Australian Drug and Alcohol Review 1989; 8 :99-104

Recent developments in drug and alcohol medical education in Australia

Ann M. Roche and John B. Saunders Centre for Drug and Alcohol Studies, Royal Prince Alfred Hospital,

Camperdown, New South Wales, Australia.

Abstract: Drug and alcohol training in Australian medical schools is about to undergo a transformation with the appointment of drug and alcohol co-ordinators to all medical schools. These federaUy-funded positions will ensure the development and implementation of integrated drug and alcohol medical curricula at the undergraduate level.

Key words: Australia, medical education, drugs, alcohol.

Background Alcohol and drug-related disorders are

acknowledged as being among the most impor- tant public health problems affecting the developed world. Australia was described in 1977 as the "intoxicated society" and alcohol- related disorders were depicted as "having reached epidemic proport ions"? Four years later, the National Health and Medical Research Council concluded that alcohol was the "fourth most serious public health problem in Australia". More recently, widespread public concern about the extent of illicit drug use led to the establishment of the National Campaign Against Drug Abuse.

Surveys among the general population con- firm the high prevalence of hazardous and harmful alcohol and drug use. 2'~'4'5'6'7 These data highlight not only the existence of a largely preventable health problem, but also, by inference the lack of interest, and some would suggest the positive disdain, of the medical pro- fession toward these issues. Research con- sistently confirms the low level of involvement of the medical profession in this area. 8'9'1°'H'12'13 What is also found is a per- vasive pessimism in regard to drug and alcohol problems. 14'15'16 Given the widespread inade- quacy of medical education in this area aT'is doctors' views are based on the stereotype of the end-stage alcoholic or drug addict who fre- quents teaching hospital casualty departments; this pessimism is hardly surprising.

Doctors' role There is now an increased awareness of the

untapped potential for doctors to function as

agents tbr detection, treatment and prevention of drug and alcohol-related problems. Surveys have indicated that 48 % of the population con- sider their general practitioner to be the single most important source of advice on drug and alcohol-related matters, t9 Fur thermore , doctors, and in particular general practitioners, are in a position to reach virtually the entire population3 °'21 In Australia more than 80% of the population visit their general practitioner each year. 22 GPs are likely to see many patients with drug or alcohol-related problems even if such problems are not recognised.

Medical implications Failing to diagnose an underlying alcohol or

drug problem can lead to mis-diagnosis, unnecessary and hazardous investigations and inappropriate and ineffective treatment. Any of these may be costly, time consuming or hazardous. For example, prescribing tricyclic anti-depressants to a patient who presents with depression but has an underlying drinking problem is usually ineffective and can cause a dangerous drug interaction. Failing to recognise that a hypertensive patient has a drinking problem can commit the patient to multiple and poorly effective anti-hypertensive therapy.

Medical education m the challenge ahead Whilst researchers and practitioners active

in the field of drug and alcohol studies have broken much new ground, those beyond the drug and alcohol mainstream (and it should be acknowledged that is the vast majority of the

100

medical profession) remain unaware of the pro- gress that has been and is being made.

The challenge facing drug and alcohol medical education is to effectively disseminate information on the progress achieved in areas such as early detection techniques, z3 screening instruments, 24'2s computerised screening, 26'2 early intervention strategies, 27'2s the applica- tion of social learning theory 29 and controlled drinking as a treatment goal? °

Failure to achieve this is partly the respon- sibility of medical educators and the training institutions responsible for undergraduate and postgraduate education. However, it also lies partly with the drug and alcohol field itself, which, beleaguered with conceptual confusion and contradictions, 31 isolated from mainstream traditional medicine 32 and in conflict with those proffering non-medical models of substance abuse problems, has failed to present a coherent, scientifically-based and workable case for the legitimacy of medical involvement. That is, until now.

The long haul

Largely through the efforts of the small group of concerned professionals, medical training is now entering a new era. After more than a decade of unflagging lobbying, all medical schools throughout Australia will now have the opportunity to introduce and integrate drug and alcohol training into the undergraduate medical curriculum through the appointment of drug and alcohol co-ordinators.

This development is a tribute to the per- sistence of the Alcohol and Drug Foundation, Australia (ADFA), in particular. Increasing concern for the need for improved drug and alcohol medical education grew out of early studies in the 1970s. Results of a survey con- ducted by AFADD (Australian Foundation on Alcohol and Drug Dependence, the forerunner of ADFA) in the mid 1970s indicated that such drug and alcohol medical education as existed tended to concentrate on the physical sequelae associated with heavy, long term alcohol con- sumption e.g. cirrhosis of the liver. Drugs other than alcohol received little attention other than from a strictly pharmacological perspective.

Much of the drug and alcohol medical educa- tion that was undertaken during the 1970s and early 1980s occurred in isolated and sporadic episodes. Such efforts were due almost entirely to a handful of enthusiastic individuals who had a strong personal commitment to the area. The

early AFADD survey supported the develop- ment of drug and alcohol teaching in an inte- grated way throughout the undergraduate curriculum.

In 1977 AFADD made an initial attempt to obtain funding to establish an educational pro- gram in Australia along similar lines to that which operated successfully (but is now defunct) in North America, the Career Teacher Program? 3 This proposal was unsuccessful? 4

Over the past decade, there has been a steady growth in interest, understanding and support for improved drug and alcohol medical educa- tion. Some of the major developments that occurred during this time are outlined in Table 1.

Table: 1 Major developments in drug and alcohol medical education in Australia

1982 AMSAD 2nd National Conference -- theme: "Post-Graduate Education on Alcohol & Drugs"

1985 National Medical Education Conference on Alcohol and Other Drugs, Royal Austral- asian College of Physicians, Sydney. Sup- ported by NH & MRC Public Health Advisory Committee, ADFA and NSW Drug and Alcohol Authority

1985 Establishment of National Task Force on Training Requirements of Professionals & Non-Professionals entering the Drug & Alcohol Field

1985 Establishment of NSW Medical Education Project on Alcohol & Other Drugs

1986 ADFA submission for teaching initiative 1988 Funding approved for ADFA proposal 1989 Appointment of drag and alcohol co-

ordinators to all medical faculties 1989 1st National Drug and Alcohol Co-

ordinators Workshop

The original AFADD proposal was endorsed at the National Medical Education Conference and through the efforts of the Professional Education Committee of ADFA it was rein- vigorated and presented at a meeting of the deans of medical faculties, where it gained crucial support. The proposal was incorporated into the recommendations of the National Task Force on Training Requirements of Profes- sionals and Non-Professionals Entering the Drug and Alcohol Field, which had been established under the National Campaign

101

Against Drug Abuse. The Ministerial Coun- cil on Drug Strategy (MCDS) accepted the recommendations of the Task Force concern- ing undergraduate medical education, and referred them to the Commonwealth Depart- ments of Education and Health. Federal elec- tions and changes in portfolios notwith- standing, an announcement was made in early 1988 by the two ministers responsible, the Hon. John Dawkins, Department of Employment, Education and Training and the Hon. Neal Blewett, Department of Community Services and Health, that funding was to be granted for an initial period of three years to establish positions for co-ordinators in all medical faculties in Australia.

Current situation In 1988 all medical faculties were granted

$55,000 per annum for three years to appoint co-ordinators of alcohol and drug education. The program is financially supported through the Commonwealth Department of Employ- ment, Education and Training (DEET) through direct funding to the university medical schools. Administration and co- ordination is provided by the Department of Community Services and Health, and monitor- ing and evaluation through the Committee on Alcohol and Drug Education in Medical Schools, which has representatives from both departments.

With these new funds medical schools were encouraged to appoint staff at a senior level to facilitate the integration of alcohol and drug training into what is often a crowded cur- riculum and where there are many competing claims for teaching time. In some instances sup- plementary funding has been made available from the respective state government to expand the appointments to full-time ones or to increase the level of seniority of the post.

Making such appointments at senior levels was seen as essential to ensure the success of the program. Such an approach is also consis- tent with overseas experience and recommen- dations. It is similar to the approach taken in the U.S. Career Teacher Program and is also urged by British commentators who encourage a "tops down" approach to drug and alcohol medical curriculum development? 2 Similarly, Goldstein 35 has recently described programs at Brown University (U.S.A.) where the goal was to involve primary care faculty members in the development, implementation and actual teaching of curriculum with the longer term

goal that the curriculum would be adopted by the targeted departments and the institution as a whole through a "trickle down" effect. Others have reported the introduction of drug and alcohol programs with relative success but found that " . . . in retrospect, it is apparent that these faculty development efforts would have been more effective in promoting long term interest in the topic had the following additional steps been taken: 1) a representative from the dean's office been invited to provide adminis- trative support, 2) appropriate clinical support been provided, 3) follow-up experience offered, and 4) the number of faculty invited to par- ticipate should have been increased"? 6

Whilst the task facing the newly appointed co-ordinators is both substantial and challeng- ing, this area of curriculum development has the potential for wider applicability to areas such as public health, geriatrics, nutrition and rehabilitation medicine, which also lend themselves to an integrated and inter- disciplinary approach. 3s It has long been sug- gested that the focus required for drug and alcohol studies is that for the management of a chronic disorder where the cause is multi- factorial and for which no specific treatment results in lasting cure. 3~ Glass 18 has also sug- gested that the approach that could be taken with addiction behaviour could also serve to illustrate a general set of issues and problems facing the doctor. The knowledge, attitudes and behaviours appropriate to the drug and alcohol area draw heavily from a wide range of disciplines including epidemiology, community medicine, psychiatry, behavioural medicine and other sub-specialties of medicine. Similarly, detection and treatment of drug and alcohol problems should not be seen as the province of any one discipline and should be incorporated within surgery, paediatrics, oncology and other strands of the traditional medical curriculum. 37

Monitoring The original proposal for the establishment

of drug and alcohol co-ordinator positions recommended that a national autonomous organisation be appointed to implement, monitor and co-ordinate the progress of the project. A national committee to oversee the establishment and direction of the new co- ordinator positions has been established - - the Committee on Alcohol and Drug Education in Medical Schools. Membership of this com- mittee is comprised of representatives from:

102

• Medical faculties, through the Vice- Chance l lo r s ' C o m m i t t e e (Prof. J o h n Hamilton, Dean of Medicine, University of Newcastle, and Prof. Laurie Geffen, Dean of Medicine, Flinders Medical School);

• The states and their Health Departments (A/Prof. John Saunders, Royal Prince Alfred Hospital and University of Sydney and Dr Michael Bolton, Director, Alcohol and Drug Dependence Services, Queensland);

• Alcohol and Drug Foundation Australia (Dr Nan Waddy);

• Drugs of Dependence Branch, Department of Community Services and Health (Mr G. James);

• Department of Employment, Education and Training (Dr Earl Dudley).

The Committee is chaired by Professor Geffen.

The Committee has the following terms of reference:

To monitor the implementation of the co- ordinators in the drug and alcohol education program and in particular to:

1) develop guidelines for the operation and administration of the program,

2) report annually on the program activities and progress made towards meeting its objectives,

3) make r ecommenda t ions considered relevant to the program objectives and activities.

Objectives of the national programme The committee has endorsed the detailed

learning objectives developed by the NSW Medical Education Project and Task Force as the basis for the future development of the teaching of drug and alcohol topics in the undergraduate curriculum (see Appendix 1). It has also incorporated a set of objectives for the project co-ordinators developed by the Medical Education Project. These project objectives are based on the premise that the care of people with drug or alcohol problems forms an important part of medical practice for all practitioners; that effective prevention and management requires specific knowledge and intervention techniques; that treatment is most effective when instituted early; that patients fre- quently present with long term problems; and that skills can be developed most effectively in the context of realistic clinical experience.

Specific objectives are:

• To introduce integrated drug and alcohol education throughout the undergraduate medical curriculum.

• To ensure that the main body of teaching is in the core curriculum, and is instituted at an early stage of the course.

• To encourage the provision of additional elective teaching in drug and alcohol education.

• To ensure that the dominant clinical experience is in the practical aspects of early detection and intervention.

• To incorporate drug and alcohol education within the general framework of health promotion.

• To develop resource material such as bibliographies, teaching materials and computer-assisted instruction units.

• To appraise the value of this national initiative and its structure as an effective model for introducing other curriculum changes in response to perceived national needs.

Medical Education Project on Alcohol and Other Drugs

The National Task Force recommended that the NSW Medical Education Project on Alcohol and Other Drugs act as a resource to the program. The Project has produced materials such as An Annotated Drug and Alcohol Bibliography Relevant to Medical Education 38 and an educational pamphlet for doctors on the early identification of alcohol problems? 9 The Medical Education Project has also reviewed the literature on the factors that constitute barriers to medical involvement in drug and alcohol problems ~° and reviewed the educational strategies relevant to drug and alcohol medical education. 41

First national workshop The newly appointed co-ordinators from all

states will meet together for the first time at a two day workshop at the University of New South Wales to clarify the objectives of the pro- gram; to become familiar with current approaches to dealing with alcohol and other drug problems, curriculum development prin- ciples; to determine learning needs of medical students and to learn ways to function as agents of change.

103

Conclusions

Drug and alcohol medical educat ion has indeed come a long way since the early 1970s when only a few voices were to be heard in sup- por t of what has now been clearly acknow- ledged as a significant a rea of medical t ra in ing requi r ing integrated, mul t id isc ip l inary and systematm at tent ion.

Correspondence to: Ms Ann Roche, Manager, New South Wales Medical Education Unit, Centre for Drug and Alcohol Studies, Royal Prince AlJred Hospital, Missenden Road, Carnperdown, New South Wales, Australia.

References 1. Senate Standing Committee on Social Welfare

(1977) Drug Problems in Australia - - an intox- icated society. Chaired by P. Baume. Canberra: Australian Government Publishing Service.

2. BungeyJ.B., Pols R.G., Frank O R . , Mortimer K.T. and Skinner H.A. (1987) Screening Alcohol and Drug Use in General Practice Unit: Comparison of Computerised and Traditional Methods. Available from Drug and Alcohol Ser- vices Council, 161 GreenhilI Road, Parkside, S.A. 5063.

3. National Health and Medical Research Council (1987) Is there a safe level of daily consumption of alcohol for men and women? Prepared by Pols R.G. and Hawks D V . Canberra: Australian Government Publishing Service.

4. Blaze-Temple D.G., Binns C.W., Radalj T. and Phillips M. (1988) Drinkers at risk in Western Australia. British Journal of Addiction, 83, 1281-1287.

5. Murtagh J. (1987) Alcohol abuse in an Australian community. Australian Family Physician, 16:1, 20-24.

6. Burns F.H. , Hanratty S.J., Reznik R. and SaundersJ.B. (1987) Prevalence o f " A t Risk" Drinkers Presenting in General Medical Prac- tice Settings. Hong Kong: Proceedings of the 9th International Conference IFNGO.

7. Redman S., Cockburn J . , Reid A.L.A. and Sanson-Fisher R.W. (1987) Alcohol consump- tion and alcohol related problems: Prevalence amongst a general practice population. Australian Drug and Alcohol Review, 6:4, 245-252.

8. Dickinson J .A. , Wiggers j . , Leeder S.R. and Sanson-Fisher R.W. (1989) General practi- tioners' detection of patients' smoking status. Medical Journal of Australia, 150, t20-426.

9. Skinner H.A. and Holt, S. (1983) Early inter- vention for alcohol problems. Journal of the Royal College of General Practitioners, 33, 787-791.

10. Barrison I.G., Viola L. and Murray-Lyon I.M. (1980) Do housemen take an adequate drink- ing history? British Medical Journal, 281, 1040.

11. Reid A.L.A., Webb G R . , Hennrikus D., Fahey P.P. and Sanson-Fisher R.W. (1986) Detection of patients with high alcohol intake by general practitioners. British Medical Jour- nal, 293, 735-737.

12. Rowland N., Maynard A., Beveridge A., Kennedy P. and Wintersgill W. (1987) Doctors have no time for alcohol screening. British Medical Journal, 295, 95-96.

13. Murphy H.B.M. (1980) Hidden barriers to the diagnosis and treatment of Mcoholism and other alcohol misuse. Journal of Studies on Alcohol, 41:5, 417-428.

14. Thom B. and Tellez C. (1986) A difficult business: detecting and managing alcohol problems in general practice. British Journal of Addiction, 81, 405-418.

15. Bergen BJ. , Price T.R.P. and KinneyJ. (1980) Medical students' conflicting perceptions of alcoholic patients. Journal of Medical Educa- tion, 55, 954-956.

16. Wechsler H. and Rohman M. (1982) Future caregivers' views on alcoholism treatment. Jour- nal of Studies on Alcohol, 43:9, 939-955.

17. Lewis D.C., Niven R.G., Czechowicz D. and TrumbleJ.G. (1987) A review of medical educa- tion in alcohol and other drug abuse. Journal of the American Medical Association, 257:21, 2945-2948.

18. Glass I.B. (1989) Undergraduate training in substance abuse in the United Kingdom. British Journal of Addiction, 84, 197-202.

19. National Campaign Against Drug Abuse (1988) Unpublished data.

20. Calnan M.W. and Johnson B.M. (1983) Influencing health behaviour: how significant is the general practitioner? Health Education Journal, 42:2, 39-45.

21. Brown R.L., Carter W.B. and Gordon M.J. (1987) Diagnosis of alcoholism in a simulated patient encounter by primary care physicians. Journal of Family Practice, 25:3, 259-264.

22. Better Health Commission (1986) Looking For- ward to Better Health. Canberra; Australian Government Publishing Service.

23. Barbor T.F., Ritson E.B. and Hodgson R.J. (1986) Alcohol-related problems in the primary health care setting: a review of early intervenuon strategies. British Journal of Addiction, 81, 23-46.

24. Rydon P., Redman S. and Sanson-Fisher R.W. (1988) The assessment of alcohol related problems. A need for a new perspective. Australian Drug and Alcohol Review, 7, 127-130.

25. SaundersJ.B. and Aasland O.G. (1987) WHO Collaborative Project on the Identification and Treatment of Persons with Harmful or

104

Hazardous Alcohol consumption. Report on Phase I: Development of a Screening Instru- ment. Geneva: World Health Organisation.

26. Skinner H.A., Allen B.A., McIntosh M.C. and Palmer W.H. (1985) Lifestyle assessment: applying microcomputers in family practice. British Medical Journal, 290, 212-214.

27. Skinner H.A. (1986) Early intervention for alcohol and drug problems: core issues for medical education. Australian Drug and Alcohol Review, 5:1, 69-74.

28. Wallace P., Cutler S. and Haines A. (1988) Randomised controlled trial of general practi- tioner intervention in patients with excessive alcohol consumption. British Medical Journal, 297,663-669.

29. Gottlieb N.H., Mullen P.D. and McAlister A.L. (1987) Patients' substance abuse and the primary care physician: Patterns of practice. Addictive Behaviours, 12, 23-32.

30. Neville R.G., Campion P.D. and Heather N. (1987) Barriers to the recognition and manage- ment of problem drinking: Lessons from a multicentre general practice study. Health Bulletin, 45, 88-94.

31. KinneyJ., Price T.R.P. and Bergen B.J. (1984) Impediments to alcohol education. Journal of Studies on Alcohol, 45:5, 453-459.

32. Glass I.B. (1988) Substance abuse and profes- sional education: a tops-down or bottoms-up approach? British Journal of Addiction, 83, 999-1001.

33. Pokorny A.D. and SolomonJ. (1983) A follow- up survey of drug abuse and alcoholism teaching in medical schools. Journal of Medical Educa- tion, 58, 316-321.

34. Gladstone W., Webster I.W. and Rotem A. (1987) An initiative for teaching about alcohol and other drugs in Australian medical schools. Medical Journal of Australia, 147, 339-341.

35. Goldstein M.G. (1988) A faculty development model for a curriculum in alcohol and substance abuse for primary care training programs. Substance Abuse, 9:3, 119-128.

36. Coggan P.G., Davis A.K. and Hadac R. (1984) Alcoholism curriculum development: an examination of the process. Journal of Family Practice, 19:4, 527-532.

37. Sanson-Fisher R.W. (1986) Are Medical Prac- titioners Possible Agents for the Detection and Treatment of Those with Excessive Alcohol Consumption? Adelaide, S.A.: Proceedings of the Workshop on Moderate Drinking.

38. Roche A.M. and Moosburger R.E. (1989) An Annotated Bibliography: Relevant to Medical Education and Clinical Practice. Sydney: New South Wales Medical Education Project on Alcohol and Drugs.

39. SaundersJ.B. and Roche A.M. (1989) One in six patients in your pract ice. . . Sydney: NSW Medical Education Project on Alcohol and Other Drugs.

40. Saunders J.B., Roche A.M. and Moosburger R.E. (1989) Barriers to effective intervention for alcohol and drug problems. A Working Docu- ment Prepared by the NSW Medical Education Project on Alcohol and Drugs.

41. Roche A.M. (1989) The Development of Effec- tive Strategies for Drug and Alcohol Medical Education: A review. Sydney: New South Wales Medical Education Project on Alcohol and Drugs.