Abstract
Background
Despite the devastating impact of alcohol and other drug involvement and misuse within society, medical students still receive very limited exposure to these issues. The Scaife Advanced Medical Student Fellowship in Alcohol and Other Drug Dependency, offered by the Institute for Research, Education and Training in Addictions for over 10 years, offers a unique, 3-week intensive educational experience, including didactic, observation, and experiential learning in these topics to first-year medical students. The goal of this project was to evaluate the impact of the Scaife Fellowship on medical students’ attitudes toward patients with alcohol and other drug involvement 1 to 5 years after completion of the experience.
Methods
Past Scaife students and individuals who applied but did not attend were located and recruited to participate in an online attitude survey.
Results
Results indicated that Scaife Fellowship students largely retain their sense of role security around working with patients with alcohol and other drug involvement at the follow-up time point. Although therapeutic commitment or the motivation to work with these patients decreased for drug use, the decrease was smaller than that typically noted in the literature. The group of comparison students showed lower scores on both subscales at the evaluation time point compared with Scaife students.
Conclusions
A three-week experiential program significantly improved medical students’ Role Security and Therapeutic Commitment toward working with patients with substance use disorders. Moreover, the positive effects gained from the program were sustained over time.
Introduction
Medical students receive little training in addiction, despite the significant public health concern of alcohol and other drug use, the prevalence of these issues across medical settings and their interaction with many chronic health conditions, and limited access to appropriate treatment. 1 Nearly regardless of specialty, it is clear that physicians will routinely come into contact with patients with problematic use of alcohol and other drugs and will be ill prepared to do so. Recent research demonstrates this issue is international in scope. 2 , 3 Calls for increased attention to substance use in curricula have been made at the medical undergraduate, 4 graduate, 5 and residency 6 levels.
The Scaife Advanced Medical Student Fellowship in Alcohol and Other Drug Dependency (Scaife Fellowship) addresses these issues by providing a 3-week intensive experience not available at most medical schools. The Scaife Fellowship combines didactic, observational, and experiential components in order to teach students how to recognize indicators of alcohol and drug issues across medical specialties and settings, how patients receive addiction treatment, and their role as doctors in the continuum of addiction. One of the unique aspects of the Scaife Fellowship is the breadth and depth of patient contact built into the program. The Institute for Research, Education and Training in Addictions has been offering this program for over 10 years and has served over 120 medical students from dozens of medical schools across the country. The program is geared toward completing first-year medical students in order to foster sensitivity to alcohol and other drug issues in the early stages of their medical education and to provide a context for the remainder of their didactic and clinical experience in medical school.
Supplementing medical students’ education with intensive experiences with patients with substance use disorders has shown positive results. The Betty Ford Institute holds a Summer Institute for Medical Students offering similar experiences to medical students over 1 week. Evaluations of that program indicate that physicians who participated in the program showed more positive attitudes and confidence with patients with addiction, relative to a comparison group that was matched on year of graduation from medical school. 7 Interview data from past participants attested to the value of the program.8
The purpose of this paper was to report on the impact of the Scaife Fellowship on medical students’ attitudes toward patients with alcohol and other drug involvement 1 to 5 years after completion of the program. In order to minimize bias, this evaluation featured a comparison sample of students who had applied to the Scaife Fellowship program but did not ultimately attend the program. The overarching goal of this ongoing evaluation is to demonstrate the long-term impact of the Scaife Fellowship program.
Methods
Participants
Participants were 47 medical students who participated in the Scaife Fellowship from 2008 to 2013 (Scaife students) and a comparison group of 38 medical students who applied for the fellowship and were accepted but did not ultimately attend (comparison students). Reasons for not attending were usually related to scheduling conflicts.
Scaife fellowship
The Scaife Fellowship offers a unique blend of didactic, experiential, and hands-on intensive experience in addictions. The objectives of the program include Diagnosis and Screening, Special Population Considerations, Epidemiology and Research, Treatment/Intervention Strategies, Professional Impairment, Recovery from Addiction, and System/Organizational Issues. An important hallmark of the experience is the breadth of site visits, where students are able to not only observe but also participate in interactions with patients. Some of the site visits include traditional inpatient and outpatient treatment centers, psychiatric emergency department, county correctional health services, methadone maintenance clinic, specialty programs for women and for LGBTQ (lesbian, gay, bisexual, transgender, queer) individuals, and 12-step programs. Finally, the students are asked to select an addiction science topic of interest about which they complete a research paper and presentation to their peers and program faculty on the last day of the fellowship.
Contacting participants
Data were collected from participants about their attitudes and perceptions around working with patients who use alcohol and other drugs immediately and 1 to 5 years after participation in the program. Several methods were employed to find and contact Scaife Fellowship students and comparison students, including the last contact information they had provided, social media sources (Facebook, LinkedIn, etc.), and medical school alumni offices and state licensing Web sites.
A total of 47 students who had participated in the Scaife Fellowship completed the survey, out of 92 contacted, for a 51% response rate. Conversely, 38 comparison students of 114 contacted completed the survey. This difference in response rates was expected, since Scaife students were seen as more likely to feel a willingness to help and respond to the survey after having attended the program. Response rates were generally higher the more recently the Scaife Fellowship had had contact with the student; for example, the response rate for Scaife students from 2013 was 88%. Again, this was expected because as more time passes, students are more likely to change contact information and be more difficult to locate. No significant differences between those who completed the survey and those who did not reply were noted on any of the demographic variables, including age or gender, at baseline.
Design
The project followed a quasi-experimental design to examine the influence of the Scaife Fellowship upon attitudes toward patients with alcohol and drug problems. The Alcohol and Alcohol Problems and Perceptions Questionnaire (AAPPQ) and the Drug and Drug Problems and Perceptions Questionnaire (DDPPQ), which are the same instruments given to the students on the first and the last day of the fellowship, were administered to the Scaife students and comparison students via online survey. Therefore, the Scaife students’ attitudes were evaluated over time, and the 2 groups also were compared on attitudes at present.
Measures
Scaife Fellowship students had already completed pre- and post-training survey data. Both groups received these same surveys (below) at the follow-up evaluation assessment. For the comparison students, this was the only administration of these instruments.
Aappq
The AAPPQ is a 30-item questionnaire that measures individual attitudes and perceptions toward working with patients who have alcohol-related problems. 9 Role Security addresses individual perceptions of the adequacy of one's skills in relation to patients with alcohol problems and how appropriate it is to work with these patients given one's professional role. Therapeutic Commitment, on the other hand, measures the degree to which individuals are motivated to work with patients with alcohol problems and the extent to which this work would be rewarding.
Ddppq
The DDPQ is a 30-item questionnaire that was constructed to be analogous to the AAPPQ but applied to patients with problems with substances besides alcohol. 10 As such, the subscales of Role Security and Therapeutic Commitment are structured in the same way as the AAPPQ. Both the internal consistency (Cronbach's α = .87) and construct and content validity of the AAPPQ and DDPPQ have been reported as satisfactory.
Statistical analysis
Descriptive statistics were determined for demographic data of the overall group as well as several subgroups. Simple t tests were utilized to determine any significant differences in demographics between groups and between responders and nonresponders. Two samples were further analyzed. First, Scaife students who had completed surveys at all 3 time points (pre-fellowship, post-fellowship, and follow-up; n = 47) were analyzed to determine differences over time using general linear modeling with repeated measures, with particular interest in the post-fellowship to follow-up difference. These results were then further analyzed by current status of student or practicing physician. Finally, Scaife students who completed the follow-up evaluation were compared with comparison students (n = 38) on attitude measures using univariate analysis of variance (ANOVA).
Participants were offered compensation in the form of a $10 amazon.com gift card in exchange for their participation. An institutional review board (IRB) protocol was submitted to the Western IRB (WIRB) for review of human subjects procedures and was considered an educational evaluation and therefore deemed exempt from the need for further review.
Results
Demographic information
Demographic data for Scaife students and comparison students (N = 85).
Note. No significant differences were noted between groups. For gender, χ2 = 0.622, P = .43; for race, Cramer's V = 0.14, P = .786; for Latino, χ2 = 0.06, P = .81; for age, t(79) = 0.96, P = .34. Degrees of freedom vary due to missing data in some cells.
Longitudinal results for attitude surveys
Aappq
The overall time effect for both Role Security and Therapeutic Commitment was significant (for Role Security, F(2, 74) = 147.8, P < .01, and for Therapeutic Commitment, F(2,74) = 22.9, P < .01). Role Security increased significantly from pre- to post-fellowship (F(1, 37) = 306.5, P < .01) and remains at that level at the follow-up evaluation (F(1, 37) = 1.2, P = .27). On the other hand, Therapeutic Commitment also increased significantly from pre- to post-fellowship (F(1, 37) = 47.6, P < .01) but then significantly decreases from post-fellowship to the follow-up evaluation (F(1, 37) = 23.9, P < .01).
Ddppq
Attitude differences between Scaife students and comparison students at follow-up evaluation (N = 84).
Group comparison results for attitude surveys
Next, Scaife Fellowship students who were still in medical school (attended Scaife Fellowship 2012–2013) were compared with those who had completed medical school at the time of the follow-up evaluation (attended 2009–2011) on AAPPQ scores over time. For Role Security, no significant differences in the pattern of scores over time were observed by this status variable. However, for Therapeutic Commitment, those who had completed medical school showed significantly lower scores than those who were still enrolled in medical school (F(1, 36) = 8.1, P < .01), although the pattern of scores (increase at post-fellowship followed by decrease at follow-up evaluation) were the same in both groups.
Follow-up results for fellowship versus comparison group
Scores for the Scaife Fellowship students and the comparison students were compared using independent-samples t test. These results are shown in Table 2. Across both scales of the AAPPQ and DDPPQ, Comparison students showed lower scores relative to the Scaife students. Although it was not possible to investigate the difference between these groups over time, these findings do support the overall demonstration that the Scaife program improves attitudes toward working with patients with alcohol and other drug issues.
Discussion
In a sample of medical students who had completed an intensive summer fellowship in addiction, we found that these students retained their understanding of their role to work with patients with alcohol- and substance-related issues 1 to 5 years later, whereas their motivation to work with these patients decreased significantly.
This differential effect on role security versus therapeutic commitment is consistent with the theory underlying the AAPPQ and DDPPQ, where training activities are thought to have a direct effect on role security and indirect if any effect on constructs of motivation or satisfaction in working with patients with alcohol and other drug issues.9
Compared with a group of students who had applied for the same fellowship but did not ultimately attend, students who completed the fellowship showed higher role security as well as therapeutic commitment. In fact, some of the scores of the comparison group at the follow-up time point were similar to the baseline scores for students in the fellowship.
The comparison group was composed of students who had presumably already had some interest in alcohol and drug issues by applying to the program. This decreased the likelihood that the difference between the groups could be attributed to preexisting characteristics in the students such as a greater interest in addiction issues and increased the likelihood that the difference could be attributed to effects of the program.
These results are consistent with the small literature addressing impact of addiction education during medical school. In a longitudinal evaluation of the week-long Betty Ford Institute's Summer Institute for Medical Students (SIMS), 7 results showed that physicians who had participated in the program were more likely to agree that they could help and find resources for patients with addiction and to believe that addiction is a disease. Although they endorsed higher confidence in speaking to patients about substance use, they were not more likely to agree that speaking to patients about substance use is clinically relevant. This last point mirrors our finding that although the Scaife Fellowship did result in a lasting increase in the endorsement of their role as physicians to work with patients with addiction, the motivation to do so was not maintained over time.
Limitations
The most apparent limitation was the lack of a baseline measurement for the comparison students. Without it, we were unable to assess statistical differences between the groups over the 3 time points. We did find significant differences between the groups at the single time point and anecdotally noted that the evaluation time point for the comparison students was similar to the baseline value for the fellowship group. Future research would certainly assess both groups across all time points; for example, applicants to the Scaife Fellowship might complete these measures at the time of application, in order to generate a baseline measure in the comparison group. Finally, the response rate was lower than would be hoped. Although the low response rate does limit conclusions that can be drawn, the uniqueness of this sample merits consideration of the results, particularly with regard to further replication and study.
In sum, the Scaife Fellowship offers a rare opportunity for medical students to immerse themselves in learning about working with patients who have alcohol-related and other substance-related issues, and the positive effects reaped by these students seem to be sustained over time.
Footnotes
This research was funded by the Scaife Family Foundation. The Scaife Family Foundation sponsored this project and approved of the decision to submit the manuscript for publication. The Scaife Family Foundation did not participate in collection, analysis, or interpretation of the data or in the preparation of the manuscript.
Author contributions
D.L.L., H.H., and P.F.L. participated in research conception and design; D.L.L., P.L., and J.W. participated in data collection; D.L.L. and P.L. participated in data analysis; D.L.L., H.H., P.L., J.W., and P.F.L. participated in manuscript writing and revision.