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Educating GPs in D&A is no easy task |
Training GPs, particularly in the field of alcohol and drug related problems, is not an easy task (1).
Several studies from various countries have shown doctors’ general negative and pessimistic attitudes towards patients with alcohol and other drug problems (2, 3, 4, 5, 6, 7). Data also suggest that, despite a strong sense of role legitimacy in working with problem drinkers (8, 9), GPs do not feel competent about treating these disorders (10,11,12). They do not like to work with problem drinkers and do not find this work rewarding (8).
So it is not surprising that caring for patients with alcohol and other drug abuse problems and caring for patients with chronic diseases were among the five most important characteristics deterring medical students from careers in internal medicine (13). Feeling poorly prepared to care for patients with substance abuse problems, many GPs resist treating them in their practice (10).
Factors that seem to be associated with more positive attitudes toward alcohol/drug abusing patients include:
- the number of patients worked with for alcohol/drug abuse;
- the doctor’s perceived effectiveness at managing alcohol/drug problems;
- the number of hours of CME on alcohol;
- and the number of patients given literature about alcohol/drugs.
The doctor’s own personal level of alcohol consumption or having a past drinking problem does not seem to be related to his or her attitudes towards alcoholic patients (8).
There is wide agreement that substance abuse, like other chronic diseases, requires effective patient management in which GPs play a key role (14). The CME curriculum content for all drug and alcohol topics should cover at least three areas: knowledge, personal attitudes and clinical skills.
Knowledge
GPs need to be familiar with the following subject areas:
1) epidemiology, including knowledge of the natural history of substance abuse and risk factors;
2) physiology and biochemistry of dependence and addiction;
3) pharmacology, including knowledge of effects of commonly abused drugs and drug-drug interactions;
4) diagnosis, intervention and referral;
5) case management, including short and long-term consequences of abuse and dependence; and
6) prevention through health promotion, early identification and patient education. GPs should know about the legal and ethical issues that are involved in cases of substance abuse.
Personal attitudes
GPs need to be taught to accept substance abuse as a problem that requires the same attention and care they devote to other chronic problems. Their attitudes need to encompass an approach toward the care of the patient and family in an objective, humanistic and compassionate manner. Lester & Bradley (1997) believe that the origin of positive or negative attitudes seem to be complex and rooted in the accretion of influences from the lay and medical communities, including influences operating before entry to medical school. The training offered for attitude change needs to challenge deeply held attitudes in a manner that is not too overt and needs to be quite intensive educationally.
Clinical skills
GPs need to have a communication pattern with their patients characterised by empathy, friendliness and explicit awareness of the patient’s feelings and medical complaints (15). Specific training in brief interventions such as motivational interviewing is both sustainable and easily incorporated into clinical practice.
Effective teaching/learning methods are essential to successful educational activities. Lectures are the mode least likely to cultivate positive attitudes, skills and behaviours (16). Other teaching techniques are preferred, such as presentation of case histories, teaching small groups, independent study, use of films and videotapes and use of simulated or real patients in role play demonstrations, followed by group discussion of the content and process (17).
There is general agreement that CME’s effectiveness depends on the use of a combination of facilitating, enabling and reinforcing strategies (18).
Totaro (19) reported that almost a million Australians could be classified as alcohol-dependent. A study by the University of NSW’s National Drug and Alcohol Research Centre also reveals that alcohol abuse is particularly prevalent among young people with up to 15% of 18-24 year olds classified as alcoholic. The figures reveal that overall, men are three times as likely to have an alcoholic problem as women - 9% against 3% - with young men between 18 and 24 the most likely group to experience alcohol problems. However, young men were also the least likely of all age groups to seek help, which is of particular concern. This often results in their needing more days away from their regular roles, whether that is work, study, recreation or parenting. This has huge social and productivity implications for Australia.
Reporting on the experiences of the Substance Misuse Project in the North East Victorian Division of General Practice, Richards (20) states that the success they experienced was due to the change in attitude that occurred amongst the members of the division as a result of the project. This has occurred because GPs designed the programs, a series of workshops over a two-year period, for GPs. The authors’ observations indicate a greatly increased interest in drug and alcohol problems.
Whilst it was initially difficult to induce GPs to attend workshops, methadone prescribers more than doubled, withdrawal in the home was eagerly adopted due to the willingness of GPs, and relationships between GPs and substance misuse services improved with marked increase in referrals and an increased sense of co-operation and teamwork.
Roche et al (21) have noted that concern about alcohol and drug misuse has been heightened by recent analyses indicating that substance use is a more prominent aetiological factor in several common medical disorders than was previously realised (22). In 1990, about 6600 deaths a year were attributed to alcohol, 18,000 to tobacco and 700 to other drugs. Up to 30% of patients admitted to hospital and 20% of patients presenting in primary health care settings have drug or alcohol related problems (23, 24).
The scope for the medical profession in the prevention and management of alcohol and drug related problems is substantial (25). Doctors, in particular GPs, are in a position to reach virtually the entire population (26). In Australia, more than 80% of the population visit a GP each year (27). Medical practitioners have a high degree of credibility and are considered to be the single most important source of advice on drug and alcohol related matters (28, 29, 30).
References
1. McAvoy, BR, 1997. Training General Practitioners. Alcohol & Alcoholism, 32,1:9-12.
Moore, R, Makkai, T & McAlliuster, I, 1989. Perceptions & Patterns of Drug Use. Canberra: Dept. of Community Services and Health with the National Campaign Against Drug Abuse.
2. Weller, D, Litt, JCB, Pols, RG, Ali, RL, Southgate, DO & Harris, RD, 1992. Drug & Alcohol Related Health Problems in Primary Care - what do GPs think? The Medical Journal of Australia, 156:43-7.
3. Anderson, P, 1985. Managing Alcohol Problems in General Practice. British Medical Journal, 290:1873-6.
4. Kinney, J, Bergen, BJ, & Price, TRP, 1982. Perspectives on Medical Student's Perceptions of Alcoholics & Alcoholism. Journal of Studies in Alcoholism, 43:488-96.
Lester, H & Bradley, C, 1997. Better Attitudes can be found by Better Training. British Medical Journal, 315:6 Sept.
5. Robinson, LH & Podnos, B, 1966. Resistance of Psychiatrists in Treatment of Alcoholism, Journal of Nervous & Mental Disease, 143:220-5.
6. Sterne, MW & Pittman, DJ, 1965. The Concept of Motivation: a Source of institutional & professional blockage in the treatment of alcoholics. Quarterly Journal of Studies on Alcohol, 26:41-57.
7. Wolf, I, Chafetz, ME, Blane, HT & Hill, MJ, 1965. Social Factors in the Diagnosis of Alcoholism. Quarterly Journal of Studies on Alcohol, 26:72-9.
8. Rush, BR, Bass, M, Stewart, M, McCraken, E, Labreque, M & Bondy, S, 1994a. Detecting, Preventing and Managing Patients' Alcohol Problems. Canadian Family Physician, 40:1557-66.
9. Rush, BR, Ellis, KS, Crowe, TG & Powell, LY, 1994b. How General Practitioners View Alcohol Use. Clearing up the confusion. Canadian Family Physician, 40:1570-9.
10. Kamerow, DB, Pincus, HA & MacDonald, DI, 1986. Alcohol Abuse, other drug abuse and mental disorders in medical practice. Prevalence, costs, recognition and treatment. Journal of the American Medical Association, 255(15):2054-7.
11. Kennedy, W, 1985. Chemical Dependency: A treatable disease. Ohio State Medical Journal, 71:77-9.
12. Sadler, D, 1984. Poll Finds M.D. Attitudes on Alcohol Abuse Changing. American Medical News, 27:60.
13. Schwartz, MD, Linzer, M, Babbott, D, Divine, GW & Broadhead, E, 1991. Medical Student Interest in Internal Medicine. Initial report of the Society of General Internal Medicine interest group survey on factors influencing career choice in internal medicine. Annals of Internal Medicine, 114(1):6-15.
14. Lewis, DC, Niven, RG, Czechowicz,D & Trumbler, JG, 1987. A Review of Medical Education in Alcohol & other Drug Abuse. Journal of the American Medical Association, 257(21):2945-8.
15. Babor, TF, 1990. Brief Intervention Strategies for Harmful Drinkers: Nerw directions for medical education. Canadian Medical Association Journal, 143(10):1070-5.
16. Johnson, NP, Lindsay, AB & Tumblin, M, 1990. Educational Factors in Substance Abuse for Physicians. The Journal of the South Carolina Medical Association, 86(1):64-5.
17. Davis, AK, Parran, TV & Graham, AV, 1993. Educational Strategies for Clinicians. Primary Care, 20(1):241-50.
18. Davis, DA, Thomson, MA, Oxman, AD & Haynes, RB, 1992. Evidence for the Effectiveness of CME. A review of 50 randomized controlled trials. Journal of the American Medical Association, 268(9):1111-7.
19. Totaro, P, 1999. 1m Australians 'hooked on drink'. Sydney Morning Herald, 13/10/99.
20. Richards, D, Geddis, A & Heery, D, 1996. Targeting General Practice - Volunteers for the front line. Drugs - policies, programs & people. 1996 Winter school in the sun conference. Brisbane, Alcohol & Drug Foundation, Qld.
21. Roche, AM, Parle, MD & Saunders, JB, 1996. Menaging Alcohol & Drug Problems in General Practice: a survey of trainees' knowledge, attitudes and educational requirements. Australian & New Zealand Journal of Public Health, 20(4):401-8.
22. English, DR, Holman, CDJ, Milne, E, Winter, MG, 1995. The Quantification of Drug Caused Mortality in Australia. Canberra: Dept. of Community Services & Health.
23. Williams, AT, Burns, FH & Morey, S, 1978. Prevalence of Alcoholism in a Sydney Teaching Hospital. Medical Journal of Australia, 2:198-200.
24. Roche, AM, n.d. Increasing Primary Case Providers' Willingness to Intervene. Substance Abuse.
25. Roche, AM, Saunders, JB & Elvy, GA, 1992. The Role of General Practice in the Prevention and Management of the Harm Done by Alcohol Use. Vienna, Austria: World Health Organization.
26. Sanson-Fisher, RW, Webb, GR & Reid, ALA, 1986. The Role of the Medical Practitioner as an Agent for Disease Prevention. In: Better Health Commission. Looking forward to better health, 3:201-12.
27. Bridges-Webb, C, 1987. General Practitioner Services. Australian Family Physician, 16:898.
28. Moore, R, Makkai, T & MaAllister,I, 1989. Perceptions & Patterns of Drug Use. Canberra: Dept. of Community Services & Health with the National Campaign Against Drug Abuse.
29. Owen, N, 1989. Behavioural Intervention Studies and Behavioural Epidemiology Research to improve Smoking-cessation Strategies. Health Education Research, 4:145-53.
30. Pols, RG & Hawks, DV, 1992. Is There a Safe Level of Daily Consumption of Alcohol for Men & Women? 2nd edn. Canberra: Australian Government Publishing Service.
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