In the past, addiction psychiatry was described as a "stepchild" in psychiatric residencies (
1). Since then, the need for more comprehensive education regarding the treatment of substance use disorders for general psychiatric residents has been more widely recognized. These advances have largely been driven by increased awareness of the need-to-treatment gap and the fact that most patients with substance use disorders will not see an addiction specialist, but will seek care from providers in other fields. Patients with substance use problems are common in both adult and pediatric clinical populations (
2,
3). Furthermore, there is a dearth of formally trained addiction specialists relative to patients with these disorders, underscoring the need for generalists of all fields, particularly psychiatrists, to be well trained in the diagnosis and appropriate treatment of patients with substance use problems (
4).
In 1996, APA issued two position statements on training needs in addiction psychiatry and substance-related disorders calling for efforts to bolster addiction curricula in general residencies (
5,
6). In January 2001 the Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME) mandated a 1-month, full-time-equivalent clinical rotation in addiction psychiatry for general psychiatric training programs (
7). A subsequent survey of 50 psychiatric residencies determined that, although most programs were able to meet the minimum ACGME requirements, program directors expressed concerns such as insufficient opportunities for residents to follow patients over extended periods and in different settings and the limited availability of qualified addiction supervisors (
8). Others affirmed that most addiction psychiatry education is not provided by supervisors trained in that subspecialty (
9). Given this shortage of supervisors, it appears that addiction fellows are surprisingly underutilized in training residents (
8).
Stigma has been cited as an additional impediment to education about the care of patients with substance use disorders (
10). Fostering appropriate attitudes and a sense of professional responsibility for the treatment of patients with substance use disorders by psychiatric residents is essential for training new physicians who are willing and able to treat these problems. Renner (
11,
12) describes these components, along with an adequate knowledge base, as the "clinician’s triad" required for successful clinical care of patients with addictions. Even brief substance abuse seminars can result in measurable improvements in medical student and resident attitudes toward patients with substance use disorders (
13,
14). Learning appropriate approaches to patients with substance abuse problems is best begun early in training (
4,
8), when role-modeling and mentoring can facilitate the development of helpful attitudes and a sense of professional responsibility for these patients (
10). This should continue through the later stages of training, when senior residents are asked to model this behavior for their more junior colleagues. Despite this, comprehensive training throughout the 4-year residency is rare (
15).
Recently, interest has increased in teaching evidence-based practices in psychiatric residency programs (
16). In 1991, Kay (
17) cited fostering scientific thinking as a primary role for psychiatric residency education. Effective substance abuse education will add to residents’ ability to evaluate scientific literature and to integrate thoughtfully this skill into the care of individual patients.
To address these concerns, the Massachusetts General Hospital (MGH)/McLean Hospital adult psychiatric residency training program initiated a review of its addiction psychiatry training. The training faculty met at the annual faculty retreat to assess the strengths and weaknesses of addiction psychiatry teaching. This retreat was followed by several curriculum planning meetings and recommendations for longitudinal, integrated teaching in addiction psychiatry throughout the 4-year program.
A six-part curriculum was developed and phased in over 3 years. Major components included a faculty seminar series in addiction psychiatry to "train the trainers" in fundamentals of diagnosis and treatment of substance use disorders, such as an overview of substances of abuse, detoxification, screening/history/assessment, evaluation and treatment of patients with co-occurring psychiatric disorders, pharmacotherapy for substance use disorders, substance-induced psychosis (case review), club drugs, and special topics regarding women and substance use disorders. Two comprehensive training binders in addiction psychiatry are used in rotations during postgraduate years (PGYs) 1 and 3. A 1-month, full-time inpatient addiction psychiatry rotation occurs during PGY-1. Addiction psychiatry teaching is integrated on inpatient services during PGY-2. A substance abuse consultation and outpatient supervision rotation in PGY-3, 10 hours per week for 2 months, was added as of July 2005 and a substance abuse research elective was added in July 2007. Substance abuse electives in PGY-4 include a chief residency in addiction psychiatry and clinical and/or research electives. This curriculum is described in detail in Table 1. Contents of the rotation binders are available upon request.
All residents participate in a 1-month, full-time substance abuse rotation during PGY-1. The main setting for this rotation is a 17-bed alcohol and drug abuse inpatient psychiatry unit, where patients receive medical detoxification and initial education and treatment. Residents also spend about 10% of their time leading groups in a partial hospital program, which focuses on substance abuse treatment, relapse prevention, and 12-step facilitation. They are also assigned an individual patient in the partial hospital program for individual therapy and are assigned a supervisor for this case.
Primary goals during the PGY-1 rotation include introducing residents to fundamentals of interviewing patients with substance use disorders, appropriate diagnosis and treatment of patients with co-occurring substance use and other psychiatric disorders, and fostering a sense of enthusiasm for and hopefulness about working with patients with substance use disorders. Residents interact with a range of clinicians from experienced faculty to residents and fellows, allowing more senior colleagues to model helpful attitudes and a sense of professional responsibility for these patients.
Also to this end, residents attend a 1-hour interviewing seminar with a different senior staff member each week. Seminar leaders represent multiple disciplines, including psychology, psychiatry, child psychiatry, and social work, but all are experienced in treating patients with substance use disorders. This further exposes general psychiatric residents to psychiatrists and other clinicians who are enthusiastic and knowledgeable about the treatment of patients with addictive disorders.
A culture of evidence-based practice and self-directed learning is introduced by providing residents with an introductory binder containing the rotation description, expectations, core competencies, and recommended readings. Some materials are explicitly discussed during meetings with faculty, senior residents, and fellows, while others are included for self-directed reading. Residents are encouraged to refer to these articles as they encounter different forms of treatment during the rotation.
During PGY-2, addiction education is integrated into residents’ other rotations, reinforcing the expectation that patients with substance problems are found in all health care settings and that most treatment of these patients occurs outside of specialty programs. Core rotations include the Acute Psychiatry Service, the MGH emergency room, the MGH medical psychiatry inpatient unit, and the McLean psychotic disorders inpatient unit.
Substance abuse education during the Acute Psychiatry Service rotation is provided through supervised direct patient care and formal substance abuse training seminars. It continues during the medical psychiatry and psychotic disorders inpatient rotations, as residents build on skills established during PGY-1.
The general focus during PGY-3 is on outpatient and consultation-liaison psychiatry, including a 2-month rotation on the Substance Abuse Consultation Service (
18), emphasizing the integration of treatment recommendations for patients with co-occurring psychiatric and substance use disorders. Residents meet twice weekly with the director of the Substance Abuse Consultation Service to review their consultations and to discuss patients from their outpatient clinic practices.
To foster their ability to provide evidence-based treatment recommendations for patients with substance use disorders, residents receive an "advanced binder" (contents are available from the author upon request). Residents also meet weekly with the chief resident for didactic instruction on eight topics drawn from the binder.
During PGY-4, residents continue to treat patients with substance use disorders in their longitudinal clinics; they may choose weekly supervision with addiction psychiatry staff or on a consultative basis in cases for which a nonspecialist is the primary supervisor. Residents particularly interested in substance use disorders receive support and mentorship for research projects or opportunities for further clinical training in PGY-4; one is selected to be chief resident in addiction psychiatry.
The chief residency is an individualized program designed by the chief resident and the associate clinical director of the alcohol and drug abuse treatment program. The chief resident plays a major role in educating junior residents about SUD treatment. He or she receives frequent supervision of teaching and clinical work. The chief resident also can pursue research and/or further clinical practice in relapse prevention treatments, motivational interviewing, and patient education groups.
Residents in PGY-4 who are not serving as chief resident are offered opportunities to continue clinical training or involvement in research and teaching projects relevant to patients with substance use disorders. Residents in PGY-4 may co-lead outpatient substance abuse relapse prevention groups including the buprenorphine/naloxone outpatient maintenance group. Many participate in ongoing outpatient work, pursue research projects, help teach seminars for junior residents, or participate in individualized electives on the different clinical services in the alcohol and drug abuse treatment program.
Implementing a comprehensive addiction psychiatry training curriculum within a general psychiatric residency presents particular challenges, including recruiting faculty, determining appropriate clinical settings in which training can take place, and generating enthusiasm among residents for their roles in the process. Although full discussion of the unique issues encountered by each residency program is not possible here, some considerations for dealing with common problems are presented below.
Like most general psychiatric residencies, the MGH/McLean Hospital program relies heavily on core teaching faculty to provide subspecialty training (including addiction psychiatry training) to residents. Obviously, some commitment on the part of the general program to providing faculty resources is necessary for any meaningful education program to take place. In particular, identifying and recruiting core teaching faculty in the treatment of substance use disorders is essential. Beyond this, a program’s success requires that faculty without specific addiction psychiatry training help train residents. A faculty training seminar can facilitate faculty acceptance of greater roles in the addiction psychiatry curriculum. This, in turn, can extend addiction education into general psychiatry clinics and wards.
For personnel-intensive components of its addiction psychiatry curriculum, the MGH/McLean Hospital residency draws heavily on its substance abuse treatment program (for instance, to provide faculty interviewers for the interviewing seminar). In programs that do not have specialized facilities, the model could be adapted by recruiting community clinicians. The time commitment required (in our program, two to four interviews, or about 2—4 hours, per academic year) should not be prohibitive. The alternative is to rely solely on core faculty, something that presents a challenge in small programs, where demands on time may already be high.
Fellows and senior residents demonstrating skill in working with patients with addictions can also be utilized, under supervision from experienced staff. By actively encouraging greater involvement of senior residents and addiction psychiatry fellows in taking on teaching roles, and by providing supervision for these activities, the efforts of primary addiction educators in any program will have greater impact on future psychiatrists. To this end, creating a chief resident position specific to addiction psychiatry may be helpful in programs trying to spark residents’ interest in teaching. Alternatively, such roles can be integrated with existing general chief resident positions by offering expert supervision (which is generally valued by residents) in exchange for greater involvement in the addiction curriculum.
Finding appropriate settings for residents to learn about treating addicted patients is also a challenge for many programs, where specialized substance abuse treatment facilities may not exist. Nonetheless, patients with substance use disorders are found in all health care settings, including nonspecialized psychiatric facilities, as well as general medical and emergency medical units. Addiction education can be integrated with general training in whatever settings are available. In fact, this more closely approximates the clinical practice of most psychiatrists.
Even in larger programs, resources that can be dedicated to training residents in addiction psychiatry are limited. For instance, in the MGH/McLean Hospital program, the positions of PGY-1 and PGY-3 rotation director, director of the Substance Abuse Consultation Service, associate clinical director, and addiction fellowship director have been held by one individual. Other programs also rely on a few core faculty to provide addiction education. Nonetheless, if comprehensive addiction psychiatry training programs are to be widely undertaken within general residencies, it is essential that more resources be dedicated to the task. Only in this way will future generations of general psychiatrists be adequately prepared to provide much needed treatment to their patients with substance use problems.
This work was presented in part at the March 2006 meeting of the American Association of Directors of Psychiatric Residency Training, in San Diego, Calif., and at the 5th Annual Medical Education Day, Harvard Medical School, Boston, Mass., in November 2006. This work was supported in part by grant K24 DA019855 (SFG) from the National Institute on Drug Abuse.
At the time of submission, the authors disclosed no competing interests.