For over a decade, IRETA has worked with medical students to improve their understanding of addiction through a program called the Scaife Medical Student Fellowship. But in a world with limited resources and many addiction-related harms, we owe it to the students (and to our funder, the Scaife Family Foundation), to ask how effective this program is.

This summer, the journal Substance Abuse published a research report on the Scaife program showing that it really works.

What Does “It Works” Mean in This Case?

The published evaluation looked at two research questions:

1. Did the program have an impact on the medical students’ attitudes toward working with people with addictions?

2. Was the effect of the program sustained over time?

The evaluation results indicate that yes, students who participate in the program do feel more responsible and motivated to help people with substance use disorders. They also suggest that the program’s effects are sustained over time–but with a catch.

Medical students in the Scaife program, 2017

Students’ Attitudes Are Significantly Different Than Those of the Comparison Group

To answer the first question about the program’s impact on attitudes, we looked at students who had completed the program between one and five years ago (n=38) and compared them to a group who had applied but did not attend, usually due to scheduling conflicts (n=47).

This was to ensure that differences we saw between groups could be attributed to the effect of program participation rather than baseline differences in, for example, interest in the issue of addiction.

We measured both group’s attitudes toward working with patients with substance use disorders using two validated tools, the AAPPQ (for alcohol use disorders) and the DDPPQ (for drug use disorders). Each tool measured two aspects of attitudes, their Role Security and their Therapeutic Commitment. Role Security is more or less their sense of responsibility for helping patients with addictions and Therapeutic Commitment amounts to their motivation to do so.

On the AAPPQ and the DDPPQ, Scaife students’ Role Security and Therapeutic Commitment were higher than the comparison group. They were significantly higher in all but one area, their Therapeutic Commitment for drug users (where it was higher, but not significantly).

The data in the published paper didn’t tell us why their attitudes changed after participating in the program, but we got hints from 28 structured interviews with former Scaife students. Emergent themes from the key informant interviews suggest the program’s utility in three important areas:

1. Building motivational interviewing skills, a flexible approach that can be used treat any health condition with a behavioral component

2. Exposing students to patient populations that they will undoubtedly see in their medical practice, including risky substance users of all demographic types

3. Introducing medication-assisted treatment methods and modalities, which will become increasingly relevant as office-based opioid addiction treatment expands

Off to a methadone clinic in Pittsburgh summer thunderstorms, 2016

Students Retain a Sense of Responsibility for Addressing Addiction, But Their Motivation Wanes

Research commonly finds that exposure to an educational program leads to positive changes in participants’ attitudes, but that the effect diminishes over time. We wanted to know if that was true of the Scaife program.

To measure attitudes over time, we compared the students’ AAPPQ and DDPPQ responses immediately after completion of the program to their response given as part of the follow-up evaluation. While recent students were still in medical school, many had moved on to residencies or other roles.

As soon as they completed the program, their Role Security got high and it stayed high. In other words, the students felt a greater sense of responsibility for addressing substance use in their practice after completing the program and this sense of responsibility did not go down after one or even five years.

Students also had a high sense of Therapeutic Commitment when they completed the program. That is, they felt motivated to work with patients with substance use disorders. However, their Therapeutic Commitment went down over time. More specifically, it went down once they left medical school and began their residencies.

Again, the data in the published paper didn’t tell us why the students did not maintain their Therapeutic Commitment, but our interviews with former Scaife students gave us some ideas about why Therapeutic Commitment might go down, based on environmental factors.

In their settings, some described negative bias toward people with substance use disorders and the subject of substance use overall:

“There is still kind of a stigma. I’m not sure if it’s their previous misconceptions, or maybe things that standardized patients say that are condescending to patients with addictions. Or that students feel insulted by drug-seeking behavior.”

“For a lot of my classmates and people I work with, it’s hard for them to separate the addiction from the person. Like when they [people with SUDs] come into the trauma department, they don’t say anything negative, but I feel like they’re being treated differently.”

Most frequently, they described substance use as a low priority in their clinical settings.

“On my rotation, I felt like a lot of physicians or practitioners relied on clinical [urine] testing or that addiction was just not their primary concern. Or sometimes it was just kind of acceptance of the patient’s addiction and just looking at their other issues.”

“When I’m practicing alone I might be more likely [to recognize risky substance use] because I’m not afraid to talk about it. In a situation when I’m being graded, let’s say I ask the first five patients I see about alcohol or drugs, and my attending doesn’t like it, that would be a hard spot to be in.”

These results came as no surprise. They gibe with our work teaching Screening, Brief Intervention, and Referral to Treatment (SBIRT) to nursing and social work students. In a nutshell: what students learn in school often isn’t supported in their clinical placements and in their professional lives. For that reason, we incorporate training for field placement supervisors as well as students, whenever possible.

Headed to the Pittsburgh VA, 2016

“Each One Teach One”

At the end of each session, IRETA staff always share an African American proverb with the students: Each one teach one. It’s an idea born during slavery, when black Americans were denied an education, and any slave who learned to read had a responsibility to share this essential knowledge with someone else.

Similarly, the students who undergo IRETA’s addiction training program are equipped with unique knowledge about substance use disorders. Not only that, the data show that they have a heightened sense of responsibility and motivation to help patients affected by addiction. Knowledge + responsibility + motivation adds up to effective advocacy.

Although at times their working environments may be hostile or indifferent toward addiction, we know that former Scaife students are becoming physicians who send new messages–in words and in actions–about the care that people with substance use disorders should receive.

Beginning a rotation at the Diagnostic Evaluation Center, 2017