Internal Medicine Resident Addiction Training at the Veteran's Health Administration: A Qualitative Evaluation of Site Directors' Response to the 2022 ACGME Requirements.

BACKGROUND: Substance use disorders (SUDs) are prevalent in the USA yet remain dramatically undertreated. To address this care gap, the Accreditation Council for Graduate Medical Education (ACGME) approved revisions to the Program Requirements for Graduate Medical Education (GME) in Internal Medicine, effective July 1, 2022, requiring addiction medicine training for all internal medicine (IM) residents. The Veterans Health Administration (VHA) is a clinical training site for many academic institutions that sponsor IM residencies. This focus group project evaluated VHA IM residency site directors' perspectives about providing addiction medical education within VHA IM training sites. OBJECTIVE: To better understand the current state, barriers to, and facilitators of IM resident addiction medicine training at VHA sites. DESIGN: This was a qualitative evaluation based on semi-structured video-based focus groups. PARTICIPANTS: Participants were VHA IM site directors based at a VHA hospital or clinic throughout the USA. APPROACH: Focus groups were conducted using a semi-structured group interview guide. Two investigators coded each focus group independently, then met to create a final adjudicated coding scheme. Thematic analysis was used to identify key themes. KEY RESULTS: Forty-three participants from 38 VHA sites participated in four focus groups (average size: 11 participants). Six themes were identified within four pre-defined categories. Current state of training: most VHA sites offered no formal training in addiction medicine for IM residents. Barriers: addiction experts are often located outside of IM settings, and ACGME requirements were non-specific. Facilitators: clinical champions help support addiction training. Desired next steps: participants desired incentives to train or hire local champions and a pre-packaged didactic curriculum. CONCLUSIONS: Developing competent clinical champions and leveraging VHA addiction specialists from non-IM settings would create more addiction training opportunities for IM trainees at VHA sites. These insights can likely be applied to IM training at non-VHA sites.

Online medical student OSCE examinations during the first three years of the COVID-19 pandemic compared to three years pre-pandemic: An Australian experience in psychiatry and addiction medicine.

PURPOSE: We have evaluated the final-year Psychiatry and Addiction Medicine (PAM) summative Objective Structured Clinical Examination (OSCE) examinations in a four-year graduate medical degree program, for the previous three years as a baseline comparator, and during three years of the COVID-19 pandemic (2020-2022). METHODS: A de-identified analysis of medical student summative OSCE examination performance, and comparative review for the 3 years before, and for each year of the pandemic. RESULTS: Internal reliability in test scores as measured by R-squared remained the same or increased following the start of the pandemic. There was a significant increase in mean test scores after the start of the pandemic compared to pre-pandemic for combined OSCE scores for all final-year disciplines, as well as for the PAM role-play OSCEs, but not for the PAM mental state examination OSCEs. CONCLUSIONS: Changing to online OSCEs during the pandemic was related to an increase in scores for some but not all domains of the tests. This is in line with a nascent body of literature on medical teaching and examination following the start of the pandemic. Further research is needed to optimise teaching and examination in a post-pandemic medical school environment.

A level playing field? Evaluation of the virtual Objective Structured Clinical Examination in Psychiatry and Addiction Medicine: A mixed methods study.

OBJECTIVE: The Objective Structured Clinical Examination (OSCE) has been used for clinical assessment of a broad range of medical student competencies in Psychiatry and Addiction Medicine. However, there has been little research into online assessments. We investigated the virtual OSCE (v-OSCE) from the user perspective to better understand its acceptability, usefulness, benefits, challenges and potential improvements. METHODS: At the conclusion of the v-OSCE, all participants (medical students, examiners and simulated patients) were invited to participate in a brief online survey, based on the Technology and Acceptance Model. Freeform qualitative feedback was also obtained to explore participants' experiences and attitudes. RESULTS: Participants reported the v-OSCE was acceptable, efficient, convenient and easy to use. It was perceived as useful for demonstrating students' interviewing skills and interacting with the simulated patient. Benefits included greater convenience, reduced stress and travel time. Challenges were similar to those experienced in 'real world' telepsychiatry, primarily related to assessment of non-verbal cues and emotional prosody. CONCLUSIONS: Our findings inform recommendations for improving online examinations. These include increased preparation, practice and professionalism, to better simulate the in-person experience. Study credibility was strengthened by the triangulation of qualitative, quantitative and psychometric data.

Commentary on alignment of medical student assessment and vocational training in psychiatry and addiction medicine.

OBJECTIVE: To comment upon the potential for alignment of medical student assessment and vocational specialist training through the RANZCP-CanMEDS model of Entrustable Professional Activities (EPAs) and Workplace-Based Assessments (WBAs). We discuss a specific post hoc example of such an alignment in an Australian graduate medical school in Psychiatry and Addiction Medicine. CONCLUSIONS: Vocational training models of assessment, such as the RANZCP specialist training program for psychiatrists, can potentially be mapped to medical student education in formative and summative assessment through CanMEDs-based EPAs and WBAs, to assist in transition to specialist training.

Final-year medical student Psychiatry and Addiction Medicine synchronous summative tele-assessments during a COVID-19 Delta-variant stay-at-home lockdown.

OBJECTIVE: We describe the planning, process and evaluation of final-year Psychiatry and Addiction Medicine summative assessments in a four-year graduate medical degree program, during a COVID-19 Delta-variant public health stay-at-home lockdown. CONCLUSIONS: We conducted separate written and clinical synchronous (real-time simultaneous) tele-assessments. We used online assessment technology with students, examiners and simulated patients, all in different physical locations. Medical students' examination performance showed a good range. This was comparable to other discipline stations, and performance in previous years. There was no differential performance of students through the day of the assessments.

Flattening the curve of COVID-19 for medical education in psychiatry and addiction medicine.

OBJECTIVE: To describe the context, challenges and responses to COVID-19 public health measures for medical education in psychiatry, with an emphasis on sharing strategies for ongoing COVID-19 challenges. CONCLUSION: The rapidity of COVID-19 public health measures instituted in Australia required swift action for medical education to address lockdowns of student clinical placements. The responses included a transition to interim online learning followed by a return to truncated clinical placements renegotiated to conform to public health measures. Adjustment of formative and summative assessment has been necessary. However, further contingencies may emerge depending upon the overall progress of the COVID-19 pandemic.

Addiction Psychiatry and Addiction Medicine: The Evolution of Addiction Physician Specialists.

Addiction Psychiatry and Addiction Medicine are two physician subspecialities recognized by the American Board of Medical Specialties (ABMS) that focus on providing care for patients with substance use disorders. Their shared and distinct historical roots are reviewed, and their respective ABMS board examination content areas and Accreditation Council on Graduate Medical Education (ACGME) fellowship training program requirements are compared. Addiction Psychiatry, a subspecialty under the American Board of Psychiatry and Neurology, began certifying diplomates in 1993, currently has 1202 active diplomates, and certifies around 150 diplomates every 2 years through 50 ACGME-accredited fellowships. Addiction Medicine, a subspecialty under the American Board of Preventive Medicine, began certifying diplomates in 2018, has 2604 diplomates with more expected before the practice pathway closes (anticipated in 2021), after which a fellowship training becomes required. Currently there are 78 accredited Addiction Medicine fellowships and more under development. The fields display substantial overlap between their respective examination content areas and fellowship training requirements, covering similar knowledge and skills for evaluation and treatment of substance use disorders and psychiatric and medical comorbidities across the full range of clinical settings, from general medical to addiction specialty settings. Key differences include that Addiction Psychiatry is open only to Board-certified psychiatrists and places extra emphasis on psychotherapeutic and psychopharmacological management strategies. Addiction Medicine is open to any ABMS primary specialty, including psychiatry. Opportunities for collaboration are discussed as both fields pursue the common goal of providing a well-trained workforce of physicians to meet the public health challenge presented by addiction. (Am J Addict 2020;00:00-00).

Faculty education in addiction training (FEAT): Evaluating an online training program for multidisciplinary health professions educators.

Background: Many health professionals lack adequate training needed to effectively address alcohol and other drug (AOD)-related problems. Building upon our previously successful in-person faculty training programs, we designed and pilot tested the brief online Faculty Education in Addiction Training (FEAT) Program for social work and internal medicine residency faculty. The present study examines baseline and post-FEAT Program AOD knowledge and teaching confidence and preparedness among faculty participants. Methods: The FEAT Program curriculum included didactic videos, online engagement with content experts, recommended readings, and a live virtual classroom experience. Participants completed self-assessments of knowledge and teaching confidence and preparedness pre- and post-FEAT program. Results: In this pilot test, thirty faculty completed the FEAT program: 15 social work and 15 internal medical residency program faculty. Both groups showed significant improvement (p < 0.001) in overall AOD-related knowledge with medium-to-large effects (Cohen's d = 1.83 [social work], 0.72 [medicine]). Both groups showed significant increases in teaching confidence (p < 0.001) for all items with large effects (Cohen's d values range from 1.08 to 1.92) and significant increases and large effects for all teaching preparedness items for social work (at least p < 0.01 | Cohen's d range = 1.03-1.56) and internal medical residency faculty (p < 0.001 | Cohen's d range = 1.08-1.69). Conclusions: Multidisciplinary health professions educators' AOD knowledge and teaching confidence and preparedness can be improved by participation in a brief online program designed to circumvent the logistical and fiscal challenges presented by in-person programs.

In-hospital training in addiction medicine: A mixed-methods study of health care provider benefits and differences.

Background: Hospital-based clinical addiction medicine training can improve knowledge of clinical care for substance-using populations. However, application of structured, self-assessment tools to evaluate differences in knowledge gained by learners who participate in such training has not yet been addressed. Methods: Participants (n = 142) of an elective with the hospital-based Addiction Medicine Consult Team (AMCT) in Vancouver, Canada, responded to an online self-evaluation survey before and immediately after the structured elective. Areas covered included substance use screening, history taking, signs and symptoms examination, withdrawal treatment, relapse prevention, nicotine use disorders, opioid use disorders, safe prescribing, and the biology of substance use disorders. A purposefully selected sample of 18 trainees were invited to participate in qualitative interviews that elicited feedback on the rotation. Results: Of 168 invited trainees, 142 (84.5%) completed both pre- and post-rotation self-assessments between May 2015 and May 2017. Follow-up participants included medical students, residents, addiction medicine fellows, and family physicians in practice. Self-assessed knowledge of addiction medicine increased significantly post-rotation (mean difference in scores = 11.87 out of the maximum possible 63 points, standard deviation = 17.00; P < .0001). Medical students were found to have the most significant improvement in addiction knowledge (estimated mean difference = 4.43, 95% confidence interval = 0.76, 8.09; P = .018). Illustrative quotes describe the dynamics involved in the learning process among trainees. Conclusions: Completion of a hospital-based clinical elective was associated with improved knowledge of addiction medicine. Medical students appear to benefit more from the addiction elective with a hospital-based AMCT than other types of learners.

Incorporation of Universal Prevention Curriculum into established academic degree study programme: qualitative process evaluation.

OBJECTIVE: Comprehensive bachelor's, master's, and doctorate-level curricula of Addiction Studies (Addictology) were developed and implemented at Charles University (First Faculty of Medicine) between 2003 and 2012. This Prague model combines three evidence-based approaches to addressing substance use - prevention, treatment, and public health - into a balanced professionalised discipline. Graduates from this programme are licensed by the State Authority as addictology, a regulated profession in the Czech Republic. Professionals with these degrees are recognised as healthcare professionals, can perform directly in the field and can be contracted by health insurance companies. In 2016, it was decided to integrate the Universal Prevention Curriculum (UPC) into these programmes of study. The UPC was developed by a group of prevention researchers from the United States. This article describes the technical steps involved when adapting the UPC into an established university degree programme. We describe the requirements needed for successful implementation and reaccreditation. Finally, we examine both barriers and enhancers of the adoption of UPC as a university programme. METHODS: A qualitative process evaluation study was conducted on the activities carried out in 2017-2018, demarcated by a successful university accreditation of the new curricula combining the original Prague model and the UPC curriculum. Field records, observation methods, official documents, curricular documents, syllabuses, content analysis, and thematic analysis were used for this process. RESULTS: We identified three clusters of issues and challenges during the adaptation and implementation process: technical (developing a new credit scheme, adopting new terminology using local and culture-specific examples, and cancelling, establishing, and/or fusing particular courses, identifying some critical issues for any practical implementation of the UPC); teaching staff-related (team work, involving motivated and qualified staff for moving from a national to an international perspective); and content and contextual (the conflict between different theoretical perspectives such as public health vs. mental health and drug use prevention vs. risk behaviour prevention). CONCLUSION: The adaptation of the UPC had a significant impact on study profiles and competencies. Such an implementation necessarily requires a team of staff members with sufficient capacities to be able to coordinate the process, facilitating each step and supervising it. The current adaptation of the UPC involved specific merging procedures to fit in with existing courses and emphasising an international perspective. This process opened a national discussion about the implementation of the UPC in the system of life-long education programmes and training. Beginning in September 2019, when the first group of students will attend this new model of Addictology studies, we will continue our evaluation of the implementation process and the factors that played a role in either hindering or supporting the implementation. The findings from this evaluation will be used to make adjustments to the curriculum.

National Addiction-specific Institutional Infrastructure - fundamental prerequisite for successful implementation of specialized academic degree study programmes: a case study in historical perspective.

OBJECTIVE: Human resources are crucial for addiction treatment and prevention services, as well as for science and research. The aim of this historical case study is to explain and demonstrate the role of specialized university academic degree study programmes in addictions in the context of a national institutional infrastructure. This specific group of very highly specialized academic programmes represents the highest level of professional development and is producing a totally new generation of addiction specialists with a very distinctive professional identity. METHODS: The study protocol is based on a case study research design and the case is defined as the historical development of addiction specialized institutions closely related to self-help, prevention, and treatment activities on the historical territory of the Czech Republic. We identified relevant historical sources related to establishing and/or running activities or institutions according to the categories specified in our concept of the national institutional infrastructure. All the materials and sources that were collected were sorted according to a timeline and categories of institutions and we systematically determined the first recorded activity/institution in each particular category. For this simple sorting system we used open and selected coding according to Grounded Theory. RESULTS: The public health model developed by Thomas Babor recognizes six different structural mechanisms to support university-based programmes in addiction studies: specialized journals, research centres, professional societies, specialized libraries and documentation centres, training and education programmes and institutions, and funding agencies. We attempted to redefine the concept of addiction studies within the broader context of the addiction field and added three additional mechanisms of support: public interest groups, self-help groups, and service providers. Using a historical case study in the Czech Republic, we demonstrate the potential for a broader context and interaction between these support mechanisms and academic institutions hosting academic programmes in addiction studies. CONCLUSION: The process of establishing integrated addiction studies programmes at Charles University in the Czech Republic had its origins in, and support from, various national institutions and professional organizations. This allowed the university to develop academic programmes at the bachelor's, master's, and Ph.D. levels. The availability of career opportunities for advanced-level addiction professionals in the Czech Republic was also a critically important factor in developing sustainable academic programmes in addiction studies. Our experience is that the creation of successful and sustainable academic programmes for addiction professionals is difficult to achieve without broad infrastructure support, national advocacy efforts, and legislative change at the national level.

Addictions Training in Child and Adolescent Psychiatry Fellowships.

OBJECTIVE: The primary purpose of this article is to identify current gaps in adolescent addictions training in order to develop a strategic plan to enhance clinical and didactic curricula for child and adolescent psychiatry fellowships. METHODS: The American Association of Directors of Psychiatric Residency Training (AADPRT) Taskforce on Addictions was assembled in 2017 and consisted of 10 AADPRT members and 4 consultants to the committee with known experience in addictions treatment and training. A 21-item survey was developed and disseminated to all AADPRT members who were Child and Adolescent Psychiatrist (CAP) fellowship directors using the AADPRT Listserv (n = 109). Data were exported from the SurveyMonkey platform to provide deidentified responses to each question. RESULTS: Forty-seven programs (43%) responded to the survey. In supervision and education, 40.43% of programs denied making use of expertise from Addiction Psychiatry Fellows, faculty, and resources. Common reasons for not offering specific teaching and clinical exposure include a limited number of faculty/staff, limited number of faculty/staff with expertise, and insufficient clinical sites. Curriculum content and teaching exposure varied substantially between programs. CONCLUSION: While a lack of services in adolescent addictions may be a limiting factor, developing expertise through faculty development activities, as well as nationally disseminated model curricula with educational resources has the potential to improve national adolescent addictions training.

Effective Strategies for Working With Patients With Substance Use Disorders.

Substance use is at epidemic proportions in the United States. Substance use disorders (SUDs) are difficult to treat and considered to be chronic with a high mortality rate. Nurses are in a prime position to help patients with SUDs in a variety of settings, but they often lack knowledge about the disorder and the skills to provide effective care. The identification and treatment of co-occurring disorders, such as trauma, are important when providing care for patients with SUDs. Empathy and perspective taking were once thought to be helpful when working with patients, but evolving thought is that compassion is more effective as it involves feeling for, and not with, patients and includes taking action to help another. Harm reduction strategies, such as accepting people where they are, as well as the use of motivational interviewing strategies are also effective when working with patients with SUDs. Involving patients with SUDs in their treatment plans through shared decision making is also effective in building a therapeutic relationship and improves outcomes. [Journal of Psychosocial Nursing and Mental Health Services, 57(9), 11-15.].

Promoting addiction medicine teaching through functional mentoring by co-training generalist chief residents with faculty mentors.

BACKGROUND: Generalist physicians should play a vital role in identifying and managing individuals with substance use but are inadequately trained to do so. METHODS: This 5-year (2008-2012) controlled educational study assessed whether internal medicine and family medicine chief residents' (CRs) addiction medicine teaching increased by co-training with faculty mentors at a Chief Resident Immersion Training (CRIT) program in addiction medicine. All CRIT CR attendees identified a residency program faculty mentor to support addiction medicine teaching after CRIT through functional mentoring with a focus on developing and implementing an Addiction Medicine Teaching Project ("Teaching Project"). Approximately half of the CRs attended CRIT with their mentor (co-trained) and half without their mentor (solo-trained). Addiction medicine teaching outcomes were compared between groups using 6- and 11-month questionnaires and 4 bimonthly teaching logs. Of co-trained CRs, mentor characteristics that positively influenced addiction medicine teaching outcomes were identified. RESULTS: One hundred CRs from 74 residency programs attended CRIT from 2008 to 2012; 47 co-trained with their mentors and 53 solo-trained without their mentors. At 6-month follow-up, the co-trained CRs were more likely to meet at least monthly with their mentor (22.7% vs. 9.6%, P < .01) and more likely to identify their mentor as a facilitator for Teaching Project implementation (82.2% vs. 38.5%, P < .01). At 11-month follow-up, a higher percentage of co-trained CRs had completed their Teaching Project (34.0% vs. 15.1%, P < .05). Both CR groups had similarly large increases in other addiction medicine teaching outcomes. Mentors with more experience, including years of teaching, was associated with better CR Teaching Project outcomes. CONCLUSIONS: Co-training generalist chief residents with a faculty mentor appeared to facilitate functional mentoring-driven Teaching Project implementation but did not further increase already high levels of other addiction medicine teaching. Faculty mentors with more years of teaching experience were more effective in facilitating Teaching Project implementation.

Training in office-based opioid treatment with buprenorphine in US residency programs: A national survey of residency program directors.

BACKGROUND: The prevalence of opioid use disorder (OUD) has increased sharply. Office-based opioid treatment with buprenorphine (OBOT) is effective but often underutilized because of physicians' lack of experience prescribing this therapy. Little is known about US residency training programs' provision of OBOT and addiction medicine training. METHODS: The authors conducted a survey of residency program directors (RPDs) at all US residency programs in internal medicine, family medicine, and psychiatry to assess the frequency with which their residents provide care for OUD, presence and features of curricula in OBOT and addiction medicine, RPDs' beliefs about OBOT, and potential barriers to providing OBOT training. RESULTS: The response rate was 49.5% (476 of 962). Although 76.9% of RPDs reported that residents frequently manage patients with OUD, only 23.5% reported that their program dedicates 12 or more hours of curricular time to addiction medicine, 35.9% reported that their program encourages/requires training in OBOT, and 22.6% reported that their program encourages/requires obtaining a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine. Most RPDs believe that OBOT is an important treatment option for OUD (88.1%) and that increased residency training in OBOT would improve access to OBOT (73.7%). The authors also found that programs whose RPD had favorable views of OBOT were more likely to provide OBOT and addiction medicine training. Psychiatry programs were most likely to provide OBOT training and their RPDs most likely to have beliefs about OBOT that were positive. Commonly cited barriers to implementing OBOT training include a lack of waivered preceptors (76.9%), competing curricular priorities (64.1%), and a lack of support (social work and counseling) services (54.0%). CONCLUSIONS: Internal medicine, family medicine, and psychiatry residents often care for patients with OUD, and most RPDs believe that increased residency training in OBOT would increase access to this treatment. Yet, only a minority of programs offer training in OBOT.