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Faculty Reviewers: Emmanuel Elueze, MD, Srinivas Merugu, MD

Resident Reviewer: Charles Ayanleke, MD

Educational Purpose and Goals

The purpose of the Addiction Medicine curriculum is to supplement residents learning by providing the specific knowledge, attitude and skills needed to manage patients with alcohol and other substance use disorders including prescribed medications and other non-proprietary drug use. The goal is that residents be able to recognize addiction problems, perform referrals appropriately and effectively, manage patients who refuse referral, work in conjunction with addiction medicine specialists for patients who accept referral and integrate addiction medicine with management of the numerous co-morbid medical and psychiatric disorders these patients often exhibit.

Institutional Resources/Strengths

  1. The hospital has a nationally acclaimed addiction treatment center (Rosary Hall). It is one of the oldest addiction treatment centers in the country and has inpatient detoxification and outpatient rehabilitation units. It is also involved in training addiction medicine fellows.
  2. Five attending physicians in our department of medicine are certified in Addiction Medicine by the American Society of Addiction Medicine. All the 5 attending physicians also run an office-based Opioid maintenance program.

Residents who have special interest in Addiction Medicine have the opportunity to do a 2 to 4 week elective rotation in the addiction Unit. All residents are also encouraged to attend regularly organized lectures, workshops and conferences by the Addiction unit, particularly the Advanced course on Opioid Prescription Writing, which is mandated by the state medical Board for some impaired physicians. 

Principal Teaching Methods

  1. By participation in care of patients with addictive disorders admitted to the medical ward and to the addiction medicine unit and also patients with substance use disorders seen in the various ambulatory practices and in the resident continuity clinics.
  2. Lectures are given on various aspects of common addictive disorders.
  3. Mix of diseases – wide range of disorders related to the use and abuse of prescribed medications, nonprescribed substances and alcohol
  4. Patient characteristics -- The patients have alcohol and other drug disorders and often medical, surgical and psychiatric co-morbidities and complications of addictive disorders.

Methods of Evaluation – For residents who do an elective

  1. Resident Performance
    Faculty complete web-based electronic resident evaluation forms provided by the Internal Medicine Residency office. The evaluation is competency based, fully assessing core competency performance. The evaluation is shared with the resident, is available for on-line review by the resident at their convenience, and is sent to the residency office for internal review. The evaluation is part of the resident file and is incorporated into the semi-annual performance review for directed resident feedback.
  2. Program and Faculty Performance
    Upon completion of the rotation, residents complete a rotation evaluation form commenting on the faculty, facilities, and service experience. These evaluations are sent to the residency office for review and the attending faculty physician receives periodic feedback after sufficient residents have completed the elective to maintain anonymity.
  3. Specific Competency Objectives
    1. Patient Care
      1. The resident will be able to conduct a patient-centered history to obtain the overarching, personal dimensions of the patient’s addiction problem and its context.
      2. The resident will be able to elicit via relationship- centered interviewing, the essential details of the patient’s addiction problem: types and amounts of substances used/abused, duration of use, pattern of use, age at first use and first abuse, prior problems, prior withdrawal experiences, legal problems, personal problems, environmental circumstances fostering substance use, prior efforts to stop and their success, wish to stop now, status as pre-contemplative vs. contemplative, what has worked in the past, associated psychiatric problems, and associated medical problems related or unrelated to the substance use.
      3. The resident will be able to use the CAGE and CAGE - AID questions to diagnose alcohol and other substance abuse disorders.
      4. The resident will be able to perform a relevant physical examination and identify evidence, for example, of cirrhosis of the liver, withdrawal manifestations, and organic mental symptoms.
      5. The resident will be able to succinctly summarize and synthesize in the patient’s chart the biopsychosocial aspects of the patient’s addiction problem.
      6. The resident will be able to articulate the key decision-making issues for each patient, particularly being able to identify what stage of change the patient now exhibits.
      7. The resident will be able to identify a management plan for those who are pre-contemplative (wish to do nothing): follow-up visits for further discussion, measures to decrease usage and available support.
      8. The resident will be able to identify a management plan for those who are contemplative (actively considering treatment): involve relevant family members, provide information about resources (AA, friends, churches, professional) and encourage their use, support and wise counsel.
      9. The resident will be able to identify a management plan for those who wish to take action: negotiation of referral to addiction specialists, remaining involved with the patient, communicating with the specialist, support, wise counsel, and co-management with regular visits and treatment of co-morbid medical and psychiatric problems.
    2. Medical Knowledge
      1. The resident will develop the knowledge base in addiction medicine to become proficient as a general internist.
      2. The resident should understand the epidemiology and various manifestations of the spectrum of alcohol and substance use disorders in adults.
      3. The resident should become familiar with the available multiple treatment modalities including pharmacotherapy for the management of alcohol and other substance use disorders.
    3. Interpersonal and Communication Skills
      1. The resident will be able to integrate relationship - centered communication skills to produce a biopsychosocial understanding of the patient’s addiction problem.
      2. The resident will be able to use similar skills in relating effectively to other team members in the addiction units.
      3. The resident will be able to practice humanistic medicine with addiction patients.
    4. Professionalism
      1. In sometimes difficult patients with addiction problems, the resident will be able to always exhibit respect, understanding of the patient’s vantage point, acknowledge the patient’s plight, and find something praiseworthy about the patient.
      2. The resident will be able to become the patient’s ally, provide support and counsel in a primary care setting, and provide information and other resources needed by the patient.
      3. The resident will be able to be sensitive to cultural, disability, lifestyle, and gender differences in addiction medicine patients.
      4. The resident will be able to articulate, understand, and practice in a way consistent with ethically sound, patient-centered practices.
    5. Practice Based Learning and Improvement
      1. The resident will be able to critically appraise the literature and apply this to the patient.
      2. The resident will be able to make self-assessments of his/her impact with addiction patients, and also learn to identify their own attitudes and emotions that might interfere with high quality care.
    6. Systems Based Practice
      1. The resident will be able to recognize and address the systems aspect of the addiction patient’s problems in their biological, psychological, and social complexity.
      2. The resident will be able to refer consultations to addiction specialists effectively, including recognizing first the need to negotiate this referral with the patient.
      3. The resident will be able to recognize the cost impact of addiction problems as well as to provide cost effective care for these patients.
      4. The resident will be able to involve families and significant others in the patient’s care and decision-making.
      5. The resident will be able to help patients identify resources in the community often needed and used by addiction medicine patients.

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