir reports. This procedure probably has an In-hibiting influence on answers. We used baseline
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data from the AimC and AMA directories whichgive rich information on schools. particularlythe AAMC directory. Substance abuse is, ofcourse, not a separate department or specialty.The A.AMC directory does not gibe hours orcourses in substance abuse.
We later site visited 12 schools. This follows aprocedure used in a recent AAMC curriculumstudy. The site visits were intended to determinethe accuracy of the school's questionnaire re-port. The plan to site visit was also mentioned inthe original letter. We think this may have hadthe effect of making the questionnaires moreaccurate. Joh' :-yer, the career teacher, didmost of the site visits,
We had thought that this suo.e. would be aone-shot thing, but actually we started out inNovember 1975 and didn't get through until Feb-ruary 1977. We got completion rates of up to 90percent of medical schools and 100 percent ofosteopathy schools. When we separated careerteacher schools from the non-career-teacherschools, we were surprised to find that the careerteacher schools' completion rate was not muchbetter than that of the non-careerteachers'schools,
For analysis, we decided to group the medicalschools in several ways: by section of the coun-try, public or private ownership (40 privateschools, 64 public), total enrollment, and size offirst-year class. Our findings concerning teach-ing are reported mainly in two categories: re-quiredteaching activities in substance abuse andelective teaching activities. We decided thatthese represent two independent things; therequired hours represent the school's notion ofa minimum level of knowledge, what everybodyshould know. Since everybody receives thisteaching, it makes sense to use averages andspeak of the average number of hours. On theother hand, elective teaching activities vary induration. Many elective courses are reported as"of variable duration" or "as arranged." Further-more, elective courses are simply offerings,many of which are never taken. It would there-fore not make sense to total up these hours andsee whether one school's average is higher thanthe other. We view electives as simply a measureof the richness of the curriculum; electives are
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more or less for the specialist, for the studentwho likes an area, is interested it it. and wants togo into it at depth. We therefore report electivessimply as total number of courses offered by aschool. To repeat, for required activities we re-port hours, and for elective activities we reportcourses.
With respect to required substance hours, thereare 9 schools which require zero hours, andthere are 26 schools in the top bracket whichrequire anywhere from 38 to 126 hours. There isa tremendous variability in schools in terms ofwhat is required.
We initially thought of separating reports of alco-holism teaching from drug abuse teaching, Un-fortunately, one or two of the items in our ques-tionnaire were ambiguously worded. We didnot note this during our field testing and onlylater decided that we couldn't reliably assignhours to alcohol or drug abuse. Furthermore, agreat many of the courses teach both topic areassimultaneously. Therefore we are reporting sub-stance abuse teaching altogether,
Regarding the number of required courses, sub-stance abuse teaching is scattered broadlythrough the medical school curriculum. Again,there is great variability, The required hourswere tabulated by departments and averagedfor all schools reporting. For the basic sciencedepartments, pharmacology, of course, teachesby far the most. Next is pathology. The averagetotal teaching in basic science is 7.6 hours, Inclinical departments, psychiatry has by gar themost teaching, with medicine being second. Theaverage total teaching in clinical departments is17 hours. The total for all departments is a littleover 25 hours; let's say 26 hours. You rememberthat Dr. Nobles aid yesterday that there had beena change from some figure to about 70 hours, butI think he was including not only required teach-ing but also elective courses. Furthermore, he wasreporting for the career teachers' schools only.
Regarding the number of elective substancecourses, 35 schools had zero courses, whereas 21have 3 to 10 elective courses. Again, there is a lotof variability.
Since many an elective is never chosen, we askedhow many students actually took each elective
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CONFERENCE 1,110CEEbmGS
during the past year, This turned out to be zeroin 4 instances and not reported in 41 instances.On the other hand, 25 courses reported 1 to 4students; 32 courses reported 5 to 14 students:and 30 courses reported 35 or more students.This seems to be a good stgnup ratehigherthan I would have predicted.
Regarding the percent of the total required cur-riculum which deals with substance abuse. therange was from zero to 3 percent and the meanwas 0.6 percent. If alcoholism alone is the No. 3health problem, and we are speaking here of allsubstance abuse. this does+, 't seem like a propor-tionate or appropriate allocation of curriculumtime. By summing up the worksheets, we calcu-lated what departments were doing the teach-ing. Psychiatry was most prominent, pharmacol-ogy next, then medicine, pathology, neurology,and then various others.
We next asked about detailed content of courses,by use of a checklist, It was found that the defini-tions and descriptions were the items most fre-quently checked, then medical complications,then treatment, rehabilitation, and so on.
With respect to the division of time between thecomplications and the basic disorder itself, myimpression had been that we teach mostly thecomplications and not the primary disorder. Theresults of this questionnaire were rather the op-posite; in fact. in over half of the courses theemphasis on the primary disorders waspredominant.
We also asked about the teaching methods used,It was found that the good old lecture is stillhighly In the lead, followed by seminars. hospitalclerkships, Slims or videotapes. demonstrations,outpatient clerkships, field trips, and self-instructional packets,
We also asked about the site or facility in whichthis teaching was done. The m -ski! ,:1 school class-room was the most commas 'I awed by theuniversity affiliated hospital.. a communityhospital, a community alcohol or drug program,library, learning center, self-help group, aid lad,prison, or other correctional facility.
We asked each school how many affiliated clin-ical programs they had that dealt with substance
abuse. The Macy Conference. the NCA Confer-ence, and other groups have emphasized that itis very hard to teach something if you 're notdoing it. Therefore, one of the big needs in in-creasing and facilitating teaching in substanceabuse is to have an affiliated clinical program.We found that 18 of the reporting schools hadno such affiliated program, 41 had 1 or 2, and 31had 3 or more.
We tried a whole series of cross-tabulations orcorrelations with various characteristics of med-ical schools (age, size of class, size of city, owner-ship, et cetera). In general. the results were neg-ative, which was somewhat disappointing andalso surprising to us. I will mention a few positiverelationships here, but no relationship was verystrong. The age of the medical schools didn'tseem to make much difference, even though mynotion had beer. that the recently founded med-ical schools had much more substance abuseteaching and that old established medicalschools had very little.
We also compared the Career teacher schoolsand the non-career-teacher schools; there was asubstantial and significant difference in requiredhours.1 believe this difference is real; however.there may be some difference in thoroughnessof reporting and how knowledgeable the personanswering thequestionnaire was regarding whatwas going on in his school. The career teacher isobviously very well informed about his ownmedical school.
Regarding the size of the medical school, it ap-pears that the smaller schools tend to have morehours of required teaching than the largerschools, but nothing sensational.
Now, I'd like to mention two representative pro-grams; these schools will remain unidentified.The first is one of the better programs; not thevery best but a good program. The substanceabuse teaching involves six or seven depart-ments. They have five hospitals with affiliatedclinical programs, three of which have two pro-grams each. The introduction to medicine in-cludes 6 hours on substance abuse. The pharma-cology course includes 12 hours on substanceabuse. The community medicine Course includes2 hours per week with one family. and many, but
1LC01101. ANL) DRL G Mil SE IN MEDIC 4.1 EDI_ C A,TIC,N
not all, of these families have alcohol or drugproblems. The pathology course includes sub-stance abuse teaching. The medicine clerkshipand teaching has 3 hours on substance abuse.This school also has nine elective courses in% olv-ing several departments. which range from a fewhours to 2 months in dui. _ion,
Next I want to describe a school typical of thehave-nots. the limited kind of program. The de-partments involved are only psychiatry, pharma-cology, and pathology. No affiliated clinical pro-gram is listed. The pharmacology course includesthree lectures which deal primarily with thepharmacology of drugs and alcohol and a 40-minute film on overdose, The sophomore psy-chiatry course includes 1V 2 hours on substanceabuse, and the preventive medicine includes 1to 4 hours on alcohol and drug dependency. Themedical student who goes through this programhas low exposure to alcohol and drug abuse.
With regard to osteopathy schools. the findingswere generally the same. The average of re-quired hours was slightly higher than for medi-cal schools, but not significantly. The teachingwas more concentrated in the preclinical years.Only one of the nine schools had an affiliatedsubstance abuse treatment program. which wasa far lower percent than for the medical schoolsand probably accounts for the different time al-location between the basic science and clinicalyears,
We made an attempt at comparing the findingsfrom this survey with the NCA report. The NCAConference in 1970 listed 30 medical schools:each of them had a separate entry in which theysaid what they were doing. We took our ques-tionnaire reports from those corresponding
medical schools and compared them. This wasnot very feasible because the NCA reportsseemed to be more qualitate. e and v. e were talk-ing quantitatively. Furthermore, they did notdiscriminate between eiecti% es and requiredcourses. We therefore concluded that wecouldn't make a very fair comparison, it did lookas if none of the schools listed had regressed,and several seemed to have improved and en-riched their programs.
Our general impression is that the amount ofSubstance abuse teaching in medical schools hasimproved. There is still tremendous variability.Nine schools report no required teaching. Someof these represent out older and most prestigiousschools. To qualify this a little, many of theseschools place great emphasis on elective and op-tional tracks, and therefore the lack of strict re-quirements doesn't necessarily mean that theirtypical student does not get substance abuse in-struction. Nevertheless. if required hours are ameasure of minimum standards. there are nineschools with no minimum requirement at all.Twenty-tive percent of the schools required S orfewer hours. Thirty-eight percent have no elec-tives and 20 percent have no affiliated clinicalprograms,
We believe that there are three simple thingsyou can look at if you want to quickly Size up amedical school's program. First is the number ofrequired hours: second is the number of electivecourses; third, whether or not the school has anaffiliated clinical program in alcoholism or drugabuse.
My general conclusion is that the overall situa-tion has improved, but we still have a longway togo.
CONFERENCE PROCEEDINGS
Report on the Site Visits John E. Fryer. M.D.
As part cat my career 'cachet award. I visitedmedical schools around the country to learnhow c urriculums were developed, not just insubstance abuse but in a variety of areas in thepreclinical and clinical years. The medical schoolsthat 1 visited were chosen in a relatively randomfashion.
I have been interested in learning more aboutthe power dvnamnics that are involved so thatperhaps 1 can develop some ideas that will beuseful to those who want to get a particularsubject such as substance abuse into the cur-riculurn. 1 have visited a total of about 20 medical-hoof. I was surprised F,. the great variety ofmedical education which 1 found on my visits. Iwas surprised. for example, to find a medicalschool where there was no psychiatry clerkshiprequired,
I would like to make a few points about thereports 11-at Dr. Pokorny gave. First, it was quitecleat ':ere would be an hour here or therein the cu, in that was misinterpreted on thequestionnaire reports. but. by and large, onlyone school grossiy misinterpreted on the lowside what was actually happening.
I did find. however, that there was at times verypoor communication among people involved insubstance abuse about what was actually beingtaught at their school. One of the really strikinghappenings was being at a very prominent medi-cal school artd talking to a very well knownresearcher in the area of addiction. I asked him,"What do you think about the 6 hours that so-and-so is teaching in the freshman year?" Theresearcher replied, "Oh, he's not teaching any-thing in addiction; I teach it all."
Then I repeated. "But this psychiatrist is teach-ing 6 hours in the freshman year." He insisted,"I'm sorry; he isn't" and very irritably called thepsychiatrist on the telephone. The psychiatristconfirmed that he was. in fact, teaching the hoursin question. The researcher then said. "What areyou doing teaching these hours? This is my field."I think this highlights the fact that there are three
areas in substance abuse: the clinicians, the researchers, and the teachers. I think that in sub-stance abuse there is often no cr.,rnmunicationor little communication amor.g tf-, three areas.a situation that is rarely foun.: in esl-er areas ofmedicine. In my own medicAl hc.k:...s 1 have to
go to lectures given by researchers to really findout what they are teaching or not teaching.
I think the other thing that needs to be com-mented on is that when we talked about theprimary disorder on the questionnaire there wasno separation between that which might be con-sidered pharmacology and that which would beconsidered phenomenology of the disorder ofsubstance abuse. I think most of us are aware ofthe fact that in our medical schools. particularlyin pharmacology departments, the material relat-ing to alcohol or morphine or morphine deriva-tives, Or whatever, is taught as a pharmacologicalfactor, often with very little emphasis on theactual phenomenology of the addicted state.
While attending a lecture in another medicalschool, I was struck by the fact that although thestudents were getting a very good lecture aboutwhat happens to heroin in the body, they weregetting very little information about heroinaddiction. Yet that material is included in theprimary disorder in this form, and I think thatneeds to be clarified.
There are still several schools in the UnitedStatesand I don't know that these are the onesthat Dr. Pokorny was talking about in his groupof nine that have no required substance abusetimesuch as Harvard. Stanford, and Pennsyl-vania where the entire curriculum is ostensiblyelective. Therefore, nothing is required. I wouldsay from talking to students and faculty in thoseschools that most of the students are not exposedto addiction at all except in a Course in pharma-cology or a course in psychiatry, Even that ex-posure does not occur with regularity.
I guess I came away front my experiences feelingvery strongly about the value of a requiredcurriculum, because it seems to me that there
ALCOHOL AND DRUG ABU5 IN MEDICAL EDUCATION
needs to be a baseline beyond which we can addother information for students as needed. Thisis, of course, a view that is open to discussion,
Another piece of data that !wish to cover relatesto the figure that, in the career teacher schoolsin Dr. Pokorny's survey, 36 hours of substanceabuse teaching was the average and in non-career-teacher schools, 19 hours. Some of youmay see the report that's been made about thecareer-teacher program by the CONSAD re-search organization which says 26 hours wererequired in career-teacher schools and 4 hoursin non-career-teacher schools.
1 think that the differences in those figures comeabout because the CONSAD data were derivedfrom intensive questioning in site visits, whenone questions people about what they areactually teaching, one finds that much of the
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material that is classified as substance abuseteaching on the questionnaire turns out to bemore accurately classified as pharmacologyrather than as phenomenology of substanceabuse.
Finally, it is very striking to me in the area ofsubstance abuse that confusion arises whencourses are taught in relatively traditional war.Frequently very important material about the ad-dictive states is not being taught to medicalstudents in a rigorous fashion.
AUTHORS
Alex Pokorny is affiliated with the Baylor Collegeof Medicine; and John E. Fryer, with the TempleUniversity School of Medicine.
The National Board Examinations
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Substance Abuse Questions on theNational Boards
introduction: John B. Griffin
During my career teacher grant, I went to theBaylor Career Teacher Training Center. One ofthe goals that I had for the month I spent therewas to develop a pool of questions that wouldhelp me in measuring knowledge among themedical students whom I was teaching. As Ipursued that goal, it became increasingly clearthat other people also were interested in meas-uring what the students had learned from thethings that were presented in substance abuse.Eventually, a committee was formed to developquestions in drug abuse and alcoholism. Thehistory of this committee is outlined in anothersection. As the committee worked, it seemeddesirable to know something about what stu-dents over the country as a whole were learningin the field of substance abuse.
We decided to attempt a survey of a significantsample of medical students across the country.In order to do this, we went to the NationalBoard of Medical Examiners to ask for their helpin devising the instrument for use in this project,
The National Board of Medical Examiners is anentirely independent body which devises theexamination that is most widely used across thecountry by medical schools to measure thequality of their students' performance. In almostall States, passing the national board examina-tion is a criterion for licensure. The questions forthe examination from the National Board ofMedical Examiners are devised by committeesworking within the national board framework.These committees, by and large, reflect de-
partments within medical schools; that is, thereis a committee on anatomy, a committee on bio-chemistry, a committee on psychiatry, one oninternal medicine, et cetera. If a subject area hasdistinct representation in the faculty of medicalschools, then it is likely to have an equivalentcommittee on the National Board of MedicalExaminers.
One of the problems for the field of drug abuseand alcoholism is that medical schools rarely, Ifever, have a department of substance abuse. Inkeeping with this, the National Board of MedicalExaminers does not have a committee specifi-cally assigned to this area. Clearly, we hope thatour committee's work with the National Boardof Medical Examiners will stimulate increasedconsideration of substance abuse questions onthe national board examination. I must empha-size that there has been no arrangement or guar-antee of any specific numbers of questions onsubstance abuse to be placed on the examina-tion. This would be totally out of character forthe board and would be contrary to the frame-work in which they operate. The National Boardof Medical Examiners attempts to reflect what isbeing taught and not to influence the directionof medical education.
I believe that as a result of our work with them,the board is probably more aware of the expan-sion of teaching in substance abuse over thecountry that has occurred in the last 5 years, inlarge part through the career teacher effort.Since the national board tends to reflect changes
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in curriculum, increased curriculum time usu-ally leads to increased numbers of questions onthe national board examination.
Our committee has learned a great deal abouthow to write questions and how to put them inthe correct form for the national board. We aregiven the opportunity to submit possible ques-tions to the national board committees for theirconsideration each year. These questions should
have a better chance of acceptance because wehave learned how to construct them properly.
We areconstructing some examination modulesdealing with substance abuse, some of whichwill be used in the research project to evaluatemedical students' knowledge in the area. Someof the modules may be incorporated in a laterqualifying and certifying examination that theNational Board of Medical Examiners is in theprocess of considering at this time, as Dr. Smithwill now elaborate.
Report on Substance Abuse Questions on the National Boards
David Smith, M.D.
I particularly appreciate your addressing anissue that was, frankly, of concern to me when Icame down yesterday and gave some thought tothe exact wording of the title that you find in theprogram before us.
The National Board of Medical Examiners, asyou have so nicely emphasized, is an independ-ent, voluntary, nonprofit, educational institu-tion that is much involved in the process of certi-fication examinations that are, in turn, used tr.0give feedback to faculties regarding perform-ance of certain types of students on certain sub-jects.
We were very flattered in the last several monthswhen Dr. Ted Cooper made some commentsabout the perception of the national board inWashington and within the American educa-tional scene. He described this perception asone of neutrality and impartiality. I think that hisbeing able to say It this way was one of the finestattainments of the goals of the national boardthat we could imagine, because we would like tobe, and try hard to be, an impartial measuringbody particularly slanted toward medicine.
Our particular orientation toward medicine
makes us different from many other testingorganizations. We are a politically neutral entity.This becomes interesting and complicated attimes. For instance, some of you may know thatsuddenly last fall we found ourselves mentionedIn the law that has to do with the return ofAmerican citizens who are in foreign medicalschools and want to transfer to advanced stand-ing in American medical schoolsthe so-called"Guadalajara" clause of Public Law 94-484.
We were, in a similarly involuntary manner, in-volved In the qualification of all alien physicianswho want to come to this country by way ofeither a i visa or an immigration visa.
It is quite a story as to how we responded tothese situations as a public obligation and, at thesame time, have tried to maintain our position asa voluntary neutral body. This is part of thebackground of why we sometimes may seem tobe overly sensitive to accusations that we aredictating curriculum or are shaping Americanmedical education instead of following and re-flecting it.
It Is obvious that I cannot deny that the NationalBoard of Medical Examiners has some effect on
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teaching. We all know that these are the realitiesof life, but the national board has no intentionaleffect. 1 also cannot deny that I am aware ofpeople with whom I have worked in your organ-ization who would like very much to encourageand emphasize teaching of alcohol and drugabuse by means of incorporation in the nationalboard examination, as well as other means. Therewas a frank recognition that this was a hiddenagenda item, and I think it has had its influencein a salutary manner.
Yesterday Dr, Gordon Deckert, from OklahomaCity,spoke on several subjects rather forcefully.Gordon has been the chairman of the PsychiatryTest Committee of the board, and he gave me aspontaneous testimony that I'll pass on to you.During the 7 years that he has worked with thePsychiatry Test Committee he feels that therehas been a very significant increase in the atten-tion that has been given to drug and substanceabuse by that committee. I can attest to you thatthe pharmacology committee, the behavioralscience committee, and several others havesimilarly shown a greater interest in this area.
You will be right if you tell your students that thenational board examinations do contain itemson substance abuse and that they are going to beheld responsible for their education in this area.The important thing Is that you are teaching thesubject. It is then reflected by your representa-tives on the test committees of the nationalboard. There are about 120 such individuals onthe board test committees, eepresenting overhalf of the medical schools at any one time. It isthrough these individuals that questions aredeveloped for the national board.
I was Interested yesterday to hear Dr, Noblemake a reference In which I believe that hecongratulated you for obtaining an entry to thenational qualifying examination, The nationalqualififying examination reminds me of what wecall our comprehensive qualifying examination,That introduces the explanation I would like togive you of the so-called national board project.
As Dr. Griffin has pointed out, there was aninterest for several years among the careerteachers in devising a test item library for educa-tional and evaluation purposes. They came to us
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to see if we had interests and facilities that wouldenable them to forward their goals.
They arrived at about the time that I had assumedsome responsibility for beginning to respond tothe challenge of the report of our Goals andPriorities Committee of the board which wasissued over 5 years ago. The challenge was tocreate an examination with more emphasis onperformance, skills, and abilities, in addition tothe emphasis that we have always placed onmeasuring knowledge. It was pointed out by thiscommittee that with the variety of curricularchanges that seem to be occurring in the Ameri-can medical educational scene, probably the onlyappropriate time to test all medical students is atthe time that they are ready to get their M.D.degree, after they have finished the varied cur-ricular patterns of their own medical schools.
This was at first, you may remember, called thequalifying A examination, and it was attached toseveral other political implications; for instance,there was the postulation that it might be a logi-cal progression for there to be a two-phaselicensing examination, a qualifying A and a qual.ifying B. People who had graduated from medi-cal school would be required by qualifying A toshow that they were ready to assume theirresponsibility for the care of patients undersupervision, but they would not obtain fulllicensure until after they had reached the end oftheir training, which for nearly all consists ofspecialty certification. That would be called thequalifying B stage.
i suspect many of you experienced some of thediscomfitures that rolled out of that concept,and I will not go any further into it except to saythat when we tried to see if we could meet thechallenges in just the testing area, we decided todivest ourselves of the term "qualifying A" andthink of something else. That Is why we call itthe Comprehensive Qualifying Evaluation Pro-gram.
We had a committee which directed us to sev-eral lines of thought, one of which is to createthis examination in a problem-oriented medicalframework with the idea that one might be ableto do this by developing several modules. Eachmodule concerns a particular problem. In this
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ALCOHOL AND ()RUC ABUSE IN Mf nicAL EDUCATION
format the student is asked to go through cer-tain kinds of problems in a described medicalsituation.
The next question is, What problems do you usefor such a test? We will approach this in severalways to try to identify the most appropriateproblems that will be challenges for the youngphysician in his first year of graduate training. Itseems to me quite logical that drug and alcoholabuse would be one of these problems. Conse-quently, when there was this coincidence of ourinterests and those of the career teachers, wewere glad to work with them. We have prof-ited greatly as the committee has worked todevelop four modules on several different situa-tions of acute drug toxicity, chronic drug abuse,chronic alcoholism, et cetera.
I would like to emphasize that the generalapproach is to try to have the measures that willbe derived from this examination expressed interms of tasks or responsibilities of the youngphysician. These would include the following:his responsibility to be proficient in the collec-tion of data; his responsibility to be able to ana-lyze situations and to find problems; his judg-ment and responsibility in relation to the role ofa physician In the course of following a patient;his judgment and skill in treatment techniques;his responsibility for maintenance of health care;and his attitudes and responsibility to the com-munity and to the profession.
We have no guarantee that we will be able signif-icantly to measure these particular things, butwhat we have done Is to create the situations,describe them, and then create problems andtest items with these different dimensions inmind. This Is in contrast to the usual subjectdimensions which you have seen on the classicexaminations. Such an approach does not yield asubscore in anatomy versus one in pharmacol-ogy. it is hoped that this will yield an overallscore that we can correlate with achievementand competence. it will still be much moreknowledge oriented and less performance ori-ented than we might like, simply because thetechniques for obtaining valid and reliablemeasures for some of these other areas are notso readily available as are the techniques formeasuring knowledge.
The committee has met with us. and we havehammered out these four separate problems.The problems are in the process of being printedas booklets and will be available for administra-tion to students. We would like to be able toadminister them to different kinds of students,particularly to groups of students who have notexperienced instruction in the areas of alcoholand drug abuse in contrast to other studentswho are more experienced.
Probably these two rather diffuse groups aresufficient for standardizing these tests. However,there are many variations on the theme. Forexample, it might be very interesting to be ableto analyze the difference between a student whocomes to medical school with an urban expe-rience in his early education and one whoseexperience is less urban; minority groups ofmedical students versus other groups would beinteresting variations to study. We cannot prom-ise that sort of thing, but if the project goes welland we can see these evaluation instrumentsused over a period of time, it might be that thisorganization can approach such a determinationthrough a measure such as this.
The principal thing that is ahead of us now,though, is to let this instrument be used first asan educational encouragement in your programsand in your schools and to give you some feed-back and information regarding the achieve-ments of your students as expressed in thisexamination. It may be possible to give compari-sons between your school and your programand other schools and other programs. These, ofcourse, were some of the goals of the career-teacher committee as they formulated theseproblems and wrote the questions.
Our next task is to begin to arrange the adminis-tration of these examinations. We hope to enlistvoluntary cooperation from persons at variousschools who can find a significant group of stu-dents, larger than 20 in number, in either ofthese categories: those not yet instructed versusthose that have been instructed. 5ome schools,we hope, will be able to give samples of bothkinds of individuals. We can give this test to youto be administered at your convenience. We willgive you some ground rules, but we will not be as
CONFERENCE PROCEEDINGS
rigid as we are in the real national board exami-nation nor will the students be under all thepressure that I think they are at the time thatthey take the national board examination, Wewould probably supply a biographical data sheetthat we would ask students to fill out with theirquestions so that we can categorize them toderive standard groups for normative compari-sons in calibrating this examination. We willwork out from the beginning some form offeedback to you, but the very first people whoparticipate in the course will really be the foun-dations of the standard setting, and scores willnot be as meaningiul at that time in a normativesense as they will be later. From the beginningwe can report to you rough scores in groupcategories of one interest or another. Later, after
we had more experience, we could report to youwhat your normative scores were
This is the projection for the next months asadministration of the tests gets underway. I amhere to explain to you the enthusiasm which wehave for this project, the appreciation we havefor the input that the committee gave, and whatwe have learned about the dynamics of bringingin a group with this particular kind of interest toforge an examination.
AUTHORS
John B. Griffin is affiliated with the Emory Univer-sity School of Medicine; and David Smith, withthe National Board of Medical Examiners.
ill 5
Educational Activities of theCareer Teachers
Moderator: Joseph Schoolar, M.D., Ph.D.
In its original concept, as it was formulated by the National Institute on Alcohol Abuseand Alcoholism and the National Institute on Drug Abuse, the career teacher programwas designed for thesenior faculty of medical schools. It was intended primarily to spreadthe word about substance abusedrug abuse and alcoholismto medical students. Thehope was to make substance abuse education an integrated, effective part of the curricu-lum in medical schools throughout the Linked States. We expected some significantimpact on the service programs of the university, because the medical school serves asthe focal point of many service programs and influences the programs of affiliatedagencies and institutions in its area and, in many cases, the entire State. in research themedical school has an equally Important impact on substance abuse, in both basic andapplied research.
This was the original concept of the career teacher training program. Forty-three careerteachers have been named and they are either in the training program or have finishedtheir 3-year award period. Two career teacher centers were established to assist in thetraining, one at State University of New York Downstate Medical Center and one at BaylorCollege of Medicine.
In a large measure our objectives have been or are being realized. One has only to look atthe record of the program's accomplishments from the standpoint of changes in curricu-lum content, the increased number of curriculum hours, and more accepting attitudesby medical students and by practicing physicians, as examples.
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In addition to changes in curriculum content, the career teachers have contributed to thedesign of teaching materials and have developed innovative approaches to teaching drugabuse and alcoholism courses in medical schools. The impetus has spread to continuingeducation and to the production of films and teaching tapes.
Dr. George Tyner exemplifies the best in innovative career teachers: He divided his grantinto four parts, so that not only did he participate in the career teacher program but so didDr. Arredondo, Dr. Weddige, and Dr. Orene Petticord, all of the Texas Tech faculty. In-stead of having one career teacher, they have had four at Texas Tech.
1 1 rI-... I
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A Dean's Perspective George S. Tyner, M.D.
I will address two topics. First, can a career teacherbe effective as a dean? Second, how does onedevelop a team model for teaching substanceabuse?
With regard to the first issue, we rank fairly highin the number of hours devoted to substanceabuse teaching-106 hours. That figure was derived from the 1974-75 academic year, whichwas the year I first became dean. We had alreadymanaged to scrounge 106 hours in the 4-yearcurriculumso It was not necessary to be deanto get an adequate amount of time.
On the other hand, I began to think of what Ihad done in the way of recruitment. Our schoolhas leaned toward faculty who have an interestin substance abuse. I wondered what kind ofpressure the chairmen feel I had exerted onthem to make them insert alcholism and drugabuse in their curriculum. I talked tosome of thechairmen about this. The chairman of medicine,who is an honest man and a good friend, said,"No, you haven't exerted pressure on any one ofus. However, I think we'd be crazy, knowing thatyou have a career teacher award in alcoholismand a real interest in that area, not to considerincluding that subject in our curriculum. So youanswer the question for yourself."
The way we achieved the number of hours wehave was done primarily by happenstance; and alittle by planned infiltration of the departments.The happenstance wasthat our school was broughton line in June of 1971, and we took our firststudents in the fall of 1972. There were six of uswho came to Texas Tech in June of 1971 andwere told to put a curriculum together for twoclasses beginning a year later.
By August we had 8 people and by the followingAugust we had around 40 people, and we hadcurricular time to burn. With the help of thechairman of psychiatry at that time, we began tofill up a lot of little spaces along the line. We
visited each basic science department and said"Could we or could you devote some time inyour curriculum to alcoholism and drug abuse?"With this initiative the basic science departmentsbegan to teach a fair amount of informationabout substance abuse.
In the clinical area we developed small groupconference teaching. There were two types. Thefirst was coordination of the hard data. We foundpeople who had an interest in alcoholism, andthey volunteered to put on small group dis-cussion for the junior students. included were atoxicologist, a pathologist, a biochemist, a special-ist in preventive medicine, and one or two others.They began a seminar which was repeated foreach clinical clerk group as they rotated in their8-week shifts in the five major specialitiesrepresenting the junior year.
In addition to the hard-data seminar, we or-ganized a group which talked about the diseaseconcept and the behavioral patterns of alco-holism as far as the patient was concerned. Thisgroup consisted of a lawyer, a priest, an intern-ist, a family practitioner, a doctor of education, apsychiatrist, and myself. Both approaches illustrate how our school is forcing the departmentsto decrease the number of lecture hours andincrease small group discussions. We feel thatwe can teach more effectively with faculty teams.
Another teaching device became available byaccident. We had invested $500,000 in televisionhardware. As dean, I was despondent over thisbig expenditure because nobody used it. So webegan to give our seminars in the televisionstudio. Now we have quite a library of all of ourdiscussions with the students. Faculty can goback and compare what we've been able to doover a period of 3 or 4 years.
In retrospect, I didn't plan to be either a dean ora career teacher. When the career teacher pro-gram came out in 1971,1 developed a grant appli-
12.1
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
cation. At about the same time our first deanquit. I didn't put in an application for the job. Ireceived the career teacher award in the summeror the fall of 1974 and 2 days later I was offeredthe job as dean. The next career teacher meetingwas In Louisville. Jim Callahan advised me not toturn the grant back, and I began to rememberthat we had twoor three interested faculty mem-bers. We began to talk about starting a teambecause I simply didn't have time to do morethan front for the program.
That's how the team concept got started. We'vehad a lot of support and encouragement. especi-ally from Joe Schoolar and Alex Pokorny at Baylor,At least three of us have gone there to partici-pate in the teaching program as students.
The program has gradually grown. Some of themethods that we used to infiltrate the curricu-lum might be of help in other schools. On thebasis of our experience, I think the technique ofinfiltration is a good one
There are other ways in which the curriculumcan be infiltrated. The career teacher who is aloner in a school has to go around and makefriends among the faculty and have an interest insubstance abuse. He can then recruit these friendsand they can put on the course together.
No dean can sit down and delineate curriculumhours, I think it has to be an interdepartmentalrelationship based on acquaintance and a simi-larity of interest.
Another thing that has helped us as a team is thatwe make ourselves available to talk to anybody.All you have to do is ask us and well be there. Inthis way we have achieved a fair amount of visi-bility. We will talk to the county medical society,to the Boy Scouts, to the parent-teacher associ-ation, in short, to anybody who will listen to us.We don't reserve all our energies for teach-ing at the undergraduate level.
Let megive you another example. We wanted toteach residents, but nobody who had residentswanted to bother withus. Our school has about103 residents, with about 75 or 80 in familypractice.
As dean, because of my interest in substanceabuse, I began to keep track of how much Valium,Quaalude. and Librium was prescribed. Theamount was outstanding, with the great pre-scribers being the family practice residents.
The chairman of family practice and I met todiscuss this production of iatrogersic disease. Hewas as uninformed about alcoholism and drugabuse as the junior medical students, so he in-vited me to bring the team in to talk to the housestaff in Lubbock. We gave our presentation tosome freshmen, sophomores, seniors, familypractice residents, and some of the faculty. I
think we made a fairly good impression, but itreally wasn't until one of the family practiceresidents, after that talk, discontinued Valiumand convulsed In the emergency room that wereally got a strong stand in the department offamily practice,
Another example occurred when a student askedme if I would get more time in the freshman andin the sophomore year to teach about alco-holism and drug abuse. She was greatly concerned that about 10 percent of our studentshave to repeat or fail. For about half of thosestudents, I can Identify a direct relationship be-tween failure and the use of alcohol or soft drugs.At least 5 percent of our students are Identifiedas getting into trouble, usually with Valium,sometimes with barbiturates, and sometimes witha smorgasbord plus a little alcohol. This experi-ence illustrates another means of getting intothe curriculum without using any inducementfrom the dean, and that is that the students haveasked for it.
Another way to develop interest is to become in-volved with other parts of the parent university.Were now becoming involved with the depart-ments of psychology, sociology, and nutritionon the main campus. In this waya cadreof inter-ested perople is being developed throughoutthe university.
Last but not least is infor mal discussion with medi-cal students. Those are times to capitalize on thefact that you are talking to a group of peoplewho are entering into a profession which hasanoccupational disease. And that occupational dis-ease is what we're talking about.
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Data on Student Attitudes John N. Chappel, M.D.
My career teacher grant marked the beginningof my intensive Involvement in medical educa-tion. I had been at the University of Chicago for6years prior to that time, but my involvement inthe curriculum was at best peripheral. We hadelective time and a half-day with the first yearstudents in community health. A few curiousstudents came to our programs, but there wasminimal impact. An additional frustration wasthe difficulty we experienced getting physiciansinvolved in the treatment of the heroin and alco-hol addicts we were seeing.
It was from this context that I went to my firstcareer teacher meeting at Louisville. At thatmeeting a revolt was in process against old, tra-ditional educational methods. There was also aspirited discussion on educational priorities.The priority emphasized was to find some way toinfluence attitudes. That emphasis was so con-genial to my own experience and to my aca-demic beliefs that I became very enthusiastic.Since then I have devoted most of my time towork on medical student and physician atti-
Current Findings on Student Attitudes
John Chappel mentioned the fact that this is astatistically sound instrument. Well, statistics arephenomena like lampposts, which some peoplein states of inebriation use for support ratherthan for enlightenment. Thestatistics that we are
tudes. The video tapes you saw yesterday arepart of that work.
Later, at the Savannah meeting, Ben Kissin, whohas had a catalytic effect on us, suggested thatwe set up a committee to develop a Standard-ized Test of Attitudes and Knowledge (STAK).A committee was formed which developed abroad spectrum of attitudinal statements. Thesewere given to the career teachers at the Portlandmeeting. Ron Krug utilized his statistical andcomputer skills to factor-analyze these state-ments. We then developed the form of STAKwhich was used with medical students in Okla-homa and Nevada. The current form is includedwith the article on a«itudes.
The attitude survey as it now stands appears tobe statistically sound and acceptable to bothmedical students and physicians. Time of adminis-tration is 15 to 20 minutes, so it can be easily usedin most settings. Further investigation i; neededto determine what relationship the attitudinalfactors have to clinical behavior with alcohol -ordrug-abusing patients. Ronald Krug will de-scribe our current findings.
Ronald S. Krug, Ph.D.
reporting are intended for enlightenment ratherthan for support of some theory.
The scoring system used in STAK was developedfrom a reasonably large data base. The initial
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ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
factor analysis used the career teachers as a ref-erence group. We examined both orthogonaland oblique rotations. The oblique rotation wasused because it revealed a treatment factor whichwas of major interest to us. Six factors were ob-tained. These factors were used to form a scor-ing system.
The first factor was a moralistic factor. Itemscharacteristic of this factor are, "Clergymenshould not drink in public" and "A physicianwho has become addicted to narcotics shouldnever be allowed to practice medicine again."This factor represents a restrictive, pessimistic,moralistic attitude to substance abuse.
The second factor was a permissiveness factor.Items that load heavily on this particular factorare, "Alcohol Is a good substance if not used toexcess," "Daily use of one marijuana cigarettehas a beneficial effect," and so forth. This factorrepresents a permissive attitude toward usingsubstances.
The third factor was a treatment factor. The itemsthat load heavily here include"Drug addicts canbe rehabilitated," "Drug addiction is an illness,"and "Group therapy is an essential part of treat-ment of alcoholism or drug addiction."
The fourth factor was a factor of restrictivenessin both use and treatment. The restrictivenessloads most heavily on this particular score. Itemssuch as "Marijuana leads to mental illness,""People should get drunk only at home," and"Chronic alcoholics who refuse treatment shouldbe legally committed to long-term treatment"characterize this factor,
The fifth factor was of drug use phobia. Itemssuch as "Heroin use leads to addiction," "Week-end users of drugs will progress on to drugabuse," and others represented a view that drugsare very dangerous.
The sixth factor is a myth-oriented factor. Manyof the myths about substance abuse load highlyon this factor. Typical Items include"Drug abuseis caused by a character weakness," "People whouse psychedelic drugs are basically mentally ill,"and "Anybody who has long hair and a beardprobably uses illegal drugs."
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We gave the revised questionnaire to our stu-dents before starting our teaching on substanceabuse. Then, after the teaching was completed,we repeated the administration of the question-naire.
There is a difference between the two medicalschools in that the University of Nevada uses ablock system which puts 28 hours of substanceabuse teaching in 1 week. The University of Okla-homa uses a spaced type of curriculum in whichmany disciplines are teaching at the same time.My course consists of 16 hours spread over a41/2-week period. So we have a compressed cur-riculum compared with a stretched curriculum.
In both courses the students go to AA meetingsto become familiar with community treatmentresources. The Nevada students make one AAvisit with a sponsor. The Oklahoma students areassigned sponsors who contact each student,take them home for dinner, then to an openmeeting, and finally to a closed meeting. Thisgives them a wider experience with AA.
T-tests compare prescores and postscores on thesix factors. The factors on which we were able todemonstrate significant movement on studentattitudes were the first, third, and fifth factors.
On the first factor, using combined data fromthe two schools, we were able to significantlydecrease the moralistic stance of students towardsubstance abuse.
We were particularly pleased with the responseon the treatment factor. The students moved toa more positive view of substance abuse as anillness which can be treated and not somethingto be ignored.
On factor 5 we have significantly decreased thephobic response to drugs and to drug use.
There were some interesting differences be-tween the students from the two schools. Onfactor 2 the Nevada students moved to a morepermissive stance toward substance use. TheOklahoma students decreased in permissive-ness, but both groups ended up at the samepoint. It therefore appears that we were dealingwith two groups of students who started fromdifferent levels of permissiveness, and moved toa common position.
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On factor 6 the Oklahoma students decreasedtheir myth orientation to drugs and substanceabuse, while the Nevada students showed littlechange,
As teachers, our goals are somewhat different.John Chappel wants his students to see substanceabuse patients as human beings with problemswhich can be treated. He works from an optimis-tic orientation toward treatment. While I sharethe second goal, I have articulated the first onealittle differently. My goal is to get thestudents tosee substance abuse as simply a phenomenon
which has no positive or negative value judg-ments to be made about it.
In conclusion, we now have an instrument thatwe can use in different settings to assess changesin student attitudes. We can set attitudinal goalsand measure the degree of success or failure inmeeting these goals. If we do not measure, wewill remain ignorant, or at best impressionisticabout how well we have achieved our teachinggoals in the attitudinal domain. With the dataobtained in this study we can now look morecarefully at our curriculums with an eye to rede-signing them in specific directions in keepingwith our attitudinal goals.
Old Dogs and New Tricks John E. Fryer, M.D.
We Inevitably move into the issue of how themedical school makes decisions. I did not realizewhen I started this just how naive I was about thesystem of governance in medical schools. I didnot know, for example, that in 18 of the 20 medi-cal schools that I visited the same pattern ofgovernance holds, i.e., no matter what else oneclaims, the dean really is not a person of muchpower. Also, he uses the power he does havesparingly.
In most instances, the history of the medicalschools, particularly thosethat were in existencebefore 1930, goes something like this: A groupof department chairmen got together in theteens, the twenties, in 1970 or whenever, decidedto form a medical school, and hire a dean. Butthey chose that dean. Now in the twenties andthirties there was a period in which some medi-cal schools found themselves with a single per-son who was the dean and powerhouse, who ranthe medical school almost singlehandedly. AtTemple Medical School, where I teach, therewas a Dean Parkinson who literally was the chief
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of the hospital, dean of the medical school, vicepresident for health sciences, and chairman ofthe admissions committee. For a period of about25 years, every person that went to the medicalschool was interviewed by Dean Parkinson. WhenDean Parkinson died, and we entered into theera of the forties and fifties, it became quite clearthat power had returned tothe department chair-men, and that nothing happened in the medicalschool about which the department chairmendid not approve. This was true in 18 of the 20facilities. When the question was asked aboutwho can veto a decision about interdisciplinaryteaching most effectively and most totally, inevery medical school except two, it was the de-partment chairmen acting as a group.
In one medical school there was a faculty senatewhich was elected in which people did respond,and in one medical school there was a deanwhom I really believe had some power simplybecause the department chairmen did not careabout anything; and he was the one who ran themedical school.
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
In short, it has become apparent that any deci-sion that involves bringing new material into thecurriculumnew interdisciplinary material inparticularrequires negotiation at the depart-mental chairman level and needs the assent ofall of those people or else the dean cannot en-force it
When we talk about getting to the dean andmaking the dean do these things, we shouldknow that while the dean does have some clout,he is not necessarily going to use it on this issue.Getting to the dean is almost an irrelevancy; theissue is strong communication with the depart-ment chairmen, making them realize this isimportant.
The next step, then, is to ask how we can makean impact on these men or women who are de-partment chairpersons. The way to r'- tke animpact, it seems clear, is through an inowidualwithin that medical school department who iscommitted and willing to do the teaching, whodoes it well, and who will follow through on it. I
would submit to you that nothing gets doneunless there is that person. Particularly when weare dealing with subjects that are not necessarilypart of the usual medical school curriculum suchas alcoholism, addiction, pain management,death and dying, cancer treatment, et cetera,there need to be people who get into the curriculum who are teaching the material that theywant to teach and which they feel should betaught. Those medical schools in which therewas not such a person generally did not havethat material being taught.
The really tricky subsequent issue has to do withwhat happens beyond the initial impetus on thepart of one person to get that material into thecurriculum. How does it get permanently intothe curriculum? Let me just submit that, althought hear of a lot of hand wringing about this,. I nowhave seen many instances in which materialshave been brought into the curriculum, and thenthe medical school chairpersons have decidedthat that material was valuable enough to keepin; and it stayed in.
In summary, deans have little real power. Thechairpersons have the power and will not give itup easily. Curricular change must be carefully
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crafted by individuals who have an interest andwho can teach. More often than not, changesrise and fall on the basis of the presence orabsence of this interested faculty member, al-though changes can sometimes become a per-manent part of the curriculum.
Some strategies seem to me to be emerging.One principle that was mentioned this morningshould be repeated: and that is that just becausepeople can do research or can do clinical workwith alcoholics and drug addicts, it does not^9cessarily follow that they can teach. I thinktills is an important thing to keep in mind.
It seems to me that career teachers as a grouphave developed many very effective strategies'or generating some lasting improvements inthe curriculums of individual medical schools.
I think I would differ a bit with Mansell Pattison'scomment that it is essential to focus on the resi-dents. It seems to me that we have a whole proc-ess involving preclinical and clinical students,residents, and continuing education, in whichwe have to continue to hammer: and we have tocontinue to hammer in a variety of ways. Weshould be dealing continually with not just mak-ing more sensitive humanistic medical students,but also with influencing some very, very criticalspecific attitudes. These are attitudes toward thecare of chronic illness. Ninety percent of thecare given by most physicians is for a chronicillness problem, and we learned nothing in medi-cal school about chronic illness. Continuity ofcare, comprehensiveness of care, and attitudestoward substance abusers fall under the sameattitudinal umbrella.
On the other side is the whole issue of knowledgein the area of substance abuse; and certainly thethird crucial area is skills.
What kind of Pollyanna then have the careerteachers offered? Certainly something that mostof the career teachers have done early is developelective courses. These are variably accepted ornot accepted by the students. But from electivecourses, a lot of general course material ultimatelygrows. I feel that it is important to do electivecourses in their own right as well as to get stu-dents interested early. Some people have doneexcellent courses. The danger of one's develop-
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ing eleo is 0 s cruises is that. w hen that person kgone, nothing else happens.
.Anot her tao tic man!, of the carver teachers has eused is to assist the basit scient e rlepartments.assist those chairpersons in dome their fob bet-ter so that the students are more responsise.
I was struck when i first went to my medical schoolby the fact that biochemistry had a 3-hour clinicalcorrelation in alcoholism, and I thought how won-derful it was that we had 3 hours of clinical correla-tion, So I put on my white coat, went across thestreet , and sra in the back of the room; and who wasdoing the clinical correlation? It was the surgeon inthe hospital who treats all the esophegeal varices. Theattitude conveyed was that every alcoholic isgoing to have esophageal varices. he is going tobe bleeding to death, and he will tend to drinkagain as soon as he gets out. I went down frontand said, "You're teaching the wrong kind ofalcoholism and you're conveying to freshmenmedical students wrong attitudes; can't we do ita little differently?" Fortunately, he saw the lightand changed, because all he wanted was forthem to learn what happens to esophageal vari-ces and to the various enzymes, and to the liverso that he could teach biochemistry a little bet-ter. Ile did not really care if he had good patientsor bad patients.
Another tactic which some people hale beenusing is to become involved behavioral scienceinterdisciplinary courses in the first 2 years. I
would simply reiterate that this has to be donethrough the department chairmen and throughthe regular departmental route. I think this isultimately the most successful route. I am fortu-nate enough in my own medical school to have a102-hour course called primary care concepts inwhich I can work on chronic disease issues, usingalcoholism as a model of continuity of care, I amable to bring in alcoholics, and it works very
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well. The some thing can be done in behavioralsciences.
Beyond the medical seelent les el, much that isinnovative has been .. rte in substance abuseeducation. The career teachers have invested agreat deal of energy in residency programs. AtTemple, we are now in the process of conveninga committee made up of a vice president of theuniversity and eight faculty members to dealwith alcoholism in the ficulty. We have 4.000faculty members at Temple, and we calculatethat there are probably 300 to 400 alcoholics orother substance abusers among them. To datewe have not found other schools. and I would beinterested in knowing of any. who have devel-oped such a faculty program. We have added aprogram into the faculty handbook and are nowin the process of educating the senior facultyabout how to make use of that program. Wehave identified close to 50 alcoholics. and theyare all in various stages of treatment. There is atremenduus need. I simply would conclude thatone of the other strategies that people can use isto work with people who are faculty members.
Finally. I would like to say publicly that I amdeeply grateful for what I have learned from allmy fellow career teachers. It has been enor-mously valuable and one of the greatest influ-ences on my life in the last few years and on myteaching.
Earlier today we were talking about the careerteacher program in psychiatry in the 1960s. Inthat program, not much emphasis was put onhow to go about teaching. That could never besaid about this program. There has been an em-phasis on how you go about teaching and how youbecome involved with the planning and administra-tion of courses and getting them into a curricu-lum from the very beginning; that is addressinga truly critical issue.
ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
Biobehavioral Studies in Substance Abuse Thomas j. Crowley, M.D.
A number of the career teachers, in addition toteaching, also do scholarly research. I will dis-cuss my own current research as an example ofthe role of research in the career of a teacher insubstance abuse. The only way that I can reason-ably organize that is to present it like a news-paper. First, I am going to give you the news, andthen I am going to give you a brief editorial. I'lltell you when I am turning the page to the edi-torial.
My research concerns drug effect on social be-havior and motility in animals and man. For anumber of years I have been studying, togetherwith colleagues at Colorado, drug effects on thesocial and motor behavior of monkeys living inpens in social groups. With these animals wecould count the frequency of a variety of differ-ent social behaviors: dominant behaviors, sex-ual behaviors, associative behaviors, and soforth.
We also measured the operant work of theseanimals for food, and in addition we could quan-titate the movements of the animals. The mon-keys wore backpacks containing radiotelemetryunits, which provided us with information abouthow much the animals moved around. We thenadministered drugs, looking for drug effects onvarious behaviors. We have studied ethanol, meth-amphetamine, pentobarbital, and morphine (1),methadone (2, 3), and two brain peptides, TRHand melanocyte-stimulating-hormone-release-inhibiting factor (4, 5).
As an example, in the methadone study (2), wegave monkeys daily oral Tang (a fruit-flavoreddrink) for 6 weeks, and then for 10 weeks theyreceived Tang containing methadone each dayin doses which produced blood levels com-parable to those seen in methadone maintenanceclinics; then for 3 weeks we withdrew the metha-done and again gave the Tang alone.
When we gave methadone to these animals inthe morning we saw a very considerable increase
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in motility for several hours after each dose.Later in the day. motility declined below base-line levels.
We were hopeful that we could repeat that studyof methadone administration in man. However,there is a problem; the activity counted inmethadone-treated monkeys is meaningful onlyin comparison to the drug-free, baseline motil-ity of the same subjects, and our methadonepatients do not give us drug-free, baseline data.They transfer directly from street heroin tomethadone, and so we weren't able to replicatethat study in man.
However, LAAM (acetylmethadol) is a long-acting, methadone-like drug which is given, notevery 24 hours as is the case with methadone,but every 48 hours. We hypothesized that if manis stimulated for several hours following the ad-ministration of methadone-like drugs (as hadoccurred in our monkeys), then when LAAM Isgiven every 48 hours, perhaps we would see agreater amount of motility on the day off. Brieflystated, we predicted that activity in LAAM-treated patients would increase on the day ofLAAM administration, when compared to theday off. So we set out to study circadian rhythmsof motility in former heroin addicts who weremaintained on LAAM as outpatients.
The technique was one that we borrowed fromthe National Institute of Mental Health (6);researchers there generously loaned us a devicefor measuring motility in human beings, andwe've since produced similar units of our own.These "ammeters," worn on the shoulder,measure how much a subject moves around.Physical movement generates electrical pulseswithin the actometer. It has a timer, and It countsup these electrical signals for a period of 15minutes and then stores those counts in a self-contained computer memory chip. It then countsfor the next 15 minutes, stores up that informa-tion, counts for the next 15 minutes, stores that,
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and so forth. The actometer continues this count-ing for up to 64 hours.
We have recorded 12 patients treated with LAAMevery other day, and 5 treated with methadoneevery day; all records covered 48 consecutivehours, The LAAM patients, on the average, wereabout 50 percent more active on the day of LAAMadministration than on the day off, a very signifi-cant difference, For the methadone patients,comparing one day against the other showed nodifference in activity.
The results seem to be compatible with ourhypothesis that there might be a relative stimula-tion early in the interval between LAAM doses,and a relative depression in motility later in thesame interval, Now, clearly, the actometer meas-ures only the quantity of movement, not itsquality. I have no idea whether these patientsare more alert and more productive on the dayof LAAM administration, or whether that increasein motility is mere random hyperactivity. Thatwould appear to be an important point to beaddressed in later research.
If these findings can be confirmed, they wouldsuggest that when we put patients on every-other-day LAAM, we put them on a kind ofbehavioral roller coaster, in which their outputof behavior varies by as much as 50 percentevery other day, That kind of subtle behavioraltoxicity from a drug could have significant andprofound effects on one's life over a period oftime. These data may suggest some adverse effectfrom every-other-day LAAM administration;such data certainly would have to be consideredwhen decisions are made about whether to re-place methadone with LAAM.
That ends the news. Now comes the editorial,which may or may not be connected to the news.
I am interested in doing a certain amount ofresearch as part of my activities as a career
teacher: I feel that it contributes to my teachingability. I also think that having some kind ofscholarship behind me gives me some credibilitywith faculty colleagues where i do my teaching.
In organizing the career teacher program. NIDAand NIAAA will continue, I hope, to recognizethat researchers tend to publish, and that thosewho publish tend to stay at universities and toget tenurethere, Thus, investment in a researchermay bear long-term interest for teaching, interestthat might not be availab:e in the case of somenonpublishing faculty members. Accordingly,perhaps one goal for the career teacher pro-gram should be to include within the careerteacher group some academicians who doresearch, with the purpose of helping good re-searchers become better teachers in the field ofsubstance abuse.
REFERENCES
1. Crowley. TT: Slynes, A.1.; Hydinger, M.; and Katsimar,I.C. Ethanol, rnethamphetarnine. pentobarbital. morphine.and monkey social behavior. Archives of General Psy-chiatry. 11:829438. 1974.
2. Crowley. T1.; Hydinger, M. Stynes. A.1.; and Feiger, A.Monkey motor stimulation and altered social behaviorduring chronic methadone administration. Psycho-ftharrnacologia Merlin), 43;115-144, 1975.
3. Crowley. T.1.; Lubanovic. W.; Halberg, F., and Hydinger, F.Daily oral methadone alters circadian activity rhythms ofmonkeys. in: International Society for Chronobiology.VI International Conference Proceedings. Milan: 11 ponte.1977. pp. 395-402.
4. Crowley. T.I., and Hydinger. M, MIF, TRH, and simianSocial and motor behavior. Pharmacorogy. Biochemistry.and Behavior, SiSupplemeni 1):79-87,1976,
5. Crowley. 11., and Hydinger, M. Comparison of Onto-tropin-releasing hormone with metanocyte-stimulatinshormone-releaseinhibiting factor as pentobarbital aniag-onists in monkeys. Psychopharmacology, 53:205-206,1977.
6, Colbourne, T.R.: Smith. B.M.; Guarini.l.l.; et at. An am-bulatory activity monitor with a solid slate memory. Bio-medical Sciences instrumentation, 12:117-122,1976.
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ALCOHOL AND DRUG ABUSE IN MEDICAL EDUCATION
AA and the Physician Kenneth Williams, M.D.
I am an internist teaching in a department ofpsychiatry. and I spend about half my time work-ing with alcoholic patients and their families,
1 have been fairly active in trying to educate theprimary care physician about alcoholism, It is agreat idea: Go out to the doctor who is alreadypracticing primary care, give him a few skillsregarding diagnosis of alcoholism and what hecan do to treat it. and then presumably we shallget many more people being treated for alcohol-ism. Unfortunately. I am not really sure it can bedone. I know it cannot be done easily, We talkedin our small groups this morning about many ofthe problems, even trying to recruit primary carephysicians to come to a conference to hear aboutalcoholism.
What I try to do in my activities in this regard is tobeat down a few more common misconceptionsabout alcoholism, educate physicians about diag-nosis.showthem how to use Antabuse, and howto refer to AA.
The film on Alcoholics Anonymous tries to givedoctors visible proof that something can be donefor the alcoholic patient. Many health care pro-fessionals have never seen a recovering alcoholic.I had not until I had been a physician for 10years. I think the attitude that one gets seeingpeople only in the active phase of their illnesscan be a very discouraging one. Yet at a universityhospitalin fact most hospitalswhat one seesis people in the active phase of their illness com-ing back to the hospital again and again. I hadn'tseen anybody recovering from alcoholism until Iwent to an AA meeting.
When I speak to a group of health care profes-sionals, I often try to bring an AA member withme as living proof that something can be done,that people-can recover. The film is a way ofbringing a lot of AA members with me at onetime to impact upon the physicians to say "yes,something Can be done."
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What the film does for health care professionalscan be summarized as follows: (1) It shows themthat recovery from alcoholism can occur, byshowing examples, (2) It educates the healthcare professional regarding Alcoholics Anony-mous (by answering many misconceptions aboutAA), (3) The film gives something of the flavor ofan AA meeting and shows that many differenttypes of people can benefit by referral to AA. (4)It shows the health care professional with a drink-ing problem (who might be in the audience, andI think we should assume that somewherebetween 10 and 12 percent of the audience willhave an active drinking problem at the time)where he might obtain helpin the film thereare two physicians and one nurse who aremembers of AA. (5) The film highlights problemsthat can occur when a doctor prescribes mind-altering medicines for an alcoholic. in my expe-rience this is the most difficult area about whichto educate the primary care physician. Showingpeople who have become cross-addicted is oneof the better ways to convince the physician to bemore careful in his prescribing of mood-alteringdrugs. The film has two examples of cross-addic-tion, one to other sedatives and one to ampheta-mines. It also gives an example of iatrogenicalcoholism. A housewife who would not everhave drun k alcohol on her own, since her motherand father had both died of alcoholism, was pre-scribed alcohol by her first pediatrician. (It isrecommended still in La Leche League book fornursing mothers to drink beer at bedtime.) Shewas told to take two beers at bedtime, but littledid the physician know that she would have sixchildren and nurse each for 9 months. Then thesame woman was again prescribed alcohol as anappetite stimulant. (6) The film encourages thedoctor to do something about his patients'alcoholism, to confront his patients and suggestto them that he can refer them to AA.
Now most of us who have tried to get an alco-holic patient to go to AA know it is not a very
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easy thing to do. It is rare that a patient says. -Ohboy. Doc. AA is just v. hat I always wanted.- Thedoctor has to use all the persuasion at his com-mand to get his patient to go to the meeting.One of the most effective sv ays for a doctor torefer a patient to AA is for the doctor himself tobe knowledgeable about AA. I think the bestthing for him to do is to go to an AA meeting. ihave recommended this to a number of doctors.I did a careful followup of 1 group of 78 primarycare physicians to whom I strongly emphasizedthe importance of going to AA meetings; noneof them ever did.
So the film is a way of bringing the meeting tothis group who will probably never go to a meet-ing even though it is a good idea. I believe that adoctor's ability to use AA is in direct proportionto his enthusiasm about the program, and if thefilm serves to educate him and provide a little bitof enthusiasm about the AA program, I think hewill be much better able to refer patients.
A pretest was prepared to be given with themovie on AA. 1, ery briefly, the results show twogroups that have viewed this film. One, a groupof 232 physicians who are mostly in clinical prac-tice, was the group for which I originally designedthe film. They had never been to an AA meeting.
The other group is everybody who has everlooked at the film-862 people. 20 percent ofwhom are not physicians, They are pr: 'v alco-holism counselors; 14 percent of tilt, .oneto more than 10 AA meetings, I st., theselatter are, in fact, AA members looking at the film.
Very interestingly, it looks as though there aretwo distinct population groups of physicians.Those who have been to one AA meeting formone group, and those who have never been toan AA meeting form another group. The twogroups as groups answer all the rest of the ques-
rr U.S. GOVERNMENT PRINTING orrice: isto- 316.774 6101
tions very, very differently. Their attitudes andtheir impressions about AA are entirely different.
I could not understand why 76 percent of the totalsaid they do encourage alcoholic patients to goto AA: I really can hardy believe that. I thinkthey answered what they thought I wanted tohear or what they would like to do.
Regarding the question, "What is your feeling ofthe role of AA as an aid in the recovery of alco-holic persons?" the group of physicians aver-aged a very high regard for AA.
This substantiates the findings of earlier studiesin California showing that practicing physiciansdo have a very high regard for AA, However,they are somewhat misinformed about AA. Ithink the major misconception is revealed intheir answer to the following true or false ques-tion: "Alcoholics Anonymous is a voluntary self-help group whose philosophy advocates theelimination of alcohol use from our society." Inthe question, AA was being equated with a tem-perance movement. Almost half of the physi-cians who had never been to a meeting said thiswas a true statement.
AUTHORS
Joseph Schoolar is affiliated with the Baylor Col-lege of Medicine; George S. Tyner. with theTexas Tech University School of Medicine; JohnN. Chappel, with the University of Nevada atReno; Ronald S. Krug, with the University ofOklahoma Health Sciences Center; John E. Fryer.with the Temple University School of Medicine;Thomas J. Crowley, with the University of Colo-rado Medical Center; and Kenneth Williams,with the University of Pittsburgh School ofMedicine.
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