Medical Student Training:
One method for training medical students is to use "standardized patients." A standardized patient is usually a paid actor who is told in advance what symptoms and medical problems to present in the training session. This cluster of symptoms is "standardized" in that the actor presents the same clinical picture to every student being trained and evaluated, so that their supervisors can assess the degree to which the students accurately detect the symptoms they are supposed to be learning to recognize. In this way, the supervisor can evaluate how well the student asks questions to first identify the symptom in question, and then how well the student follows through with proper medical treatment. In 1991, the first standardized patients having to do with alcohol abuse were used to train senior medical students as a part of the University of Washington School of Medicine's Standardized Patient Assessment Program. Since that time, similar cases have periodically been included in assessments of second through fourth year students.
Following these training encounters between student and standardized patients, standardized patients complete clinical performance checklists. These checklists assess whether students asked them specific alcohol screening questions which the students had been instructed to ask when alcohol abuse is suspected. These questions typically include ones about frequency and quantity of alcohol use as well as the four CAGE screening questions (Have you ever Cut down on your drinking? Have you ever been Annoyed by others complaining about your drinking? Have you ever felt Guilty about your drinking? Have you ever had an Eye-opener?). Other key questions students are trained to ask are whether the patient views alcohol use as a problem and, if so, whether the patient has any interest in working on the problem. Options for working on the problem that students are taught to discuss with patients include specialized treatment, attending Alcoholics Anonymous, and cutting down or abstaining on oneís own.
Data obtained by the UW School of Medicine indicates that although medical student performance as indicated by these checklist items has remained consistent over the years, attitudes change. In the time from early medical school to final years of residency, hopeful and respectful attitudes toward patients with alcohol problems diminish, and clinical efforts toward directly addressing these problems with patients decline.
To improve studentsí attitudes toward problem drinkers, to increase their awareness of alcohol abuse among their patients, and to encourage them to actively screen and intervene with alcohol-abusing patients, we did the following as part of this project:
Delivered a 2-hour lecture for every Surgery Clerkship rotation on: the prevalence of alcohol problems among surgery patients with traumatic injuries, the outcomes of brief interventions for alcohol problems in trauma centers, how to screen for alcohol problems, and how to perform brief interventions. Dr. Chris Dunn, addiction psychologist, and Dr. Larry Gentilello, trauma surgeon, delivered these lectures. Students were encouraged to share and discuss their current attitudes and perceptions toward patients with drinking problems, as well as their past experiences in dealing with these patients. Brief interventions were demonstrated in role plays in which the trainer played the doctor and students played the patient. Then, students were given chances to practice these skills in role plays with supportive feedback by the trainer. All of these training activities were done within a single 2-hour time slot. This was done for each clerkship involving approximately 20 students per clerkship rotation.
We delivered a 2-hr. lecture for every Psychiatry Clerkship rotation. Dr. Richard Ries, psychiatrist, and Dr. Chris Dunn delivered these lectures. The focus of this lecture was to introduce students to a workbook on how to do a brief intervention with a psychiatry patients abusing alcohol/drugs. This workbook (see Appendices) guides students through the screening, assessment, and counseling process, emphasizing the need for students to collaborate with their multi-disciplinary treatment teams. Since psychiatry is a required rotation, all 160 third-year medical students were trained each year. Informal follow-up with Psychiatry Clerkship students who performed a brief intervention using the workbook yielded a range of feedback. Some students felt that their patient was not fully engaged in the intervention. Other students perceived the brief intervention to be useful for the patient and valuable for their own training.
The overall reception of the medical student trainingóboth for surgery and psychiatry students-- was very positive. This is a sample of positive comments received on the lecture evaluations: "A very interesting and useful lecture." "I didnít know I could make a difference in patients with drinking problems." "Excellent demonstration and role plays." "I can use technique with any kind of patient I see."
Dr. Dunn participated on an expert panel as part of a lecture given to all students in one of their first year courses, Introduction to Clinical Medicine. This panel included community providers who taught students about the kinds of treatment services they provide and answered questions from students about recovery from alcohol and drug abuse. The emphasis was on how brief interventions can help motivate patients to participate in such treatment services. Since Introduction to Clinical Medicine is required of all first year students, all 160 students were trained each year during the course of the grant.