A Telemedicine Approach to Increase Treatment of Alcohol Use Disorder in Primary Care: A Pilot Feasibility Study.

BACKGROUND AND AIMS: Unhealthy drinking is a leading threat to health, yet few people with alcohol use disorder (AUD) receive treatment. This pilot tested the feasibility of addiction medicine video consultations in primary care for improving AUD medication adoption and specialty treatment initiation. METHODS: Primary care providers (PCPs) received training and access to on-call addiction medicine consultations. Feasibility measures were training attendance, intention to use the service and/or AUD pharmacotherapy, and user feedback. Secondary outcomes were utilization, prescription and treatment initiation rates, and case reports. χ2 tests were used to compare prescription and treatment initiation rates for consult recipients and non-recipients. RESULTS: Ninety-one PCPs (71.1%) attended a training, and 60 (65.9%) provided feedback. Of those, 37 (64.9%) mentioned pharmacotherapy and 41 (71.9%) intended to use the video consult service. Of 27 users, 19 provided feedback; 12 (63.1%) rated its value at 8 or above, on a scale of 1 to 10 (average 6.9). The most useful aspect was immediacy, and users wanted an easier workflow and increased consultant availability. Of 32 patients who received a consult, 11 (34.4%) were prescribed naltrexone, versus 43 (6.4%) of non-recipients (P < 0.0001); 11 (34.4%) initiated specialty treatment, versus 105 (19.7%) of non-recipients (P < 0.05). CONCLUSIONS: PCP training attendance and feedback suggest that an addiction telemedicine consult service would be valuable to PCPs and might increase AUD medication uptake and specialty addiction treatment initiation. However, future research should include significant modifications to the piloted telemedicine model: robust staffing and simpler, more flexible methods for PCPs to obtain consults.

Self-reflection in multicultural training: be careful what you ask for.

Self-reflection in multicultural education is an important means to develop self-awareness and ultimately to change professional behavior in favor of more equitable health care to diverse populations. As conceptualized by scholars in the field of psychology, racial identity theory is critical to understanding and planning for the potentially wide range of predictable reactions to provocative activities, including those negative reactions that do not necessarily herald a flaw in programming. Careful consideration of racial identity developmental phases can also assist program planners to optimally meet the needs of individual physician trainees in their ongoing constructive professional and personal development, and in strategically mobilizing and having ready the type of institutional leadership that supports trainees' change processes. The authors focus on white physician trainees, the largest racial group of U.S. physicians and medical students. They first explain what they mean by the terms white and nonwhite. Racial identity theory is then applied, with true case examples, to explore such issues as where the self-proclaimed "color-blind" trainee fits into this theoretical schema, and how medical educators can best serve trainees who are resistant or indifferent to discussions of racism in medicine and equity in health care delivery. Ultimately, the authors' goal is to demonstrate that engendering genuine self-reflection can substantively improve the delivery of health care to the nation's diverse population. To help achieve that goal, they emphasize what to anticipate in effecting optimal trainee education and how to create an institutional climate supportive of individual change.

Dialogue as skill: training a health professions workforce that can talk about race and racism.

Efforts in the field of multicultural education for the health professions have focused on increasing trainees' knowledge base and awareness of other cultures, and on teaching technical communication skills in cross-cultural encounters. Yet to be adequately addressed in training are profound issues of racial bias and the often awkward challenge of cross-racial dialogue, both of which likely play some part in well-documented racial disparities in health care encounters. We seek to establish the need for the skill of dialoguing explicitly with patients, colleagues, and others about race and racism and its implications for patient well-being, for clinical practice, and for the ongoing personal and professional development of health care professionals. We present evidence establishing the need to go beyond training in interview skills that efficiently "extract" relevant cultural and clinical information from patients. This evidence includes concepts from social psychology that include implicit bias, explicit bias, and aversive racism. Aiming to connect the dots of diverse literatures, we believe health professions educators and institutional leaders can play a pivotal role in reducing racial disparities in health care encounters by actively promoting, nurturing, and participating in this dialogue, modeling its value as an indispensable skill and institutional priority.