Addressing Alcohol-Impaired Driving: University of Washington School of Medicine

University of Washington School of Medicine Curriculum Development:

The first two years of medical school at the University of Washington consist of formal course work. We believed that it is important for students to become exposed to information concerning alcohol abuse and counseling during this period as well as during clinical clerkships. To increase the amount of substance abuse training in this curriculum, we surveyed all UW School of Medicine Human Biology Course Coordinators who teach our Human Biology curriculum courses, asking for descriptions of any substance abuse content offered by them or anybody lecturing as part of their courses. The results of this survey are shown below in Table 2.

Table 2:
Current Substance Abuse (SA) Content in Human Biology Curriculum: Results of Survey of all Classroom Medical School Instructors

Title	Qtr	Substance Abuse (SA) Content
Micro Anatomy (Histology)	A1	no SA content
Anatomy & Embryology	A1	SA mentioned in context of living anatomy of the liver & portal circulation
Mechanisms in Cell Physiology	A1	discusses synaptic mechanism of cocaine
ICM I	A1	lecture on interviewing patients about use of alcohol and drugs
Biochemistry I-A	A1	no SA content
Human Behavior I-A	A1	lecture on fetal alcohol syndrome
Cell & Tissue/Injury	W1	Mechanism of alcohol-induced cell death & pathogenesis of liver disease
Nat History Infectious Diz I-A	W1	covers problems associated with AIDS, bacteremia, endocarditis, and hepatitis with alcohol/drugs
ICM I	W1	lecture on SA, patients in recovery describe experiences
Introduction to Immunology	W1	No SA content
Biochemistry I-B	W1	No SA content
Human Behavior I-B	W1	No SA content
Epidemiology	S1	Not specifically addressed, but research methods taught apply to SA research
Head, Neck, EN & T	S1	No SA content
Nervous System	S1	No SA content
Natural History Infec Diz I-B	S1	Discusses wound botulism associated w/ cocaine inhalation
	S1	Lecture/discussion on topic similar to A1 and W1 quarters
Cardiovascular System	A2	No SA content
Respiratory System	A2	20 minutes on smoking, no other substances covered
ICM II	A2	Making and giving SA diagnosis: interview and write HPI on a patient w/SA problem
Principles of Pharmacology I	A2	Pharmacology of alcohol, toxicity, dependence, tolerance, abuse potential
Endocrine System	A2	No SA content
Systemic Pathology	A2	Discusses liver disease: dose & cirrhosis
Genetics	A2	No SA content
Skin System	A2	No SA content
ICM II	W2	Visit AA mtg, interview an AA member, hand in write-up of HPI on their SA
Gastrointestinal System	W2	Seminar on liver disease w/case discussion on liver transplant
Hematology	W2	Discussed as part of sickle cell disease lecture:
Musculoskeletal System	W2	No SA content
Medicine, Health & Society	W2	No SA content
ICM II	S2	Interviewing styles demonstrated, panel discussion, attend AA meeting
Urinary System	S2	No SA content
Human Behavior II	S2	1 hr. alcohol abuse and 1 hr. substance abuse
Principles of Pharmacology II	S2	Stimulants: mech. of action, clinical use, side effects, psychotomimetics
Reproduction	S2	Nothing in syllabus, passing remarks on steroid abuse effects on males
Nutrition for Physicians	S2	Consequences of alcohol abuse covered in one of the lectures
Note: A= autumn, W= winter, S= spring. "1" and "2" refer to first and second years of medical school, when all course work is taken.

This survey demonstrated that teaching on alcohol abuse can be done in many courses throughout the curriculum. It is more effective to include discussions in many different courses rather than confining it to one short period during medical school.

We surveyed all Clinical Clerkship Coordinators who are responsible for developing curriculum for the clinical rotations constituting the second two years of medical school. These results are shown below in Table 3.

Table 3:
UW Substance Abuse Training Content in 6 Required Clerkships: Survey of Clinical Clerkship Coordinators.

Clerkship	Substance Abuse Training Experiences Provided
Psychiatry (Ries, Dunn)	Advanced assessment of substance use/abuse/dependence 2-hr. lecture and demonstration of a brief intervention Treatment models and recovery taught Structured intervention work-up with Psychiatry patient with SA problem Perform brief intervention with that patient Visit different Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous meetings other than those visited in ICM II course
Surgery (Dunn)	90-minute lecture on alcohol abuse, trauma, and brief interventions has been cancelled
Pediatrics (Robertson)	Students given syllabus of 36 case scenarios (at least one case addresses substance abuse). Most students have contacts with Fetal Alcohol Syndrome, cocaine babies, and teens abusing substances, but not guaranteed Occasional lecture on adolescent substance abuse Adolescent substance abuse lecture seldom given anymore
Family (Stern)	19 common problems in Family Practice are focused on; Substance abuse is subsumed under only one of these topics, "depression" Alcoholism not focused on as common problem ("too many others to do") One chapter to read on alcoholism and drug abuse May include SA among required web site references for students
Medicine (Paauw)	There is an alcohol abuse section in the student syllabus that is required reading Most students take care of alcohol and drug-abusing patients in clinic, but not specifically mandated

All the rotations above are required of all medical students. The results indicate that students are exposed to information about substance abuse at a number of times during their clinical training. This repeat exposure is very useful in changing behavior and instilling skills and a sense of self-efficacy.

We presented the results of the two surveys to the UW Substance Abuse Theme Committee that included the Assistant Dean of the Medical School. This presentation included our recommendations for including many more substance abuse training topics. These recommendations were derived from the International Medical Education Model, and we believe are generalizable to other schools of medicine across the U.S. They represent a strategy for training future physicians in screening for and management of patients with problem drinking. These recommendations are summarized in Table 4 below.

Table 4:
Recommended Substance Abuse (SA) Training Topics
(from International Medical Education Model, Fleming & Murray):

	Topic	Topic Description
1	Epidemiology & Phenomenology	Continuum of SA problems (low-risk, hazardous, abuse/dependence) Natural history of SA disorders Prevalence of SA disorders vs. other medical disorders Special populations w/special SA problems Stages of change readiness
2	Etiology & Prevention	Risk & buffer factors Clinically-based prevention opportunities
3	Special Populations	Adolescents, women, elderly Age & gender physiological differences Screening & assessment issues Patients with psychiatric disorders
4	All drugs of abuse	Trends in use, availability, preparations of, routes of administration of all drugs of abuse Behavioral effects of all drugs of abuse Biopsychosocial consequences of acute & chronic abuse of all drugs Clinical signs & symptoms of each
5	Clinical Research	Research methods used for epidemiological & clinical studies Outcomes of various SA treatment modalities SA treatment outcomes vs. outcomes for other chronic disorders
6	Screening & Assessment	Standardized screening & assessment techniques Interviewing skills
7	Brief intervention	Learn how non-specialists can treat SA Listening to patients and giving them feedback and advice How to do brief interventions across numerous medical specialties
8	Alcohol-related Medical Problems	Medical conditions caused or exacerbated by SA: perinatal & FAS, HTN, cardiac, stroke, GI, pancreatitis, malabsorption, liver, cancers, sexual dysfunction, HA, sleep problems, peripheral neuropathy, organic brain disorders, hematological problems
9	Specialized Treatment	Continuum of treatment modalities: what they are and what they do The art of referring patients for treatment
10	AA & Self-help Groups	Know basics of AA and other self-help groups Referring to and visiting meetings Meet successfully recovering people
11	Pharmaco-therapy	Neurobiology of drug actions and craving
12	Medical Detoxification	Neurobiology and clinical treatment of withdrawal for all drugs of abuse Withdrawal & co-morbid conditions
13	Management of Anxiety & Pain	Abuse potential of commonly prescribed drugs Breathalyzer/drug testing Assessment of pain & psychiatric symptoms Pharmacological & non-pharmacological treatment of pain Pain contracts, informed consent procedures
14	Tobacco Cessation	Screening & brief intervention procedures Pharmacotherapy Office-based systems
15	Harm Reduction Methods	Pregnancy IV drug users Sexually transmitted disease prevention
16	Psychiatric Comorbidity	Psychiatric problems caused, complicated, exacerbated by substance abuse
17	Legal & Ethical Issues	Patient autonomy Confidentiality and charting issues around SA Protection of records, liability, child abuse

We provided to the UW Substance Abuse Theme committee copies of the National Institute of Alcoholism and Alcohol Abuse’s (NIAAA) "An International Model for the Prevention and Treatment of Alcohol Use Disorders." This material contains a comprehensive substance abuse knowledge base that teaches evidence-based medical treatment for substance abuse. The intent is that information in this model would be incorporated into the curriculum.
Recommendations were made to the School of Medicine on how the UW curriculum could further comply with NIAAA’s training recommendations, such as including topics listed in table 4 in the Human Biology course curriculum.
Key faculty members were identified in General Internal Medicine, Family Medicine, Pediatrics, and Obstetrics and Gynecology who would become future "substance abuse champions," thereby promoting the inclusion of more substance abuse training experiences into the clinical clerkships.
We revised the UW Substance Abuse Theme Committee’s "Substance Abuse Roadmap," a document summarizing the substance abuse training experiences our medical students receive from year 1 through year 4 of their education in the School of Medicine.