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Medical Education

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  • 1. Medical Education & Research FoundationMedical Education & Research Foundation For TheFor The Treatment of Alcoholism and Other DrugTreatment of Alcoholism and Other Drug DependenciesDependencies M E R FM E R F
  • 2. M E R FM E R F  1988 Created1988 Created MISSION STATEMENTMISSION STATEMENT PREVENT THE HARM BEINGPREVENT THE HARM BEING DONEDONE TO PATIENTS BY PHYSCIANSTO PATIENTS BY PHYSCIANS WHOWHO LACK THELACK THE KNOWLEDGEKNOWLEDGE,, SKILLSKILL ANDAND
  • 3. M E R FM E R F  Private DonationsPrivate Donations  Focus on improving identification andFocus on improving identification and care of patients with substance usecare of patients with substance use problemsproblems  EducateEducate  Medical EducatorsMedical Educators  ResidentsResidents  Medical StudentsMedical Students
  • 4. M E R FM E R F W H Y ?W H Y ?
  • 5. M E R FM E R F  Deficient Medical Education aboutDeficient Medical Education about Substance UseSubstance Use  Unacceptably low rates of identifyingUnacceptably low rates of identifying persons with substance use problemspersons with substance use problems  Difficulties creating space in MedicalDifficulties creating space in Medical School and Residency CurriculumSchool and Residency Curriculum  Committed to overcome Deficiencies,Committed to overcome Deficiencies, Improve identification and ImproveImprove identification and Improve patient care.patient care.
  • 6. M E R FM E R F OPPORTUNITYOPPORTUNITY
  • 7. M E R FM E R F OPPORTUNITY LOSTOPPORTUNITY LOST
  • 8. M E R FM E R F SCOPE OF LOSTSCOPE OF LOST OPPORTUNITIESOPPORTUNITIES
  • 9. M E R FM E R F PROBLEM DRINKERS -- VISITS TOPROBLEM DRINKERS -- VISITS TO MDMD  65 % had a65 % had a Medical visitMedical visit in the past year.in the past year.  <25% had drinking problem addressed.<25% had drinking problem addressed.  33% had a33% had a Psychiatric visitPsychiatric visit in past year.in past year.  65% had drinking addressed.65% had drinking addressed.  >40 years old: More visits/year, not more likely to>40 years old: More visits/year, not more likely to have drinking addressed.have drinking addressed.
  • 10. M E R FM E R F CASA STUDYCASA STUDY 650 PCP’s + 500 patients in CD treatment650 PCP’s + 500 patients in CD treatment  > 50% said “PCP DID NOTHING”> 50% said “PCP DID NOTHING”  > 10% said “PCP KNEW & DID NOTHING”> 10% said “PCP KNEW & DID NOTHING”  < 1/3< 1/3rdrd of PCP’s Screen for Substance Useof PCP’s Screen for Substance Use Source: CASA 2000Source: CASA 2000
  • 11. M E R FM E R F  > 9 in 10 US physicians fail to spot> 9 in 10 US physicians fail to spot substance abuse in adult patientssubstance abuse in adult patients  > 4 out of 10 miss diagnosis in teens> 4 out of 10 miss diagnosis in teens Source: Missed Opportunity: National Survey of Primary Care Physicians and Patients, theSource: Missed Opportunity: National Survey of Primary Care Physicians and Patients, the National Center on Addiction and Substance Abuse (CASA) @ Columbia University, NYNational Center on Addiction and Substance Abuse (CASA) @ Columbia University, NY 20002000
  • 12. M E R FM E R F  > 55% of PCP’s prescribed drugs that> 55% of PCP’s prescribed drugs that could be dangerouscould be dangerous  30% of patients: ”PHYSICIAN KNEW30% of patients: ”PHYSICIAN KNEW ABOUT PATIENT’S ADDICTION ANDABOUT PATIENT’S ADDICTION AND STILL PRESCRIBED PSYCHOACTIVESTILL PRESCRIBED PSYCHOACTIVE SUBSTANCES.”SUBSTANCES.”  75% of PCP’s not involved in TX decision75% of PCP’s not involved in TX decision Source: CASA 2000Source: CASA 2000
  • 13. ““Elevated GGT, elevatedElevated GGT, elevated SGOT and your MCV isSGOT and your MCV is >105. Let’s see, you can’t>105. Let’s see, you can’t sleep, your stomach burnssleep, your stomach burns and you’re nervous……..…and you’re nervous……..… I’ll prescribe someI’ll prescribe some Diazepam for you.”Diazepam for you.”
  • 14. M E R FM E R F Missed Opportunities – Northern CAMissed Opportunities – Northern CA  627 Alcohol Dependent & Problem Drinkers627 Alcohol Dependent & Problem Drinkers  926 Consec. Admissions to CD Treatment926 Consec. Admissions to CD Treatment  Interviewed one year laterInterviewed one year later  2/3 ≥ 1 MEDICAL VISITS (prev. year)2/3 ≥ 1 MEDICAL VISITS (prev. year)  1/31/3 ≥ 1 MENTAL HEALTH VISITS (prev.≥ 1 MENTAL HEALTH VISITS (prev. year)year)
  • 15. M E R FM E R F PROBLEM DRINKERS -- VISITS TOPROBLEM DRINKERS -- VISITS TO MDMD  65 % had a65 % had a Medical visitMedical visit in the past year.in the past year.  < 25% had drinking problem addressed.< 25% had drinking problem addressed. Weisner & Matzger;Weisner & Matzger; Alc: Clin. Exp. Res., 2003Alc: Clin. Exp. Res., 2003
  • 16. M E R FM E R F DSM-IV ALCOHOL DEPENDENTDSM-IV ALCOHOL DEPENDENT 62%62% - Alcohol use NOT addressed – Medical Visit- Alcohol use NOT addressed – Medical Visit 28%28% - Alcohol use NOT addressed – Mental Health- Alcohol use NOT addressed – Mental Health PROBLEM DRINKERS W/O DEPENDENCEPROBLEM DRINKERS W/O DEPENDENCE 84%84% - Alcohol use NOT addressed – Medical Visit- Alcohol use NOT addressed – Medical Visit 44%44% - Alcohol use NOT addressed – Mental Health- Alcohol use NOT addressed – Mental Health Weisner, C. & Matzer, H., Alcoholism: Clin. Exp. Res., July 2003Weisner, C. & Matzer, H., Alcoholism: Clin. Exp. Res., July 2003
  • 17. M E R FM E R F Member Survey of AmericanMember Survey of American AssociationAssociation for the Surgery of Traumafor the Surgery of Trauma  ~~ 40 % screen ≤25% of their patients40 % screen ≤25% of their patients  ~~ 20 % screen “most patients”20 % screen “most patients”  75 % not familiar with the most common75 % not familiar with the most common screening instrumentsscreening instruments  >80 %>80 % no trainingno training in alcohol screeningin alcohol screening  75 % not familiar with CAGE75 % not familiar with CAGE
  • 18. M E R FM E R F OBSTETRICIANS &OBSTETRICIANS & GYNECOLOGISTSGYNECOLOGISTS DURING PREGNANCYDURING PREGNANCY  80-95 % ask patients about alcohol use80-95 % ask patients about alcohol use  25 % assess maximum drinks (most uncertain25 % assess maximum drinks (most uncertain what recommended maximum is or means)what recommended maximum is or means)  < 10 % use screening instruments< 10 % use screening instruments  Only 20 % counsel that abstinence safest way toOnly 20 % counsel that abstinence safest way to avoid adverse pregnancy outcomesavoid adverse pregnancy outcomes  < 45 % who assess alcohol problems intervene< 45 % who assess alcohol problems intervene Obstet and Gyn (2000)95 & J Gen. Intern Med (2000)15Obstet and Gyn (2000)95 & J Gen. Intern Med (2000)15
  • 19. M E R FM E R F 20 years Organized Medicine20 years Organized Medicine RecognizesRecognizes Need to Increase Medical EducationNeed to Increase Medical Education toto Improve DETECTION & TREATMENTImprove DETECTION & TREATMENT  NIAAANIAAA  Institute of MedicineInstitute of Medicine  AMAAMA  APAAPA
  • 20. M E R FM E R F 20 YEARS WITHOUT20 YEARS WITHOUT CHANGECHANGE  No Changes in:No Changes in:  Screening RateScreening Rate or # of Pt’s screenedor # of Pt’s screened  Recognition/Recognition/DiagnosisDiagnosis RateRate  Number of PatientsNumber of Patients DischargedDischarged with awith a Diagnosis of AlcoholismDiagnosis of Alcoholism  Number of Patients Receiving Psych. orNumber of Patients Receiving Psych. or AddictionAddiction ConsultationConsultation
  • 21. M E R FM E R F What IfWhat If Something couldSomething could be done tobe done to help?help?
  • 22. M E R FM E R F QUALITY OF HEALTH CAREQUALITY OF HEALTH CARE DELIVEREDDELIVERED TO ADULTS IN THE UNITEDTO ADULTS IN THE UNITED STATESSTATES McGlynn, et. al., NEJM, June 2003McGlynn, et. al., NEJM, June 2003  54% of Recommended/Standard care is54% of Recommended/Standard care is delivered for 25 common conditionsdelivered for 25 common conditions  HighHigh - 79% - Senile Cataracts- 79% - Senile Cataracts  MediumMedium - 53% - Asthma- 53% - Asthma  LowestLowest - 10% - Alcohol Dependence- 10% - Alcohol Dependence
  • 23. M E R FM E R F OPPORTUNITIESOPPORTUNITIES
  • 24. M E R FM E R F PRIMARY CAREPRIMARY CARE OUTPATIENT CLINIC VISITSOUTPATIENT CLINIC VISITS  > 20% of Patients Seen Exceed NIAAA Alcohol> 20% of Patients Seen Exceed NIAAA Alcohol Consumption GuidelinesConsumption Guidelines  2 – 9% Prevalence of Alcohol Dependence2 – 9% Prevalence of Alcohol Dependence NIAAA, July 2005NIAAA, July 2005  9 – 35% Prevalence of Harmful Drinking9 – 35% Prevalence of Harmful Drinking
  • 25. M E R FM E R F PREVALENCE OF ALCOHOLPREVALENCE OF ALCOHOL ABUSEABUSE AND DEPENDENCE INAND DEPENDENCE IN HOSPITALIZED PATIENTSHOSPITALIZED PATIENTS  7 – 47% Various studies, settings & criteria7 – 47% Various studies, settings & criteria  ~~ 20% Community Hospitals20% Community Hospitals Compare with 7% prevalence in CommunityCompare with 7% prevalence in Community
  • 26. M E R FM E R F HOW MANY PEOPLEHOW MANY PEOPLE WITHWITH SUBSTANCE USESUBSTANCE USE PROBLEMSPROBLEMS SEE PHYSICIANSSEE PHYSICIANS ??
  • 27. M E R FM E R F  70 % of population sees PCP70 % of population sees PCP at least once every 2 yearsat least once every 2 years  200 million patient visits to PCP200 million patient visits to PCP annuallyannually Source: CASA(2000)
  • 28. M E R FM E R F REMEMBERREMEMBER 2/3 OF PROBLEM DRINKERS2/3 OF PROBLEM DRINKERS →→ at leastat least ONE MEDICAL VISITONE MEDICAL VISIT PER YEARPER YEAR
  • 29. M E R FM E R F FAMILY PHYSICIANS SEEFAMILY PHYSICIANS SEE 22 TO 28 PATIENTS22 TO 28 PATIENTS PER DAYPER DAY AAFP, 2005AAFP, 2005
  • 30. M E R FM E R F Average Primary Care PhysicianAverage Primary Care Physician PracticePractice -- EXAMPLE SCENARIO ---- EXAMPLE SCENARIO --  Low estimate of 10 % Prevalence ofLow estimate of 10 % Prevalence of Problematic Substance UsersProblematic Substance Users  2 to 3 Patients Per Day With a Substance2 to 3 Patients Per Day With a Substance Use ProblemUse Problem (OPPORTUNITY)(OPPORTUNITY)
  • 31. M E R FM E R F Average Primary Care PhysicianAverage Primary Care Physician ---- EXAMPLE SCENARIO --EXAMPLE SCENARIO --  CURRENT STANDARDS (for substance use) @ 10%CURRENT STANDARDS (for substance use) @ 10%  DetectDetect 40 to 6040 to 60 Patients per year with Substance UsePatients per year with Substance Use ProblemProblem  IF INCREASED TO MEET THE AVERAGE U.S.IF INCREASED TO MEET THE AVERAGE U.S. STANDARD (STANDARD (~~50%)50%)  IMPROVESIMPROVES DETECTIONDETECTION TOTO 200 to 300200 to 300 Patients perPatients per yearyear
  • 32. M E R FM E R F ADDRESSING NEEDADDRESSING NEED WITH EDUCATIONWITH EDUCATION
  • 33. M E R FM E R F FULFILLMENT OF MERF’SFULFILLMENT OF MERF’S MISSIONMISSION  Scholarships to multi-day addiction medicineScholarships to multi-day addiction medicine educational conferences/workshopseducational conferences/workshops  ResidentsResidents  Residency Educators/FacultyResidency Educators/Faculty  Mentored learning experienceMentored learning experience  Collegial/group learning environmentCollegial/group learning environment
  • 34. M E R FM E R F  Clinical Problem solving -- DiscussionClinical Problem solving -- Discussion  Familiarization discussing substance use,Familiarization discussing substance use, abuse, addictionabuse, addiction  Improve comfort discussing substance useImprove comfort discussing substance use [demystifying][demystifying]
  • 35. M E R FM E R F Collegial Interaction FacilitatedCollegial Interaction Facilitated and Encouragedand Encouraged  Conference facultyConference faculty  MentorsMentors  Fellow attendees and scholarship recipientsFellow attendees and scholarship recipients  MealsMeals  Special Conference EventsSpecial Conference Events
  • 36. M E R FM E R F  Groundwork for Network of ResidencyGroundwork for Network of Residency Program DirectorsProgram Directors  Perpetuate and Maintain EducationalPerpetuate and Maintain Educational and Medical Practice Gainsand Medical Practice Gains  MoreMore
  • 37. M E R FM E R F  MERF’S APPROACH IS:MERF’S APPROACH IS: ““ONE PHYSICIAN AT AONE PHYSICIAN AT A TIME”TIME”  WE CAN AND ARE MAKING AWE CAN AND ARE MAKING A DIFFERENCEDIFFERENCE  Those making an impact:Those making an impact:
  • 38. M E R FM E R F 2005 Residency Educators’ Table2005 Residency Educators’ Table
  • 39. M E R FM E R F 2005 Resident Scholars’ Roundtable2005 Resident Scholars’ Roundtable
  • 40. M E R FM E R F 20012001
  • 41. M E R FM E R F 20042004
  • 42. M E R FM E R F 20052005
  • 43. M E R FM E R F TESTIMONIALSTESTIMONIALS
  • 44. M E R FM E R F  ““I found all elements helpful. The lecturesI found all elements helpful. The lectures were fantastic. I feel my comfort level withwere fantastic. I feel my comfort level with ETOH patients has definitely improved.”ETOH patients has definitely improved.”  ““I feel like part of the larger body of peopleI feel like part of the larger body of people in the field of addiction treatment now.”in the field of addiction treatment now.”  ““The conference provided me with muchThe conference provided me with much needed information.”needed information.”
  • 45. M E R FM E R F  ““Interacting with the experts in the fieldInteracting with the experts in the field and other residents and the people atand other residents and the people at MERF was excellent.”MERF was excellent.”  ““I wish all of the residents in my programI wish all of the residents in my program could get this education.”could get this education.”  ““Very informative…contrary to someVery informative…contrary to some teaching at my program, the attitude andteaching at my program, the attitude and approach to dealing with SA wasapproach to dealing with SA was refreshing.”refreshing.”
  • 46. M E R FM E R F FROM EDUCATORSFROM EDUCATORS  ““The things I learned.…have alreadyThe things I learned.…have already changed my practice and the residents’changed my practice and the residents’ education.”education.”  ““My next step is to incorporate thisMy next step is to incorporate this knowledge into curricular and clinicalknowledge into curricular and clinical teaching.”teaching.”  ““I felt like I walked away with a newI felt like I walked away with a new toolbox.…..to use in my teaching.”toolbox.…..to use in my teaching.”

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