Enhancement of Medical Student Attitudes in the Treatment of Patients with Substance Use Disorders: a Follow-up Study

To the Editor:

Substance use disorders (SUD), one of the costliest public health problems in the USA [1], are characterized by denial and rationalization, which may generate strong countertransference among clinicians. Attitudes towards patients with SUD may be also influenced by clinicians’ adverse personal experiences involving family or friends with addiction. Clinicians’ confidence and role legitimacy are associated with better standards of screening and treatment practices for patients with SUD [2]. Conversely, negative attitudes towards patients with SUD may impact the quality of care provided [3]. Hence, effective treatment approaches require a specific set of attitudes from clinicians. In disproportion to these clinical challenges, the training in addiction in some medical schools focuses largely on transmitting scientific knowledge, and comparably less attention is given to attitudes central to effective prevention and treatment [4]. Given that medical students train under physicians from a broad array of disciplines, they may be particularly exposed to greater variation of attitudes towards addiction.

Considering this, we developed and administered a focused and structured addiction curriculum to psychiatry clerkship medical students. First, we conducted a cross-sectional study comparing the attitudes of those students exposed to the curriculum to those who were not, the results of which were published in Academic Psychiatry in 2017 [5]. Second, to further validate these results, we examined the effects of this educational program by comparing the attitudes of a different cohort of students before and after completion of the curriculum.

The Human Subjects Committee at the school of medicine reviewed and provided exemption for this study. Over the course of 12 months, we recruited 27 medical students to voluntarily and anonymously participate in a survey, before and after completion of their randomly assigned 3-week clerkship rotation in the psychiatric emergency room (PER) at a Veteran Affairs (VA) Hospital. Those involved in evaluating student performance were blinded to which students completed the survey. The intervention in the current study was composed by our previously published curriculum [5], which had two primary components: (1) graduating levels of student independence in evaluating patients in the PER, based on individual student performance scored by the same supervisor; and (2) a series of seven lectures given by staff members of the PER. The lecture topics included the following: (1) the disease model of addiction, (2) opioid use disorder, (3) alcohol use disorder, (4) Alcoholics Anonymous, (5) suicide risk assessment, (6) personality disorders, and (7) legal issues.

Data were collected via an anonymous paper survey. Attitudes towards addiction were surveyed using a 5-point Likert Scale for 19 different questions related to attitudes and confidence.

Responses to all questions were compared prior to and following exposure to the addiction educational program by bivariate analysis. First, individual survey responses were compared between the two groups using t tests. Next, categories of questions were combined. Aggregate measures related to belief that addiction is a chronic medical illness (questions 1, 2, 3, 4, and 5), confidence (questions 7, 8, 9, 11, and 16), and enjoyment (questions 8, 10, and 15) in working with patients with addictions, and attitudes towards AA/NA (questions 16, 17, 18, and 19) were calculated using the numeric means of questions related to these topics. Aggregate measures were compared between groups using one-sided t tests. All statistical analyses were performed using Microsoft Excel.

The pre-rotation and post-rotation survey response rates were 88.9% (N = 24/27) and 59.3% (16/27), respectively. Students who completed the survey after the curriculum did not differ significantly from those who completed the survey prior to the curriculum with regard to gender (X² = 0.15, p = 0.698), age (X² = 0.06, p = 0.81), spirituality (X² = 0.02, p = 0.89), identifying as religious (X² = 0.07, p = 0.79), or likelihood of having a family member with a substance use disorder (X² = 1.17, p = 0.28). Compared to respondents prior, students who completed the curriculum were (1) more likely to express confidence in managing patients with alcohol (t(15) = 9.88, p < 0.001, d = 0.84) and opioid use disorders (t(15) = 7.82, p < 0.001, d = 2.24); (2) more likely to express confidence in discussing AA/NA during clinical encounters (t(15) = 7.64, p < 0.001, d = 2.01); (3) more likely to enjoy working with individuals with SUD (t(15) = 5.52, p < 0.001, d = 1.34); and (4) more likely to conceptualize SUD as chronic medical conditions (t(15) = 2.13, p = 0.02, d = 0.24).

Our results indicate that a focused addiction curriculum during a clerkship rotation may have significant impacts on medical student attitudes towards SUD and confidence in treating patients with addiction. These results were demonstrated in the previously published cross-sectional comparison of students exposed to those not exposed [5], and in the current longitudinal study, comparing students before and after exposure.

This study has limitations that may be addressed in further studies. Despite the lack of substantial difference between survey completers, this teaching intervention was performed at one clerkship site at one institution, with a limited number of participants and for a relatively short period of time. Longer follow-up and multi-site intervention are therefore required to establish the relationship between exposure to structured curricula such as ours and enduring changes in attitude towards addiction.

Adaptations of the proposed curriculum to online learning modules may provide a viable solution to time and financial constraints, and their effectiveness should be examined in contrast to exclusive on-site teaching in future studies. Given the medical consequences of SUD, such curricula could be widely disseminated and easily incorporated in various disciplines other than psychiatry.

In summary, a supplemental addiction curriculum can improve medical students’ attitudes towards managing patients with SUD. Provided that these attitudes endure, they could potentially lead to more compassionate, thoughtful and effective care of individuals suffering from SUD, a timely endeavor for our field.