POSTGRADUATE
MEDICAL TRAINING
(PGY-5,6 RESIDENCIES)
IN ALCOHOLISM
AND DRUG ABUSE
FROM THE CENTER FOR MEDICAL FELLOWSHIPS
IN ALCOHOLISM AND DRUG ABUSE,
at New York University.
The Center is sponsored by the American Academy of Addiction Psychiatry (AAAP), the Association for Medical Education and Research in Substance Abuse (AMERSA), and the American Society of Addiction Medicine (ASAM). Support for this project was provided by the Scaife Family Foundation.
á PGY-5,6 Residencies in Alcoholism and Drug Abuse
á Program Requirements for Residency Education
á Center for Medical Fellowships in Alcoholism and Drug Abuse
á Survey of Residency Programs
á List of Programs
á Residency Program Descriptions
This brochure was prepared by the Center for Medical Fellowships in Alcoholism and Drug Abuse at NYU, in conjunction with the American Academy of Addiction Psychiatry. It was edited by Marc Galanter, M.D., Director of the Center, Department of Psychiatry, NYU School of Medicine, 550 First Avenue, New York, NY 10016
An electronic copy of the contents of this brochure is available at the Center's website at www.med.nyu.edu/substanceabuse.
PGY-5,6 RESIDENCIES IN ADDICTION:
THEIR NEED AND THEIR EVOLUTION
The Issue
The magnitude of the alcohol and drug abuse problem today is well documented, with the cost to the public calculated at over $246 billion per year in health care and lost work. In general medical facilities alone, on average 25% of the patients present with such problems, many of which go undiagnosed. When the sequelae of addiction, such as cirrhosis, trauma, and infection present, they may receive proper medical attention. On the other hand, patients' primary addictive problems go untreated. Furthermore, the rate of substance abuse among general psychiatric patients without primary addictive disorders has been found to be 25% to 60%, depending on the region and the clinical setting. Despite this, medical education has been seriously lacking in the addictions until recently. For example, training in this area was not formally required in psychiatric residencies until 1985, and is only recently required in internal medicine.
Federal Efforts
Clearly we need to assure greater medical sophistication in substance abuse. Where, however, do we stand in developing the needed teaching faculty and specialists in the field? In 1972, the federal government initiated a program of 3-year grants for Career Teachers in Alcoholism and Drug Abuse, but in 1981, after only one grantee had been funded in each of 55 of the 124 eligible schools, the program was terminated. Subsequently, modest grants have addressed curriculum development, but have failed to provide meaningful support for training positions. Recent federal faculty development awards and Project Mainstream have provided partial support for training faculty, but none for residents or fellows.
A comparison of these developments with those that took place in other medical subspecialties is compelling. For decades, federal funding for fellows in subspecialties, from cardiology to child psychiatry, served as the basis for developing expert practitioners and teaching faculty. No such support exists for training physicians in the alcoholism and drug abuse field, thereby necessitating new conceptions for how to underwrite such programs. Such programs will now generally come from clinical staff lines and research training dollars. Constraints imposed by managed care, however, have compromised clinical training overall.
Specialty Recognition
The legitimacy of medical subspecialties and their ability to establish standards of training and attract trainees has traditionally rested on various forms of the board certification process, through the American Board of Medical Specialties (ABMS). For example, over 90% of all graduates from American medical schools achieve certification through an ABMS member board by means of postgraduate training and exam.
In order to attract qualified young physicians, the substance abuse field moved toward implementing an educational format that parallels those accepted in medicine broadly. Since 1986, the American Society of Addiction Medicine has given a certifying exam in addiction to physicians of all specialties. However, this certification is not recognized by the ABMS.
The established option for such training is now subspecialty certification. This current procedure of the ABMS entails modification of specialty certification to reflect that a candidate has completed at least one year of full-time formal training in a subspecialty program and has passed an additional examination prepared by a member of the Board. Geriatric medicine was the first such program to be established format of added qualifications, in 1987. The certification process can be initiated by component boards of the ABMS in order to institutionalize post-residency training in addiction and promote development of a cadre of physicians who will serve as medical academics and practitioners for the field.
The American Board of Psychiatry and Neurology established subspecialty certification in addiction psychiatry, primarily in response to supportive information provided by the American Academy of Addiction Psychiatry. The first examination was given in March 1993. Through 1998 board certified psychiatrists with clinical experience in addiction could sit for the subspecialty exam. Completion of training in an ACGME accredited PGY-V addiction psychiatry residency is now required. As of 1999, 1817 psychiatrists have been certified.
The Accreditation Council for Graduate Medical Education
The ACGME is sponsored by the American Board of Medical Specialties, the American Hospital Association, the American Medical Association, the Association of American Medical Colleges, and the Council of Medical Specialty Societies. Its purpose is to establish standards and accredit graduate medical education training programs throughout the United States. It therefore represents the principal accrediting body for residencies and fellowships nationwide. The ACGME also approves additional training beyond the basic residency, often called fellowship training. In 1995, the ACGME approved the first Addiction Psychiatry residencies. At present, the ACGME has established standards and is accrediting training programs in Addiction Psychiatry for one or two years following completion of a basic psychiatry residency. Training in an accredited addiction psychiatry residence is now required in order to qualify for taking the examination for Subspecialty Certification in Addiction Psychiatry. At present there are 40 programs accepting residents which have already been approved through the ACGME accreditation process and they are designated in the ensuing text (two approved programs were no longer accepting residents). Further information on additional programs approved subsequently is available through the ACGME at (312) 464-4920. With the establishment of this process, formal approval under the U.S. mainstream organization for medical training has been achieved in addiction psychiatry. ACGME Program requirements for accredited addiction psychiatry residencies are available at http://www.acgme.org/req/401pr795.asp
Although there are positions for non-psychiatrists in conjunction with some of the approved programs, and although fellowships in addiction have been organized for non-psychiatrists in other specialties, an ACGME accredited process for postgraduate addiction training of non-psychiatric physicians remains to be established. Such a system would be helpful in formalizing the role of addiction training for non-psychiatrist physicians. Efforts are being made in this direction. Furthermore, Addiction Medicine has been given a place on the roster of specialty areas within the American Medical Association.
Residency Requirements
Both psychiatry and internal medicine now require training in addiction in their respective residency training programs. Psychiatry has now instituted a formal one-month full-time equivalent requirement in its postgraduate medical sequence.
PROGRAM REQUIREMENTS FOR RESIDENCY EDUCATION IN ADDICTION PSYCHIATRY
Areas A-D below are ones which are addressed in detail in the Graduate Medical Education Directory of the ACGME. Area E is detailed to illustrate the clinical experiences and curriculum content prescribed by the ACGME. For the complete listing of all requirements, please refer to the ACGME Graduate Medical Education Directory.
A. Introduction
1. Definition of the subspecialty
2. Duration and scope of education
3. Educational goals and objectives
B. Institutional Organization
C. Faculty and Staff
1. Program Director
2. Number and qualifications of the physician faculty
3. Multidisciplinary team exposure
4. Other program personnel
D. Facilities and Resources
1. Inpatient care facility
2. Partial hospitalization and day treatment center
3. Ambulatory care service
4. Library
5. Ancillary support services
6. Patient population
7. Additional educational environment
8. Faculty supervision
E. Educational Program
Clinical Experiences
The training program must include the following clinical components:
1. Evaluation, consultation, and treatment of:
a. Patients with primary alcohol and/or drug abuse and their families.
b. Medical and surgical patients in the emergency department, intensive care units, and general wards of the hospital with acute and chronic drug and/or alcohol abuse and dependency, including acute intoxication and overdose.
c. Psychiatric inpatients and outpatients with chemical dependencies and co-morbid psychopathology, to include a broad range of psychiatric diagnoses, such as affective disorders, psychotic disorders, organic disorders, personality disorders, and anxiety disorders, as well as patients suffering from medical conditions commonly associated with substance abuse such as hepatitis and acquired immune deficiency syndrome.
d. Medication-dependent patients with chronic medical disorders.
2. Exposure to the following substance-abuse problems:
a. Alcohol
b. Opioids
c. Cocaine and other stimulants
d. Marijuana and hallucinogens
e. Benzodiazepines
f. Other drugs of abuse, including sedative/hypnotics and nicotine
g. Miscellaneous/unusual, eg, khat, nutmeg, designer drugs, organic solvents.
3. Resident treatment of a minimum of five addicted outpatients with a variety of diagnoses requiring individual treatment for at least six months.
4. Rotations should provide residents with experience in evaluating acute and chronic substance-abusing patients in inpatient and outpatient settings. There should be an identifiable structured educational experience in neuropsychiatry relevant to the practice of addiction psychiatry that includes both didactic and clinical training methods. The curriculum should emphasize functional assessment, signs and symptoms of neuropsychiatric impairment associated with substance abuse, and the identification of physical illnesses and iatrogenic factors that can alter mental status, behavior, and management.
5. The program must provide specific experience in consultation to acute and chronic, medically ill substance-abusing patients being treated on medical, emergency, intensive care, and/or surgical services of a general hospital. Supervision of addiction psychiatry residents in their clinical evaluation of such patients, as well as in their consultative role, is essential. The program should provide residents with the opportunity to function at the level of a specialist consultant to physicians in the primary care specialties and to intensive care specialists.
6. Experience in working with multidisciplinary teams as a consultant and as a team leader.
7. Experience in working with patients who are concurrently participating in self-help programs.
Curriculum Content
The field of addiction psychiatry requires knowledge of neurology, pharmacology, psychiatry, general medicine, and psychology, as well as an understanding of the interaction of these disciplines. Programs must include both direct experience in clinical care and formal conferences. Instruction and experience must include the performance of the mental status examination, a neuropsychiatric evaluation instrument such as Mini-Mental Status examination, community and environmental assessment, family and caregiver assessment, medical assessment, and physical and psychological functional assessments. These skills compose the basis for formal assessment of the addicted patient using a synthesis of clinical finds, historical and current information, and data from laboratory and other special studies. Residents must acquire knowledge and skills in the following areas:
1. Knowledge of the signs and symptoms of the use and abuse of all of the major categories of drugs enumerated in VA.2.a-g, as well as knowledge of the types of treatment required for each.
2. Knowledge of the signs of withdrawal from these major categories of drugs and knowledge and experience with the range of options for treatment of the withdrawal syndromes and the complications commonly associated with such withdrawal.
3. Knowledge of the signs and symptoms of overdose, the medical and psychiatric sequelae of overdose, and experience in providing proper treatment of overdose.
4. Management of detoxification and acute hospital treatment of the chronic use of the major categories of drugs. Experience in working collaboratively with specialists in the emergency department and intensive care units in the diagnosis and management of acute overdose symptoms.
5. Knowledge of the signs and symptoms of the social and psychological problems as well as the medical and psychiatric disorders that often accompany the chronic use and abuse of the major categories of drugs.
6. Experience in the use of psychoactive medications in the treatment of psychiatric disorders often accompanying the major categories of substance abuse.
7. Experience in the use of techniques required for confrontation of and intervention with a chronic drug abuse and in dealing with the defense mechanisms that cause the patient to resist entry into treatment.
8. Experience in the use of the various psychotherapeutic modalities involved in the ongoing management of the chronic drug abusing patient, including individual psychotherapies, couples therapy, family therapy, cognitive-behavioral therapy, and group therapy.
9. Experience in working collaboratively with other mental health providers and allied health professionals, including nurses, social workers, psychologists, nurse practitioners, counselors, pharmacists, and others who participate in the care of substance-abusing patients.
10. Knowledge and understanding of the special problems of the pregnant drug abuser and of the babies born to substance-abusing mothers.
11. Knowledge of family systems and dynamics relevant to the etiology, diagnosis, and treatment of substance abuse disorders.
12. Knowledge of the genetic vulnerabilities, risk and protective factors, epidemiology, and prevention of substance-abuse disorders.
13. Familiarity with the major medical journals and professional-scientific organizations dealing with research on the understanding and treatment of substance abuse.
14. Critical analysis of research reports, as presented in journal clubs and seminars.
15. Experience in teaching and supervising student clinicians in the care of substance-abusing patients.
16. Understanding of the current economic aspects of providing psychiatric and other health-care services to the addicted patients.
17. Knowledge of quality assurance measures and cost effectiveness of various treatment modalities for substance-abusing patients.
CENTER FOR MEDICAL FELLOWSHIPS IN ALCOHOLISM AND DRUG ABUSE
The Center for Medical Fellowships in Alcoholism and Drug Abuse was established in 1987 under sponsorship of the American Academy of Addiction Psychiatry and the Association for Medical Education and Research in Substance Abuse to promote postgraduate medical training in the addictions. This goal is carried out by: (1) establishing training standards for medical training in the addictions, (2) disseminating information on existing postgraduate programs, and (3) promoting the establishment of new programs in qualified medical training centers. The Center draws on the expertise of its advisory group, leaders in education of medical specialists in alcohol and drug abuse. For further information write to the Center at the Division of Alcoholism and Drug Abuse, NB20N28, Department of Psychiatry, NYU School of Medicine, 550 First Avenue, New York, NY, 10016, or at our website www.med.nyu.edu/substanceabuse. The Division is a collaborating center of the Programme in Substance Abuse of the World Health Organization.
The following National Advisory Committee of the Center for Medical Fellowships in Alcoholism and Drug Abuse was originally established in 1989 to determine the guidelines for training of fellows and to enhance collaboration among training programs. Their efforts were central to initial formulation of addiction training. They and their schools were: John Chappel, M.D. (Nevada), Paul Cushman, M.D. (SUNY), Richard J. Frances, M.D. (UMD/NJ), Marc Galanter, M.D. (NYU Chair), Enoch Gordis, M.D. (NIAAA), James A. Halikas, M.D. (Minnesota), Edward Kaufman, M.D. (California, Irvine), Herbert D. Kleber, M.D. (Yale), Mary Jeanne Kreek, M.D (Rockefeller), David C. Lewis, M.D. (Brown), Roger E. Meyer, M.D. (Connecticut), Sheldon Miller, M.D (Northwestern), Robert B. Millman, M.D. (Cornell), Robert M. Morse, M.D. (Mayo), Charles O'Brien, M.D. (Pennsylvania); Carolyn Robinowitz, M.D. (American Psychiatric Assn), Sidney Schnoll, M.D., Ph.D. (Medical College of Virginia), Mark Schuckit, M.D. (University of California, San Diego), Barry Stimmel, M.D (Mt. Sinai) Zebulon Taintor, M.D. (NYU), David Van Thiel, M.D. (Pittsburgh), Joseph Westermeyer, M.D. (Minnesota), Joel Yager, M.D. (UCLA)
The Consortium for Medical Fellowships in Alcoholism and Drug Abuse was established by the Center to promote postgraduate fellowship training of high caliber by its primary sponsors, the American Academy of Addiction Psychiatry, the Association for Medical Education and Research in Substance Abuse, and the American Society of Addiction Medicine. The goal of the Consortium is to assure the availability of clinical research and teaching specialists in the addiction field through well organized and effective training programs. Representatives of the following additional medical specialty organizations were sponsors as well: American Academy of Neurology; American Academy of Pediatrics; Society of General Internal Medicine; Society of Teachers of Family Medicine. For further information, please write to the Center for Medical Fellowships at the address above.
The CenterŐs Sponsoring Organizations
The American Academy of Addiction Psychiatry was established in 1985 in order to accumulate and share pertinent information concerning the delivery of health care services by providers in the field of addiction treatment; to stimulate and encourage scientific and medical research of alternative methods of addiction treatment and its etiology; to develop standards of professional practice in the field of addiction; to disseminate and publish information in the field of addiction treatment for members of the profession and the public-at-large; to develop and maintain a liaison with organizations and government authorities in areas of common concerns and interest; and to educate and inform the public about the role of psychiatry and psychiatrists in the care of patients with a diagnosis of alcoholism and addictions. For further information: AAAP at www.aaap.org, 7301 Mission Road, Suite 252, Prairie Village, KS 66208.
The American Society of Addiction Medicine is a national/international organization of physicians interested in the diseases of alcoholism and other drug dependencies and in other problems associated with psychoactive drug use as they affect the public health, who wish to extend and disseminate knowledge in these fields, and to enlighten and inform medical and public opinion with regard to these problems. For further information: ASAM at www.asam.org, 4601 N. Park Avenue, Chevy Chase, MD 20815.
The Association for Medical Education and Research in Substance Abuse is a national organization of medical educators, clinical researchers and other health professionals in the field of alcohol and drug abuse that provides: (1) a scholarly interdisciplinary forum for the exchange of information on techniques and teaching, (2) a network of educators and researchers in the field of substance abuse, and (3) a national voice in support of academic programs in universities and professional schools for substance abuse education and research. For further information: AMERSA at www.amersa.org, Brown University Center for Alcohol and Addiction Studies, Box G, Providence, RI 02912.
The Research Society on Alcoholism is dedicated to promoting investigation into the cause and treatment of alcoholism, as well as to related educational activities. The Board of RSA resolved to support the establishment of standards for postgraduate medical training in alcoholism and drug abuse that would include research training. The RSA has endorsed the fellowship program described here in particular to support the development of residency training for subspecialty fellows in addictions. For further information: RSA at www.rsoa.org
SURVEY OF U.S. (PGY-5 AND 5-6) RESIDENCY PROGRAMS
In order to provide a basis for planning and coordination, The National Center for Medical Fellowships in Alcohol and Drug Abuse, in conjunction with The American Academy of Addiction Psychiatry surveyed programs in 2003. All programs and facilities approved by the ACGME were contacted and asked to complete a questionnaire on items related to the history of their programs, their current status, and activities of current and past fellows. Thirty-five responded to surveys on numerical data on their programs. The results from these 35 programs (plus six programsŐ data from 2001) are given below:
Current status of residency programs (for which responses were received):
Total number of positions available in 2004.......................................................................... 90
Total number enrolled at present........................................................................................... 96
Number of programs approved by ACGME as of 7/03............................................................ 47
Inactive programs.................................................................................................................... 2
Closed programs....................................................................................................................... 1
The earliest reported residency programs were established in 1978, but the most frequently occurring year of establishment (reported by 4 of the programs) was 2003.
Duration of residencies:
Programs may be certified for one year or for two years (N=41)
N %
12 Months 21 51
12-24 Months 17 42
24 Months 3 7
Fellows' activities:
Mean percent of fellows' time devoted to each of the following activities (N=41):
%
Patient care 62
Research 12
Classroom/instructional time 13
Teaching others 8
Administration 5
Programs in which fellows provide at least some patient care (N=41):
N %
Alcoholism Inpatient Program 38 93
Addiction (Non-Methadone) Outpatient Program 39 95
Drug Abuse Inpatient Program 38 93
Non-Methadone Drug Abuse Outpatient Program 35 85
Dual Diagnosis Program 34 83
Consultation Service 41 100
Methadone Clinic Program 35 85
Residential Therapeutic Community 19 46
General Medical Service 16 39