A 2012 survey of internal medicine residents at Massachusetts General Hospital (MGH) – one of the nation's leading teaching hospitals – found that more than half rated the training they had received in addiction and other substance use disorders as fair or poor. Significant numbers felt unprepared to diagnose or treat such disorders, results similar to surveys of practicing physicians. In response to the findings, recently published online in the journal Substance Abuse, the MGH has increased residents' training in addiction medicine.
"Our residents estimated that one in four hospital inpatients has a substance use disorder, which matches what other studies have found and represents a disease prevalence similar to that of diabetes," says Sarah Wakeman, MD, chief medical resident at MGH and lead author of the report. "Finding that the majority of residents feel unprepared to treat addiction and rate the quality of their education so low represents a tremendous disparity between the burden of disease and the success of our current model of training."
The study's authors note that residents provide most direct medical care in teaching hospitals and often find caring for patients with addictions to be troublesome – possibly due to a lack of training and faculty role models – which can lead to a lack of trust between patients and physicians. Several previous studies have pointed out deficiencies in addictions education for primary care and internal medicine residents, with some programs offering none at all. Wakeman explains, "Our findings are in line with previous data from training programs that reported limited addictions training and with studies of medical residents showing low satisfaction in caring for addicted patients. It is unlikely that MGH is unique in this educational deficiency, but rather these findings may demonstrate a critical failure in medical education as a whole."
Wakeman and her colleagues designed their survey to assess residents' basic knowledge of substance use disorders, how they evaluated the training they had received and how prepared they felt to diagnose and treat addiction to alcohol or drugs. In May 2012 the survey was e-mailed to all MGH residents in internal medicine, primary care and in a joint medicine/pediatrics residency – a total of 184 recipients. Survey recipients were informed that their participation was voluntary and anonymous, and 101 of them completed and returned the survey. The authors note that while psychiatrists care for many patients with addiction, people with substance use disorders are most likely to seek medical care from internists, often for problems caused by their addictions.
At the time the survey was taken, formal addiction training for most residents was confined to a single noontime conference on alcohol withdrawal and three highly rated lectures on addiction-related topics during ambulatory rotations. The primary care residency, however, included an intensive two-week outpatient rotation in addictions, which was available as an elective to other residents. One quarter of survey respondents indicated feeling unprepared to diagnose addiction, and 62 percent felt unprepared to treat it. Addictions training in the outpatient setting was rated fair to poor by 72 percent of respondents, and 56 percent rated inpatient addictions training as fair to poor. In contrast, 95 percent of participants in the primary care addictions rotation rated it as good or excellent.
Participants were also asked six questions evaluating their knowledge about diagnosing and treating substance abuse, and while their diagnostic answers were more accurate than their knowledge of treatment options – including the available FDA-approved medications – none of them answered all questions correctly, and only 6 percent correctly answered all three questions regarding pharmacologic treatment options for addiction. How many years into residency the respondents were made no significant differences in any of the survey responses.
James Morrill, MD, PhD, an MGH internist and core faculty member of the outpatient addictions elective rotation, says, "It's time to bring the level of addictions education in elite medical training programs like MGH's up to the same high level that residents receive in areas such as cardiology. We need to help our residents recognize the great potential of primary care to stem the tide of morbidity and mortality due to addiction and keep addicted patients in treatment and out of the hospital."
Also on the faculty of the outpatient addictions rotation, Michael Bierer, MD, an MGH internist specializing in addiction treatment, says, "Addictions are highly prevalent; they affect general health and health care, break up families and cause suffering that extends beyond the patients themselves. But they are highly treatable. Ignoring these problems doesn't make sense from any perspective, and doing the right thing at the right time is not hard. Treating addictions well is certainly no more complex than some of the sophisticated skills our residents typically master."
In response to the survey's findings, the MGH has expanded resident education on addictions – adding another ten noontime conferences and including addiction case histories in 25 percent of ambulatory intern reports. Wakeman and her co-authors are now repeating the survey to assess the impact of those changes. They also hope to expand the survey to a national sample of residents to determine whether their findings can be broadly applied to programs nationwide. Wakeman, Morrill, Bierer and several other faculty members have formed a group that meets monthly to discuss additional educational needs in addiction medicine and develop more resources for MGH residents.
"Along with designing new addiction treatment models, the more we can involve patients in our educational programs, the better," Wakeman says. "Having patients involved in lectures and in small-group teaching settings may help residents develop more empathy for the courageous men and women living with and recovering from addiction. And as we enter an era of patient-centered medical homes, having patients as the central focus point of our care models is crucial."