Developing and Implementing a Multispecialty Graduate Medical … SBIRT... · 2019-10-08 · (26),...
Transcript of Developing and Implementing a Multispecialty Graduate Medical … SBIRT... · 2019-10-08 · (26),...
This article was downloaded by: [Yale University Library]On: 12 April 2012, At: 06:59Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK
Substance AbusePublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/wsub20
Developing and Implementing a Multispecialty GraduateMedical Education Curriculum on Screening, BriefIntervention, and Referral to Treatment (SBIRT)Jeanette M. Tetrault MD a , Michael L. Green MD a , Steve Martino PhD b , Stephen F. ThungMD c , Linda C. Degutis DrPHMSN d , Sheryl A. Ryan MD e , Shara Martel MPH d , Michael V.Pantalon PhD b , Steven L. Bernstein MD d , Patrick G. O’Connor MDMPH a , David A. FiellinMD a & Gail D’Onofrio MDMS da Department of Internal Medicine, Yale University School of Medicine, New Haven,Connecticut, USAb Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut,USAc Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven,Connecticut, USAd Department of Emergency Medicine, Yale University School of Medicine, New Haven,Connecticut, USAe Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut,USA
Available online: 21 Dec 2011
To cite this article: Jeanette M. Tetrault MD, Michael L. Green MD, Steve Martino PhD, Stephen F. Thung MD, Linda C. DegutisDrPHMSN, Sheryl A. Ryan MD, Shara Martel MPH, Michael V. Pantalon PhD, Steven L. Bernstein MD, Patrick G. O’ConnorMDMPH, David A. Fiellin MD & Gail D’Onofrio MDMS (2012): Developing and Implementing a Multispecialty Graduate MedicalEducation Curriculum on Screening, Brief Intervention, and Referral to Treatment (SBIRT), Substance Abuse, 33:2, 168-181
To link to this article: http://dx.doi.org/10.1080/08897077.2011.640220
PLEASE SCROLL DOWN FOR ARTICLE
Full terms and conditions of use: http://www.tandfonline.com/page/terms-and-conditions
This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form toanyone is expressly forbidden.
The publisher does not give any warranty express or implied or make any representation that the contentswill be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses shouldbe independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims,proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly inconnection with or arising out of the use of this material.
Substance Abuse, 33:168–181, 2012Copyright c© Taylor & Francis Group, LLCISSN: 0889-7077 print / 1547-0164 onlineDOI: 10.1080/08897077.2011.640220
Developing and Implementing a Multispecialty GraduateMedical Education Curriculum on Screening, Brief
Intervention, and Referral to Treatment (SBIRT)
Jeanette M. Tetrault, MDMichael L. Green, MD
Steve Martino, PhDStephen F. Thung, MD
Linda C. Degutis, DrPH, MSNSheryl A. Ryan, MDShara Martel, MPH
Michael V. Pantalon, PhDSteven L. Bernstein, MD
Patrick G. O’Connor, MD, MPHDavid A. Fiellin, MD
Gail D’Onofrio, MD, MS
ABSTRACT. The authors sought to evaluate the feasibility and acceptability of initiating a Screening,Brief Intervention, and Referral to Treatment (SBIRT) for alcohol and other drug use curriculum acrossmultiple residency programs. SBIRT project faculty in the internal medicine (traditional, primary careinternal medicine, medicine/pediatrics), psychiatry, obstetrics and gynecology, emergency medicine,and pediatrics programs were trained in performing and teaching SBIRT. The SBIRT project facultytrained the residents in their respective disciplines, accommodating discipline-specific implementationissues and developed a SBIRT training Web site. Post-training, residents were observed performingSBIRT with a standardized patient. Measurements included number of residents trained, performanceof SBIRT in clinical practice, and training satisfaction. One hundred and ninety-nine residents were
Jeanette M. Tetrault, Michael L. Green, Patrick G. O’Connor, and David A. Fiellin are affiliated with theDepartment of Internal Medicine; Steve Martino and Michael V. Pantalon are affiliated with the Departmentof Psychiatry; Stephen F. Thung is affiliated with the Department of Obstetrics and Gynecology; Linda C.Degutis, Shara Martel, Steven L. Bernstein, and Gail D’Onofrio are affiliated with the Department of Emer-gency Medicine; and Sheryl A. Ryan is affiliated with the Department of Pediatrics, Yale University Schoolof Medicine, New Haven, Connecticut, USA.
Address correspondence to: Jeanette M. Tetrault, MD, Department of Internal Medicine, Yale Uni-versity School of Medicine, 367 Cedar Street, 4th Floor, New Haven, CT 06510, USA (E-mail:[email protected]).
This work was supported by the Substance Abuse and Mental Health Services Administration(5U79TI020253-02).
This work was presented as an oral presentation during the Innovations in Medical Education abstractsession of the 33rd annual Society of General Internal Medicine conference in Minneapolis, MN, on April29, 2010.
Dow
nloa
ded
by [
Yal
e U
nive
rsity
Lib
rary
] at
06:
59 1
2 A
pril
2012
Tetrault et al. 169
trained in SBIRT: 98 internal medicine, 35 psychiatry, 18 obstetrics and gynecology, 21 emergencymedicine, and 27 pediatrics residents. To date, 338 self-reported SBIRT clinical encounters haveoccurred. Of the 196 satisfaction surveys completed, the mean satisfaction score for the training was1.60 (1 = very satisfied to 5 = very dissatisfied). Standardized patient sessions with SBIRT projectfaculty supervision were the most positive aspect of the training and length of training was a notedweakness. Implementation of a graduate medical education SBIRT curriculum in a multispecialtyformat is feasible and acceptable. Future efforts focusing on evaluation of resident SBIRT performanceand sustainability of SBIRT are needed.
KEYWORDS. Brief intervention, graduate medical education, screening
INTRODUCTION
Alcohol and other drug use and misuse causesignificant morbidity and mortality in the UnitedStates and worldwide (1). According to the2008 National Survey on Drug Use and Health,roughly 20 million Americans over 12 years ofage were current illicit drug users. Heavy drink-ing (defined as drinking 5 or more drinks on thesame occasion on each of 5 or more days in thepast 30 days) was reported by 17 million people(7% of the US population); and 15 million peo-ple met criteria for alcohol abuse or dependence(2). During this same year, only 9% of patientsin need of treatment for unhealthy alcohol orother drug use actually received specialty care,leaving 21 million people in need of treatmentbut not receiving it.
Recognizing the effectiveness of Screening,Brief Intervention, and Referral to Treatment(SBIRT) approaches for alcohol (3–7), the USPreventive Services Task Force and the JointCommission have recommended routine alco-hol screening during medical encounters (8, 9).There are fewer published studies regarding theefficacy of SBIRT with drug use, but there isa growing body of literature, which is promis-ing (10–14). Investigator-initiated research byJ. Bernstein reported the efficacy of SBIRT fordrug use in an urgent care ambulatory setting(14), and another study by E. Bernstein demon-strated that a trial of SBI promoted marijuana ab-stinence and reduced consumption among emer-gency department (ED) patients 14–21 years old(13). Madras and colleagues also demonstratedthat SBIRT services implemented in a range ofmedical settings across 6 states was feasible andthe self-reported patient status at 6 months in-
dicated significant improvements over baselinefor illicit drug use and heavy alcohol use (11).The World Health Organization (WHO) spon-sored a study of screening and interventions forillicit drug (marijuana, cocaine, amphetamine-type stimulants, opioid). This randomized con-trolled, multinational study yielded significantshort-term reductions (∼3 months) in illicit druguse in combined data from 731 participants (15).However, many physicians still do not screen forthe spectrum of unhealthy alcohol or other druguse, defined as the spectrum for at-risk use todependence, nor refer those in need of specialtytreatment (3, 5, 16–22). A variety of barriershave been identified including lack of knowl-edge, time, and training resources (23).
To begin to resolve these implementation bar-riers, the Substance Abuse and Mental HealthServices Administration (SAMHSA) launchedthe SBIRT initiative to promote the system-atic identification of patients with alcohol andother drug use; provision of brief counseling (in-cluding advice and motivational enhancement)where appropriate; and referral of patients inneed to specialty treatment (11, 24). Six monthsafter a federally funded SBIRT training programwas implemented in 6 different states, both alco-hol and other drug use decreased in participantsscreening positive at baseline (11).
Regarding physicians in training, brief inter-vention curricula have proven feasible and effec-tive in a variety of medical education settings,including emergency medicine residency pro-grams (21, 25), psychiatry residency programs(26), and medical schools (27). However, fewgraduate medical education programs offer es-tablished addiction or SBIRT curricula. A sur-vey of 1183 program directors in emergency
Dow
nloa
ded
by [
Yal
e U
nive
rsity
Lib
rary
] at
06:
59 1
2 A
pril
2012
170 SUBSTANCE ABUSE
medicine, family practice, internal medicine, ob-stetrics and gynecology, osteopathic medicine,pediatrics, and psychiatry found that roughly56% of programs had training in substance abusewith a median number of 7 hours (interquartilerange 4–15) of training devoted to the curricu-lum throughout the length of the residency (28).
This report describes the development,implementation, and initial evaluation ofa SAMHSA-funded multispecialty (internalmedicine [traditional, primary care, medicine/pediatrics], psychiatry, obstetrics and gynecol-ogy, emergency medicine, and pediatrics) grad-uate medical education SBIRT curriculum at theYale University School of Medicine.
METHODS
Curriculum Development
The core curriculum was developed using es-tablished criteria in medical education curricu-lum development (29, 30). Namely, we (1) per-formed a targeted needs analysis of patients andlearners; (2) reviewed and catalogued existingexpertise at our institution; (3) reviewed cur-ricula published in the medical literature; (4)assembled a multispecialty SBIRT faculty; and(5) developed and implemented our curricula at-tending to individual programmatic needs, antic-ipated implementation barriers, and curriculumsustainability.
We began with a targeted analysis to iden-tify the particular needs of our patients, and ourresident learners. Our residents care for patientswith a high prevalence of unhealthy alcohol andother drug use (31). Connecticut ranks in thetop 20% of states for alcohol abuse and depen-dence in persons 12 years of age and older, andin the top 20% for marijuana use, cocaine use,and nonmedical use of prescription pain reliev-ers among persons 18 to 25 years old (2, 32).Only 8% and 2% of the state population who arein need of treatment for alcohol and other drugabuse/dependence, respectively, are receiving it(33). Many patients with unhealthy alcohol andother drug use are uninsured or underinsured andare cared for disproportionately by our residencyprograms (31).
Regarding learners, residents nationally haveidentified the need for more training in how toscreen for and treat alcohol and other substanceuse (26, 34, 35) and this also has been the case atour institution. To address this need, members ofour SBIRT core senior faculty previously devel-oped and implemented brief intervention cur-ricula using standardized patient scenarios forpractitioners in the emergency department (36)and for medical students (27). Trainee’s knowl-edge and skills in SBIRT increased after partici-pation in these curricula (27, 37), demonstratingthat brief intervention can be effectively taughtto medical trainees. Given the demographics ofalcohol and other drug use in our state and thedemonstrated efficacy of SBIRT knowledge andskill acquisition in residents at our institution,this widespread curriculum to teach residentshow to screen for and treat unhealthy alcoholand other drug use was established to help closethe treatment gap in our state (38).
We next reviewed the literature to identifyinstructional strategies with demonstrated effec-tiveness and potential barriers to SBIRT curricu-lum implementation (11, 21, 25–28, 37). Lo-cally, we identified existing curricula, resources,and faculty expertise and availability. Variouscomponents of addiction medicine educationhad already been in place in the internal medicine(traditional, primary care, medicine/pediatrics),psychiatry, obstetrics and gynecology, emer-gency medicine, and pediatrics residency pro-grams at Yale University School of Medicine.SBIRT core senior faculty took the followingsteps: (1) convened a series of discussions togarner support from the Graduate Medical Edu-cation committee for this multispecialty project;(2) engaged experts and opinion leaders in eachdepartment; (3) secured participation from resi-dency program directors and clinical service di-rectors; (4) assembled the multispecialty SBIRTproject faculty—team leaders within each spe-cialty to function as experts and opinions lead-ers/role models (Figure 1); and (5) outlined andarticulated learning objectives (Table 1) and in-structional strategies.
In developing the instructional strategies,we coordinated, expanded, and standardizedexisting efforts in our residency programswhile attending to “contextual variables” (39)
Dow
nloa
ded
by [
Yal
e U
nive
rsity
Lib
rary
] at
06:
59 1
2 A
pril
2012
Tetrault et al. 171
FIGURE 1. Flowchart of SBIRT faculty.
TABLE 1. SBIRT Curriculum Objectives
Programmatic objectives:1. To expand and adapt our SBIRT curriculum for alcohol
and other drugs for residents and practitioners(nurses, physician associates) in the specialties ofmedicine, pediatrics, medicine/pediatrics, obstetricsand gynecology, emergency medicine, and psychiatry.
2. To modify the microsystems in each respectivespecialty practice site to ensure long-term adoption ofSBIRT.
Learner objectives:1. Understand the neurobiology, epidemiology,
screening, diagnosis, and management of unhealthyalcohol use. (Knowledge)
2. Demonstrate competence in screening patients foralcohol and other drug use, performing briefinterventions, and referring appropriate patients forspecialized care. (Skill)
3. Appreciate that unhealthy alcohol and other drug useis a condition with a biochemical basis and thatrelapse should not be consider a “failure” but rather anexpected course of a chronic disease. (Attitude)
4. Perceive fewer barriers to screening for alcohol andother drug use and performing brief interventions.(Attitude)
5. Improve actual practice performance in screeningpatients for alcohol and other drug use and performingbrief interventions. (Behavior )
(resources, schedules, values, patient demo-graphics, accreditation requirements, etc.) in theindividual programs. In particular, we designedour curriculum to address the AccreditationCouncil for Graduate Medical Education’s(ACGME) core competencies (29, 34, 40). TheSBIRT curriculum was designed to augment pa-tient care and medical knowledge and proficientuse of SBIRT skills would enhance profession-alism, interpersonal and communication skills,practice-based learning and improvement, andsystems-based practice.
As part of the development process, we antic-ipated several barriers (41) to translating SBIRTtraining into several diverse clinical settingsand populations. We considered practitioner-level, patient-level, and system-level barriers(41). Practitioner resistance to SBIRT has beenreported in multiple disciplines (42–44). Fac-tors cited for such resistance have included lackof knowledge about SBIRT and local referralsources, lack of knowledge of efficacy of SBIRT,time constraints in busy and chaotic medicalsettings, and discomfort with counseling (44).
Dow
nloa
ded
by [
Yal
e U
nive
rsity
Lib
rary
] at
06:
59 1
2 A
pril
2012
172 SUBSTANCE ABUSE
Our approach was to increase knowledge ofSBIRT and local referral sources and convinceresidents and faculty of the feasibility of per-forming SBIRT within a busy clinical encounter.
Patient level barriers were also considered andintegrated into the curriculum. We anticipatedthat residents would be most concerned aboutpatients who were resistant to changing their al-cohol or other drug use. To address this mo-tivational enhancement challenge, the curricu-lum included specific instruction and practice ofstrategies to engage patients with little motiva-tion or commitment to change their alcohol orother drug use (36).
Finally, at the system level, we recognizedthat each program had different approaches tomedical education and time allotted to didacticand case based teaching. With multiple com-peting topics in graduate medical education, wekept the SBIRT curriculum compact, requiringno more than 3 hours of instruction. Our incor-poration of program-specific team leaders intothe curriculum development process and earlyengagement from the residency program direc-tors aided the prioritization of SBIRT training ineach specialty program.
To promote sustainability, residency pro-gram faculty in the internal medicine, obstet-rics/gynecology, and pediatrics programs whodirectly supervised residents were offered anhour-long faculty development session that in-cluded elements of the SBIRT training and ob-servation tools to monitor residents in clinicalpractice. Additionally, SBIRT project faculty inall programs met with clinic directors and super-visors to be sure that processes within the clini-cal setting were developed to ensure successfulimplementation of SBIRT into the day-to-dayoperation of the clinic.
Core Curriculum
Although program-to-program variation oc-curred in the curricula (Table 2), there was acommon core shared by all disciplines. The corecurriculum consisted of 2 distinct parts: the di-dactic/practice portion and the standardized pa-tient portion. The didactic/practice portion of the
core curriculum consisted of 1 to 1.5 hours ofinstruction and began with a review of the epi-demiology and public health impact of alcoholand other drug use. For screening, residents weretaught to use the National Institute on Alco-hol Abuse and Alcoholism quantity/frequencyquestions (45) and the CAGE (46, 47), mod-ified to screen for unhealthy alcohol and andother drug use (48), in the internal medicine,psychiatry, obstetrics and gynecology, and emer-gency medicine programs and the CRAFFT (49)in the pediatrics program. The residents werethen introduced to the Brief Negotiation Inter-view (BNI). The BNI, a type of brief inter-vention, is a manual-guided 5-step interview-ing technique to reduce alcohol and other druguse among patients presenting in medical set-tings (25, 36, 37, 50). The BNI included in-struction on how to raise the subject of alcoholand drug consumption, provide feedback on thepatient’s drinking and drug use levels, enhancemotivation to reduce or stop drinking and druguse, and negotiate and advise a plan of action.All residents were provided with a laminatedpocket card outlining screening techniques onone side and the full BNI on the other side (seeFigure 2). Residents first viewed a 10-minutevideo clip of the BNI and then learned eachstep.
Next, residents practiced the BNI in triads,role playing discipline-specific cases in whicheach resident took turns playing the role of thephysician, patient, and observer. SBIRT projectfaculty circulated during the role-play exerciseand provided direct feedback. Residents werealso provided with discipline-specific instructionregarding referral sources to be used in caseswhere screening revealed more severe alcoholor other drug use disorders (i.e., abuse or depen-dence) (51). Residents were provided with anupdated listing of national, state, and local refer-ral sources for them to directly refer patients to ifthey have identified to have more severe alcoholor other drug use.
After the initial training, residents demon-strated their acquired BNI skills within a stan-dardized patient case. The standardized patientportion of the curriculum took 1 to 1.5 hours oftime and was broken up into 15-minute time slots
Dow
nloa
ded
by [
Yal
e U
nive
rsity
Lib
rary
] at
06:
59 1
2 A
pril
2012
TAB
LE2.
Pro
gram
-Spe
cific
Cur
ricul
umC
ompo
nent
s
Med
icin
eO
b/G
ynP
edia
tric
sP
sych
iatr
yE
mer
genc
ym
edic
ine
Pre
-tra
inin
gas
sess
men
tsK
now
ledg
e-ba
sed
alco
hola
nddr
ugsu
rvey
XX
XX
X
Sta
ndar
dize
dpa
tient
enco
unte
rX
XX
Cor
ecu
rric
ulum
-C
lass
size
•5–9
•9–1
1•2
–4•1
7–19
•8–1
3-
Leng
thof
trai
ning
-S
cope
ofth
epr
oble
m-
Scr
eeni
ngto
ols
-E
vide
nce
for
SB
IRT
•(2)
11 2
or(1
)3-
hour
sess
ions
•Ini
tiala
ndfo
llow
-up
use
mpr
imar
yca
re
•(1)
3-ho
urse
ssio
n•S
ubst
ance
use
durin
gan
dbe
yond
preg
nanc
y
•(1)
2-ho
urse
ssio
n•U
seof
CR
AF
FT
and
subs
tanc
eus
ein
adol
esce
ntpo
pula
tion
•(2)
11 2
hour
sess
ions
•Sub
stan
ceus
ean
dps
ycho
logi
cal
prob
lem
s
•(1)
3-ho
urse
ssio
n•T
raum
aan
dot
her
subs
tanc
eus
ere
late
dE
Dvi
sits
Vie
w“T
heE
mer
genc
yP
ract
ition
eran
dT
heU
nhea
lthy
Drin
ker”
DV
D(B
riefI
nter
vent
ion)
XX
XX
X
Facu
ltyob
serv
edre
side
ntro
lepl
ays
XX
XX
XP
ost-
trai
ning
asse
ssm
ents
1–7
days
1m
onth
2–3
wee
ks1
wee
kan
d30
days
2–4
wee
ksS
tand
ardi
zed
patie
nten
coun
ter
Trai
ning
Sat
isfa
ctio
nsu
rvey
(GP
RA
)∗X
XX
XX
1M
onth
post
-tra
inin
g30
day
trai
ning
satis
fact
ion
surv
ey(G
PR
A)∗
XX
XX
X
Kno
wle
dge-
base
dal
coho
land
drug
surv
eyX
XX
XX
1Ye
arpo
sttr
aini
ngS
tand
ardi
zed
patie
nten
coun
ter
XX
XX
XK
now
ledg
e-ba
sed
alco
hola
nddr
ugsu
rvey
XX
XX
X
3Ye
ars
post
-tra
inin
gK
now
ledg
e-ba
sed
alco
hola
nddr
ugsu
rvey
XX
XX
X
∗ Gov
emm
entP
erfo
rman
ceR
esul
tsA
ct.
173
Dow
nloa
ded
by [
Yal
e U
nive
rsity
Lib
rary
] at
06:
59 1
2 A
pril
2012
174 SUBSTANCE ABUSE
FIGURE 2. Laminated pocket card of screening and BNI steps (Color figure available online).
per resident. For larger groups of residents, 2standardized patients were run at the same time.Cases were discipline specific and standardizedpatient actors were trained by the core seniorfaculty. Standardized patient sessions were ei-
ther directly observed by SBIRT project facultyand feedback provided at the time of the en-counter or the sessions were taped and feedbackwas provided to the residents within 2 weekstime via e-mail.
Dow
nloa
ded
by [
Yal
e U
nive
rsity
Lib
rary
] at
06:
59 1
2 A
pril
2012
Tetrault et al. 175
FIGURE 2. (Continued)
Dow
nloa
ded
by [
Yal
e U
nive
rsity
Lib
rary
] at
06:
59 1
2 A
pril
2012
176 SUBSTANCE ABUSE
Prior to curriculum implementation, thisproject was approved by the Human Investiga-tions Committee at Yale University School ofMedicine.
Curriculum Implementation
The SBIRT faculty consisted of a group ofsenior, multispecialty core faculty experts andleaders in the field of addiction medicine anda project coordinator. The core faculty enlistedthe interest and support of residency direc-tors to assist with facilitating the mechanicsof collating residents for training, and prac-tice consultants who were responsible for as-sisting with integrating the processes identifiedto facilitate SBIRT into the specific practice set-ting. Specialty-specific project faculty were thenidentified and supported by the grant in eachspecialty (Figure 1). Following an establishedmethod, the senior core faculty organized sev-eral “train the trainer” sessions for the team lead-ers, who then took responsibility for organizingand training the residents and residency programfaculty when possible to enhance continual rolemodeling and resident observation in the clin-ical setting (52). In addition, the SBIRT fac-ulty (core and project faculty) developed a cur-riculum Web site (www.yale.edu/sbirt), whichincluded specialty-specific modules and cases,training manuals, readings, screening tools, slidepresentations, and video clips of real patient sce-narios of the BNI. Implementation occurred inthe 2008–2009 and 2009–2010 academic yearsand was discipline specific (see Table 2).
Internal Medicine
All 148 residents in the 3- to 4-year residencycycles of the internal medicine programs (tra-ditional, primary care, and medicine/pediatrics)were targeted for training. Residents weretrained on the ambulatory block and in eithertwo 1 1
2 -hour sessions separated by 1 week (tra-ditional residency program) or two 1 1
2 -hour ses-sions broken up throughout a day-long “addic-tion medicine” curriculum day (primary care andmedicine/pediatrics residency programs).
Psychiatry
All of the second-year psychiatry residents(n = 35) were offered SBIRT training in two 1 1
2 -hour sessions separated by 1 week as part of theirtraditional core curriculum that prepares them todeliver a variety of empirically supported psy-chosocial treatments.
Obstetrics and Gynecology
Obstetrics and gynecology is a 4-year res-idency training program consisting of 25 res-idents. Within the obstetrics and gynecologyprogram, residents have one full afternoon ofprotected didactic time on a weekly basis. Allavailable residents were trained together in a3-hour session.
Emergency Medicine
Residency training in emergency medicine(EM) involves a 4-year program that includes13 residents in each of the 4 years for a totalof 52 residents. As most of the EM residents inthe third and fourth years of the program hadreceived SBIRT training previously, we specif-ically targeted the first- and second-year resi-dents, and the few third- and fourth-year resi-dents who had not been available for previoustraining, for a total target group of 30. First-yearresidents received the training during their orien-tation to the emergency medicine program, andother residents received the curriculum in a 2-hour session during an allotted weekly 5-hourresident education block.
Pediatrics
The pediatrics residency is a 3-year trainingprogram. We offered SBIRT training to all resi-dents during either their second-year pediatrics(n = 20) or third-year medicine-pediatrics (n =4) residency. Training occurred in one 2 1
2 -hoursession during the required adolescent medicinerotation.
Dow
nloa
ded
by [
Yal
e U
nive
rsity
Lib
rary
] at
06:
59 1
2 A
pril
2012
Tetrault et al. 177
Curriculum Evaluation Methods
Number of Residents Trained andPerformance of SBIRT in Practice
We tracked numbers of residents trained. Ad-ditionally, 30 days post-training, we evaluatedskill translation into clinical practice by docu-menting resident’s performance of alcohol andother drug use screening and brief interventions.In the internal medicine, obstetrics/gynecology,and emergency medicine programs, residentsdocumented their screens and BNIs in clinicalpractice using the online procedure log track-ing mechanism in E∗Value (www.e-value.net).In the obstetrics and gynecology programs, res-idents documented alcohol and other drug usescreens and BNIs performed through the elec-tronic medical record. Additionally, residentsin all training programs were sent e-mail re-minders and required to fill out an electronicsurvey to track the numbers of self-reportedscreens and BNIs they performed in the clin-ical setting. Resident-specific assessment andevaluation took place in the form of a stan-dardized patient interview where residents per-formed screening and brief intervention using adiscipline-specific case and were evaluated us-ing a standardized checklist (37).
Training Satisfaction
After the training, residents then completeda satisfaction survey, the Government Perfor-mance and Results Act (GPRA) Client OutcomeMeasures for Discretionary Programs (11). Aspart of the satisfaction evaluation, residents wereencouraged to leave comments regarding thestrengths and weaknesses of the training. Wecollected resident feedback from the commentssection of the training satisfaction survey to eval-uate both elements of success and criticisms.
Barriers and Proposed Solutions
Barriers to implementation were catalogedindividually by the SBIRT project faculty andbrought to the senior core faculty to discuss andbrainstorm possible solutions.
RESULTS
Number of Residents Trained and Useof SBIRT in Practice
To date, 199 residents have been trainedacross all specialties, representing 78% of thetotal number of residents we had originally tar-geted (Table 3). Forty-five percent of residentswere male and 65% were white. Twenty-sevenpercent were postgraduate year (PGY)-1, 53%PGY-2, 18% PGY-3, and 2% PGY-4.
Since the trainings began in January of 2009,residents have reported performing 338 BNIsin clinical practice: 105 in internal medicine,105 in psychiatry, 18 in obstetrics/gynecology,81 in emergency medicine, and 29 in pediatrics.Translation of BNIs performed into patient-leveldata regarding use of alcohol or other drugs isbeyond the scope of this report.
Training Satisfaction
Residents were very satisfied with the train-ing. Out of 196 satisfaction surveys returned(98% response rate), the mean satisfaction scorewas 1.60 (1 = very satisfied to 5 = very dis-satisfied). Overall, residents felt that this train-ing addressed a void in their education. Resi-dents reported that the role-play exercises werevery useful; direct performance feedback givenby faculty at the end of these exercises wasa noted strength. Other strengths included theprovision of the laminated pocket card, brevityof the approach, and utility with patients resis-tant to changing their alcohol and other drug
TABLE 3. Residents and Performance
Number of Number ofresidents residentstargeted trained to SBIs
Specialty to train date % (n) performed
Internal medicine 148 66% (98) 105Psychiatry 35 100% (35) 105Emergency medicine 30 70% (21) 81Ob/Gyn 25 72% (18) 18Pediatrics 24 100% (24) 29
Total 254 78% (199) 338
Dow
nloa
ded
by [
Yal
e U
nive
rsity
Lib
rary
] at
06:
59 1
2 A
pril
2012
178 SUBSTANCE ABUSE
use. Some residents felt that the training wouldhave been more effective if an additional ses-sion was included with more role play and stan-dardized patient scenarios. However, others feltthat the training repeated some curricular con-tent they received during medical school trainingand, therefore, felt that less time could have beenspent on the training.
Barriers and Proposed Solutions
Despite securing support from residency pro-gram administrators, lack of time in the curricu-lum to deliver SBIRT training and difficulties co-ordinating resident’s schedule given work-hourrestrictions remained a significant implemen-tation barrier. To overcome this barrier, teamleaders maintained flexibility with schedulingand offered additional trainings throughout theyear. Any resident who missed training was re-ferred to the SBIRT Web site for self-directedstudy prior to the standardized patient session.Tracking completed screens and BNIs in clinicalpractice also proved to be difficult, particularlyin those residency programs where electronictracking of procedures was not already in place.In an effort to promote tracking, team leaders inseveral of the programs worked with members ofinformation technology teams to establish clin-ical reminders and checklists within the variouselectronic medical records at the outpatient sites.Finally, supporting the residents’ use of BNI inclinical practice was challenging because it mayhave occurred in other clinical settings wherecore program faculty might not be able to ob-serve their practice or encourage its application.Faculty development was offered in several ofthe programs to promote curricula sustainabil-ity and to create an opportunity for observation-based feedback. These faculty participants wereencouraged to observe screening and BNI per-formance in all clinical settings. We used e-mailreminders to faculty to promote this process andfurther marketed their adherence by noting howit could satisfy the requirements for resident ob-servation mandated by residency accreditationcommittees.
Some unique barriers arose per discipline. Inpsychiatry, residents found the BNI to be too for-mulaic in its stepwise approach, in contrast to the
clinical flexibility they felt they had within otherpsychotherapeutic interventions. SBIRT projectfaculty coached these residents on how to usethe BNI steps to guide rather than rigidly dic-tate what they might say or do with patientswho might have alcohol or other drug use prob-lems. Moreover, project faculty encouraged theuse of SBIRT as most relevant in acute care psy-chiatric settings where time constraints mightdictate rapid screening, brief intervention, andreferral.
In pediatrics, residents do not routinely en-counter patients with unhealthy alcohol andother drug use, and the opportunity to engagein intervention is more limited than with adultpopulations. However, pediatrics residents havenumerous opportunities in primary care outpa-tient settings, emergency settings, and inpatientwards to perform screening for alcohol and otherdrug use. The tracking procedure for the pedi-atrics program did not capture screening, butonly BNIs that were performed on patients witha positive screen. Additional methods to capturescreening efforts are being instituted throughthe electronic medical record systems for usein both the inpatient and outpatient settings. Asa potential result of the fewer numbers of BNIsperformed with the pediatric populations, resi-dents’ skills were at risk for degradation fromnonuse. To overcome this barrier, monthly re-minders and annual faculty development wereprovided to maintain skills among the residents.
CONCLUSIONS
We describe the development, implementa-tion, and preliminary evaluation of a novel mul-tispecialty graduate medical education SBIRTcurriculum at a single institution. Our resultssuggest that implementation of a comprehen-sive SBIRT curriculum is feasible across res-idency programs in multiple specialties. Resi-dents were highly satisfied with this training andintegrated these techniques in their clinical prac-tices. Despite barriers that arose throughout dif-ferent phases of implementation, we found thatopen communication, problem solving amongthe SBIRT core faculty, and involvement ofthe Graduate Medical Education committee,
Dow
nloa
ded
by [
Yal
e U
nive
rsity
Lib
rary
] at
06:
59 1
2 A
pril
2012
Tetrault et al. 179
residency program directors, and clinical servicedirectors were critical to the successful imple-mentation of this program.
Certain unique features of our results shouldbe highlighted. The pediatrics and psychiatryprograms were both able to train 100% of theresidents originally targeted for training whilethe other programs continue to train residents.Additionally, the SBIRT curriculum was foldedinto required coursework, which occupied pro-tected didactic time in these 2 disciplines, al-lowing for improved attendance. Residents inthe PGY-2 level seemed to be the most acces-sible for training and the psychiatry and pedi-atrics programs specifically targeted residentsat this level of training. By the time traineeshave reached the PGY-2, in many of the primarycare–based disciplines, they are following a co-hort of patients and have had significant expo-sure to patients with alcohol and other drug use,allowing for greater interest in topics such asSBIRT.
Given the significant burden of alcohol andother drug use and the lack of recognition andtreatment of these conditions by the health caresystem, it is important for medical educators toconsider the public health impact of screeningand brief intervention as part of a comprehen-sive teaching program for house staff (2, 3, 19,53). A recent systematic review pooling datafrom 1992 to 2004 found that although alco-hol screening and counseling was one of themost cost-effective preventive services (ratio of$1755/quality-adjusted life-years), it was amongthe preventive services least frequently deliv-ered by physicians (54). A recent evaluation ofa large, multisite SBIRT initiative found thatof 459,599 patients screened, 23% of patientsscreened positive for alcohol and other drug usewith 16% receiving a brief intervention (11). Al-though this large-scale service initiative showedthat SBIRT could be implemented in many di-verse sites and populations, ours, to our knowl-edge, is the first report of the successful imple-mentation of a multispecialty graduate medicaleducation SBIRT curriculum. Other reports havedescribed feasibility of implementing SBIRTcurricula within medical school training, singleresidency training programs, or clinical settings(26, 27, 37), but to our knowledge, this is the firstto describe the development, implementation,
and initial evaluation of such a curriculum acrossmultiple specialties. Additionally, our programis unique in its systematic approach to curricu-lum development and implementation, its track-ing of resident performance, and its approachto cataloguing barriers and proposed solutionsto curriculum implementation. Given that alco-hol and other drug use are amenable to effectivescreening and intervention, it is imperative thatmedical educators give resident physicians thetools necessary to effectively deliver this cost-effective and underutilized service (54).
This report has several limitations. The uniqueaspects of this multispecialty program and thesignificant infrastructure for training in addictionmedicine already in place at our institution maycompromise generalizability. Additionally, wedo not know how many residents actually con-ducted the 350 BNIs or the impact on patients’successful treatment referral or alcohol or druguse outcomes. Finally, we have not reported onthe extent to which the curriculum positively im-pacted on the residents’ SBIRT knowledge andskill acquisition. A more extensive evaluation ofthe effectiveness of our program is underway. Wehave been measuring SBIRT knowledge beforeand after training using standardized surveysthat have been used in prior studies (21, 36, 55,56). We also have been collecting recorded sam-ples of the residents’ BNI performance withinstandardized patient encounters pre- and post-training. These will be independently rated foradherence to the SBIRT approach using a stan-dardized checklist (37). We plan to contact res-idents 1 year and 3 years post-training to assessagain their BNI adherence and the frequency ofSBIRT usage in clinical practice.
Despite these limitations, implementation of amultispecialty graduate medical SBIRT curricu-lum is feasible and acceptable. Given its integra-tion across multiple specialty areas of medicineand the involvement of key faculty memberswithin each program, the program is likely tobe sustainable at our institution and could beadapted by GME programs at other institutions(29). By providing residents with the skills toappropriately identify and treat unhealthy alco-hol and other drug use, a multispecialty SBIRTcurriculum has the potential to make a profoundimpact on the health of patients in various set-tings and populations.
Dow
nloa
ded
by [
Yal
e U
nive
rsity
Lib
rary
] at
06:
59 1
2 A
pril
2012
180 SUBSTANCE ABUSE
REFERENCES
1. World Health Organization. Substance Abuse, Factsand Figures. Geneva: World Health Organization; 2009.
2. Substance Abuse and Mental Health Services Ad-ministration. Results from the 2008 National Survey onDrug Use and Health: National Findings. Rockville, MD:Office of Applied Statistics; 2009.
3. Babor TF, Higgins-Biddle JC. Screening, Brief In-tervention, and Referral to Treatment (SBIRT): toward apublic health approach to the management of substanceabuse. Subst Abuse. 2007;28:7–30.
4. Estee S, Wickizer T, He L, Shah MF, Mancuso D.Evaluation of the Washington state screening, brief inter-vention, and referral to treatment project: cost outcomes forMedicaid patients screened in hospital emergency depart-ments. Med Care. 2010;48:18–24.
5. Fleming MF, Barry KL, Manwell LB, Johnson K,London R. Brief physician advice for problem alcoholdrinkers. A randomized controlled trial in community-based primary care practices [see comment]. JAMA.1997;277:1039–1045.
6. Fleming MF, Mundt MP, French MT, Manwell LB,Stauffacher EA, Barry KL. Brief physician advice for prob-lem drinkers: long-term efficacy and benefit-cost analysis.Alcohol Clin Exp Res. 2002;26:36–43.
7. Academic Emergency Department SBIRT ResearchCollaborative. The impact of screening, brief intervention,and referral for treatment on emergency department pa-tients’ alcohol use. Ann Emerg Med. 2007;50:699–710.
8. The Joint Commission. Performance MeasureInitiatives: Screening and Treating Tobacco and AlcoholUse. 2009. Available at: http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Screening+and+Treating+Tobacco+and+Alcohol+Use.html. Accessed March 10, 2010.
9. Whitlock EP, Polen MR, Green CA, Orleans T,Klein J. Behavioral counseling interventions in primarycare to reduce risky/harmful alcohol use by adults: a sum-mary of the evidence for the U.S. Preventive Services TaskForce. Ann Intern Med. 2004;140:557–568.
10. Zahradnik A, Otto C, Crackau B, et al. Randomizedcontrolled trial of a brief intervention for problematic pre-scription drug use in non-treatment-seeking patients. Ad-diction. 2009;104:109–117.
11. Madras BK, Compton WM, Avula D, Stegbauer T,Stein JB, Clark HW. Screening, brief interventions, referralto treatment (SBIRT) for illicit drug and alcohol use at mul-tiple healthcare sites: comparison at intake and 6 monthslater. Drug Alcohol Depend. 2009;99:280–295.
12. Otto C, Crackau B, Lohrmann I, et al. Brief in-tervention in general hospital for problematic prescrip-tion drug use: 12-month outcome. Drug Alcohol Depend.2009;105:221–226.
13. Bernstein E, Edwards E, Dorfman D, Heeren T,Bliss C, Bernstein J. Screening and brief interventionto reduce marijuana use among youth and young adults
in a pediatric emergency department. Acad Emerg Med.2009;16:1174–1185.
14. Bernstein J, Bernstein E, Tassiopoulos K, Heeren T,Levenson S, and Hingson R. Brief motivational interven-tion at a clinic visit reduces cocaine and heroin use. DrugAlcohol Depend. 2005;77:49–59.
15. World Health Organization. The Effectiveness of aBrief Intervention for Illicit Drugs Linked to the Alcohol,Smoking, and Substance Involvement Screening Test (AS-SIST) in Primary Health Care Settings: A Technical Re-port of Phase III Findings of the WHO ASSIST Random-ized Control Trial. Geneva: World Health Organization;2008. Available at: http://www.who.int/substance abuse/activities/assist technicalreport phase3 final.pdf. Acces-sed February 17, 2011.
16. Babor TF, Higgins-Biddle JC. Alcohol screeningand brief intervention: dissemination strategies for medicalpractice and public health. Addiction. 2000;95:677–686.
17. Babor TF, Higgins-Biddle JC, Higgins PS, GassmanRA, Gould BE. Training medical providers to conductalcohol screening and brief interventions. Subst Abuse.2004;25:17–26.
18. Kaner EFS, Beyer F, Dickinson HO, et al. Effec-tiveness of brief alcohol interventions in primary carepopulations [see comment]. Cochrane Database Syst Rev.2007;(2):CD004148.
19. Kuehn BM. Despite benefit, physicians slow tooffer brief advice on harmful alcohol use. JAMA.2008;299:751–753.
20. Institute of Medicine. Improving the Quality ofHealthcare for Mental and Substance-Use Conditions:Quality Chasm Series. Washington, DC: The NationalAcademy Press; 2005.
21. D’Onofrio G, Pantalon MV, Degutis LC, et al. Briefintervention for hazardous and harmful drinkers in theemergency department [see comment]. Ann Emerg Med.2008;51:742–750.e2.
22. Saitz R. Unhealthy alcohol use. N Engl J Med.2005;352:596–607.
23. Bien, TH, Miller WR, Tonigan JS. Brief in-terventions for alcohol problems: a review. Addiction.1993;88:315–335.
24. Substance Abuse and Mental Health Services Ad-ministration. Screening, Brief Intervention and Referralto Treatment (SBIRT), 2009. Available at: www.sbirt.samhsa.gov. Accessed December 10, 2009.
25. Bernstein E, Bernstein J, Feldman J, et al. An evi-dence based alcohol screening, brief intervention and refer-ral to treatment (SBIRT) curriculum for emergency depart-ment (ED) providers improves skills and utilization. SubstAbuse. 2007;28:79–92.
26. Polydorou S, Gunderson EW, Levin FR. Trainingphysicians to treat substance use disorders. Curr PsychiatryRep. 2008;10:399–404.
27. Martino S, Haeseler F, Belitsky R, Pantalon M,Fortin AH. Teaching brief motivational interviewing to yearthree medical students. Med Educ. 2007;41:160–167.
Dow
nloa
ded
by [
Yal
e U
nive
rsity
Lib
rary
] at
06:
59 1
2 A
pril
2012
Tetrault et al. 181
28. Isaacson JH, Fleming M, Kraus M, Kahn R, MundtM. A national survey of training in substance use disordersin residency programs. J Stud Alcohol. 2000;61:912–915.
29. Green ML. Identifying, appraising, and implement-ing medical education curricula: a guide for medical edu-cators. Ann Intern Med. 2001;135:889–896.
30. Kern DE, Thomas PA, Hughes MT, eds. CurriculumDevelopment for Medical Education: A Six-Step Approach.2nd ed. Baltimore, MD: The Johns Hopkins UniversityPress; 2009.
31. Holt S, Ramos J, Harma MA, et al. Prevalence ofunhealthy substance use on teaching and hospitalist medicalservices: implications for education. Am J Addict. In press.
32. Centers for Disease Control and Prevention (CDC).Behavioral Risk Factor Surveillance System Survey Data.Washington, DC: US Department of Health and HumanServices; 2006
33. Substance Abuse and Mental Health Services Ad-ministration. Results from the 2007 National Survey onDrug Use and Health: National Findings. Rockville, MD:Office of Applied Statistics; 2008.
34. Jackson A, Alford D, Dube C, Saitz R. Internalmedicine residency training for unhealthy alcohol and otherdrug use: recommendations for curriculum design. BMCMed Educ. 10:22.
35. el-Guebaly N, Toews J, Lockyer J, Arm-strong S, Hodgins D. Medical education in substance-related disorders: components and outcome. Addiction.2000;95:949–957.
36. D’Onofrio G, Pantalon MV, Degutis LC, FiellinDA, O’Connor PG. Development and implementation ofan emergency practitioner-performed brief intervention forhazardous and harmful drinkers in the emergency depart-ment. Acad Emerg Med. 2005;12:249–256.
37. D’Onofrio G, Nadel ES, Degutis LC, et al. Improv-ing emergency medicine residents’ approach to patientswith alcohol problems: a controlled educational trial. AnnEmerg Med. 2002;40:50–62.
38. Fiellin DA, Butler R, D’Onofrio G, Brown RL,O’Connor PG. The physician’s role in caring for pa-tients with substance use disorders: implications formedical education and training. Subst Abuse. 2002;23(3Suppl):207–234.
39. Stenhouse L. An Introduction to Curriculum Re-search and Development. London: Helnemann; 1975.
40. Accreditation Council for Graduate Medical Edu-cation Web site. 2009. Available at: www.acgme.org. Ac-cessed December 10, 2011.
41. Saitz R, Svikis D, D’Onofrio G, Kraemer KL, PerlH. Challenges applying alcohol brief intervention in di-verse practice settings: populations, outcomes, and costs.Alcohol. Clin Exp Res. 2006;30:332–338.
42. Lowenstein SR, Weissberg MP, Terry D. Alcoholintoxication, injuries, and dangerous behaviors—and therevolving emergency department door. J Trauma InjuryInfect Crit Care. 1990;30:1252–1258.
43. Diekman ST, Floyd RL, Decoufle P, SchulkinJ, Ebrahim SH, Sokol RJ. A survey of obstetrician-gynecologists on their patients’ alcohol use during preg-nancy. Obstetr Gynecol. 2000;95:756–763.
44. McCormick KA, Cochran NE, Back AL, Merrill JO,Williams EC, Bradley KA. How primary care providers talkto patients about alcohol: a qualitative study. J Gen InternMed. 2006;21:966–972.
45. Solberg LI, Maciosek MV, Edwards NM, Khan-chandani HS, Goodman MJ. Repeated tobacco-use screen-ing and intervention in clinical practice: health impactand cost effectiveness. Am J Prevent Med. 2006;31:62–71.
46. Ewing JA. Detecting alcoholism. The CAGE ques-tionnaire [see comment]. JAMA. 1984;252:1905–1907.
47. Ewing JA. Screening for alcoholism using CAGE.Cut down, Annoyed, Guilty, Eye opener [comment]. JAMA.1998;280:1904–1905 [erratum JAMA. 1999;281:611].
48. Brown RL, Rounds LA. Conjoint screening ques-tionnaires for alcohol and other drug abuse: criterionvalidity in a primary care practice. Wisconsin Med J.1995;94:135–140.
49. Knight JR, Shrier LA, Bravender TD, Farrell M,Vander Bilt J, Shaffer HJ. A new brief screen foradolescent substance abuse. Arch Pediatr Adolesc Med.1999;153:591–596.
50. D’Onofrio G, Bernstein E, Rollnick S. Motivat-ing patients for change: a brief strategy for negotiation.In: Bernstein E, Bernstein J, eds. Emergency Medicineand the Health of the Public. Boston: Jones and Bartlett;1996:51–62.
51. Lane C, Hood K, Rollnick S. Teaching motivationalinterviewing: using role play is as effective as using simu-lated patients. Med Educ. 2008;42:637–644.
52. Wong JG, Holmboe ES, Jara GB, Martin J, BeckerWC, Fiellin DA. Faculty development in small-groupteaching skills associated with a training course onoffice-based treatment of opioid dependence. Subst Abuse.2004;25:35–40.
53. McLellan AT, Lewis DC, O’Brien CP, Kleber HD.Drug dependence, a chronic medical illness: implicationsfor treatment, insurance, and outcomes evaluation [seecomment]. JAMA. 2000;284:1689–1695.
54. Solberg LI, Maciosek MV, Edwards NM. Primarycare intervention to reduce alcohol misuse ranking itshealth impact and cost effectiveness. Am J Prevent Med.2008;34:143–152.
55. Saitz R, Friedmann P, Moskowitz M, Samet JH.Professional satisfaction experienced when caring forsubstance-abusing patients: faculty and resident physi-cian perspectives. J Gen Intern Med. 2002;17:373–376.
56. Matthews J, Kadish W, Barrett SV, Mazor K, FieldD, Jonassen J. The impact of a brief interclerkship aboutsubstance abuse on medical students’ skills. Acad Med.2002;77:419–426.
Dow
nloa
ded
by [
Yal
e U
nive
rsity
Lib
rary
] at
06:
59 1
2 A
pril
2012