Acts of affordable caring: Changing clinical culture around substance use

Doctor comforting patientby Margaret Chisolm, MD

The vast majority of Americans who engage in problematic use of either licit or illicit substances have never received treatment for their substance use. The recent implementation in the United States of the Mental Health Parity and Affordable Health Care Acts means that – finally – these patients will have access to the care they need.

Problematic substance use refers not only to substance use disorders, but to any use that confers an added health risk (for example, women at high genetic risk for breast cancer, or pregnant women who continue to drink even small amounts of alcohol). Substance use is one of the most common conditions seen in medical practice and is associated with significant morbidity and mortality. Treatment for substance use is now considered an essential service in healthcare plans, required for Accountable Care Organizations. As a result, the role of physicians in the prevention and treatment of substance use is expanding in importance and magnitude.

Greater access to care for substance-using patients means that physicians will need enhanced training and support to effectively identify and care for patients with problematic substance use. To achieve this, we need to combine these three elements:

  1. Pre-clinical courses. Several entities, including the Hazelden Betty Ford Foundation and Treatment Research Institute, are currently developing pre-clinical courses for medical students in order to meet this growing need.
  1. Role modeling. Students will need role models to demonstrate humanistic and professional attitudes and behaviors (e.g., respect, compassion, integrity) that will enable them to translate their pre-clinical knowledge and skills into clinical practice.
  1. Culture change. To make a significant impact on the overall clinical culture of an institution, we need strategies designed to develop and support more caring attitudes in all healthcare team members towards patients with problematic substance use.

Each of these three strategies is dependent on the others. Any benefits gained from pre-clinical substance use curricula or will risk significant erosion if students are not exposed to positive role models. And positive role modeling will not be possible in a hospital culture that continues to stigmatize and marginalize these patients.

A broad change in cultural attitudes that supports humanistic role models, combined with pre-clinical curricular strategies to increase knowledge and skills, is what will result in implementation of improved clinical practice behaviors. In turn, these will lead to:

  • improved rates of screening
  • shorter overall length of treatment
  • effective referrals for continued treatment, and
  • increased access to treatment for patients with problematic substance use.

One approach currently being used to affect broad culture change at the practitioner level is Project Engage. Project Engage, based in the clinical setting of the Emergency Department (ED) at Christiana Care Health System, trains Emergency Department (ED) nurses to screen all patients regarding their substance use. Patients who screen positive for problematic substance use are then referred to behavioral counselors in the ED for a brief intervention and referral to further treatment, if indicated.

Preliminary results suggest Project Engage has had a positive impact on nurses’ screening and referral behaviors, as well as on their attitudes about the efficacy of brief engagement interventions (Pecoraro et al, poster presented at the College on the Problems of Drug Dependence, 2014). It is hoped that changing attitudes of ED nurses will influence attitudes of the entire ED culture around substance use treatment.

Another approach, and one that I’m interested in studying, is the use of team training programs to change attitudes. Team training programs have been shown to make a strong impact on teamwork culture and can serve as a curricular model for reducing preventable harm in patients with problematic substance use.

Johns Hopkins University’s Armstrong Institute for Patient Safety and Quality is one of several sites in the US that offer a Master Trainers course in TeamSTEPPS–Team Strategies and Tools to Enhance Performance and Patient Safety. TeamSTEPPS was developed by the Agency for Healthcare Research and Quality and the Department of Defense Patient Safety Program and has rapidly become the healthcare industry standard for teamwork training.

I am exploring ways that this training can be adapted for the care of patients with substance use. With such training, nursing and medical students would be empowered to speak out against the prevailing culture of nihilism found in many clinical care settings. Framed as a patient safety issue, students would demonstrate evidence-based attitudes, knowledge, and practice towards patients with substance use problems. Thus, these students would have the potential not only to impact attitudes of other team members, but to make a significant difference in health outcomes for patients with problematic substance use.

Addiction kills.  Empowering medical students to model respect, compassion, and integrity towards these vulnerable patients will save lives.

Margaret Chisolm M.D. 5-17-07Margaret Chisolm, MD is a board-certified psychiatrist with over 20 years of experience as a clinician educator.  A member of the faculty at Johns Hopkins University School of Medicine, Dr. Chisolm is also a Gold Humanism Scholar at the Harvard Macy Institute Program for Educators.  Dr. Chisolm is most dedicated to developing and implementing internationally-transferrable educational interventions that promote humanistic values, enhance patient-centered care, and improve patient outcomes.