International Education and Training in Addiction Medicine - ISAM 2013 - Kuala Lumpur

(The following are my rough notes from the International Society of Addiction Medicine Conference Kuala Lumpur Symposium. I hope that it will give some idea of the depth and breadth of presentations but apologize if there are any errors and would ask that you go to the sources for the definitive information in the area of specialization-W.Hay)
Greg Bunt, President Elect of ISAM


Gabrielle Welle-Strand, Norway - hosted ISAM conference in Norway 2 years ago - coordinating project to assess training around the world

1) Addiction Psychiatry Training in the US - Merrill Herman

I began wanting to be an orthopedist but a psychiatrist working in addiction at Cornell served as my mentor.  There was a methadone clinic there…. Then at Einstein….I met Greg Bunt…..met Marc….he wanted me to come to NYU to be his first fellow …..somehow Dr. Bunt joined us and we became first two fellows in addiction psychiatry….2 years program….but a lot of the training was on a dual diagnosis unit at Bellevue……not a lot of addiction psychiatry with medicine…..mostly dual diagnosis and that was role of addiction psychiatrist….went to be medical director of adolescent dual diagnosis unit….I'm from the Bronx and got recruited to come back to do the Methadone program…..integrated primary care program….I became first psychiatrist in department of family medicine…..AIDS epidemic hitting full on in New York…worked with Peter Selwin, HIV researcher…I was working and teaching residents….department of psychiatry didn't want anything to do with addiction….all the addiction medicine was coming out of family medicine….then they asked me to become director of addiction psychiatry fellowship - we now have addiction consultation in general medicine service….expose students to HIV, hepatitis, methadone, we have classic methadone, ISAM is interesting because the Bronx is multi cultural and a lot of my fellows came from all over the world…..and they'd tell stories of alcoholism around the world…..one of my residents is a sik and there's a major problem with alcoholism in sik community - crossing cultures, where do they fit in….I went to temple and was honorary sik for day - they couldn't talk about alcoholism - talked about it through the other medical problems, hypertension, diabetes……department of psychiatry began to like us and then they took us over and theres this evolution, full circle back into psychiatry…..there are 46 addiction psychiatrist fellowships and 16 addiction medicine residents - theres now parity between medicine, psychiatry and addiction - there are people who leave our family medicine , psychiatry and go to addiction…we need way to find way - there's a big need - there's not going to be enough addiction psychiatrists or addiction medicine - where are we going to go - where in psychotherapy and psychopharmacology - we need to link our forces together, addiction psychiatry and addiction medicine.  ISAM is bringing the various expertise from around the world
2) Addiction Medicine Training in the US - Dr. Stuart Gitlow - president of American Society of Addiction Medicine


First question I want to ask is what per cent of public is addicted …you might think …somewhere between 10 and 15 % - we have 5000 doctors in states certified - not all active -I'm a young addiction - there are 3000 actively practicing - more than half have only 8 years before they retire.  There are 60 fellowships, about 100 doc produced per year - were losing numbers - at the very time when we passed the affordable care - that will increase demand for addiction docs in the socioeconomic area likely to use -where are they going to go
Who can treat addiction - we dx'ed it as a disease of the brain - the reward system of the brain - in a way different from the substance - we may in future be able to identify a person who will need treatment - what is the difference between sw, counsellor, nurse , peer, psychologist, non addiction doctor, addiction doctor, addiction psychiatrist - they're all important but what is the difference. ---Spectrum of training - we need to be able to readily what a nurse can do that a doctor can't and what a doctor can do and nurse can't - ny times ran series on buprenorphine treatment - many doctors are prescribing buprenorphine inappropriately - we looked at what percentage of prescribes were members of addiction therapy - only 20% were members - so what percentage of nurses, and others were doing wrong - we in ASAM decided to move away from being a guild and letting non doctors in to the organization - we could provide training for the people - if I gave you 20 hours or a 1 year course - would a person with nursing or psychologist would that person differ from the physician.
Not many people go into field of addiction ….we wanted to know what to do to maintain people in their interest - medical students year1 - if we ask them 80 to 90% say yes, but in year 4 - 80 to 90% say no - something we're doing in medical school is wrong - so we took willing students  and placed them in a rehab program for 1 month - they went through as if they were patients - these students wrote book chapters on their experience -thought they were just like them
I encourage that kind of experiential process
 We followed them and everyone who did that was involved in some type of addiction work years later

3) Training in Addiction Medicine Training around the world and ISAM's network of addiction.- Gabrielle Wells-Strand

ISAM -evidence baed education and adequate training
we have ISAM exams
established network of national contacts in as many countries as possible
developped questionnaire
Limitations - some of questions in questionnaire not clear enough, my interpretation may be wrong but it's a start

National contacts

Populations
greater than 100 million
50 to 100
10 to 50
less that 1o million

Organization of drug treatment
primary care - belgium denamark
Secondary care  hungary japan,
Mixed models - australia
Under which speciality is addiction medicine organized
psychiathry - canada, england, indian, japan, sweden
Medicine - australia new sealan
several - france
primary care - belgium

Present training and certification
-advance training and certification - austrailia , NZ
Systematic training and certification - Finland 2 years, Hungary 2 years
Master program - australia, NZ, nethenlands
 National training courses in addiction medicine - canada, denmakr
Part of psychiatry

Future Plans
-full specialty - norway
Subspecialty - sweden, thailand
master - indonesia

Where do we go from here
- ISAM products - feed back on ISAMS rol in promoting Addiction Medicine training in different countries and discussion
Put national contracts and survey on ISAM web page
mobilize more national contacts and evaluation

4) Barriers to Addiction Medicine Training in Australia and New Zealnd  -Dr. Mark Montebello - Chair Chapter of Addiction

Medicine Education Committee -
Population australia 23 million-156 ChAM Fellows
New Zealand 4.5 million - 21 ChAM trainees
There were 4 models and we now can't get people in because of the barriers.  The program is great but has a very high standard.
Problem with aging workforce and shortages
To get into the program you have to have done another specialist

Pre requisites
Registered medical practitioner
and fellow of one of the following
-anaethetics, emergency medicine, general practice, adult medicine, pain medicine, psychiatry, rehabilitation, Rural and remote Medicine, Pediatrics and Child health Division
or completion of RACP General Basic Training - 3 years
To develop a fellow who is competent to provide a specialist level, unsupervised comprehensive medical are in Addiction Medicine
18 months core training
- prescribing, pain meds, public health, psychiatry and co morbidity, general medicine
- non core - working in rural setting, isolated communities, indigenous, specialists in research,
-everyone has to do research program and quality improvement
- all under review - moving towards the canadian model - must demonstrate learning objectives learned in clinics

Clinical assessment, attitude, ethical issues, administration, teamwork, medico-legal, self-education, patient management, communication, cultural competency, clinical decision making, health advocacy

23 specialities in college - hard to get consensus
get stigmatized,
Study investing ChAM Training Program Barirs
Aims to examine Junior Medical Officers knowledge about cham
to identify barires.
said things like I don't know, it's okay
JMO's - in medical curriculum - get huge exposure to hematology - very little to addiction medicine - the addiction ward is very old wing, versus the hematology ward
We've become more flexible and offer 3 months
Looking at having a 'masters'  - it's already done in Public Health
Looking at it as another way of getting into the program
Also developing diploma for 6 months and this is already in other specialities

5) Improving Conversational Skills in Addiction Medicine -Cor de Jong - Netherlands

- Residents in Addiction Medicine - have 80 well trained
Master in Addiction Medicine
2 years full time cours, 20 residents per group, accredidtated by Royal Dutxh Society of Medicine
Competencies
Themes
Modules
Academic teaching at University and Clinical teaching
Evidence based medicine and professional medical communication
Relationship - rapper building and relationship management
Motivational interviewing
Shared decision making

General aspects of a conversation - welcome, introduction, agenda setting, time monitoring, involvement , empathy, word choice
Non verbal communication
Retreat, Motivational Interviewing, Bedside , role playing, Moral dilemans, family counselling, aggression management
Personal learning style, Interpersonal behaviour Feelings.
Measuring quality aspects of professional communication
Can we measure this, Instruments and video assessment, rate with 3 or 4 observers.  Cross correlation  - intra class - showed reliable instrument
Means scores given at the end of 2 years
Instrument - successful and then get others who get second chance
We developed focussed training course in professional conversation skills in addiction medicine

6) Norway II - shaping of a full speciality in addiction medicine - Garbrielle Well Strand

- first medical specialty in 15 years
 first medical specialty developed by norwegian directorate of health
at the same time - suggested change in the education across the board
first proposal turned down in 1999 - said existing specialities should take care of these patients
2003 - turned down  - better strategy to increase training in family practice and pscyhiatry
2012 - successful - drug reform of 2004 - specialized health care got the responsibility for drug treatemnt
documented increased and severity of health problems among drug users
increased research and knowledge based medciine

Ministry of Health has commissioned Norwegian Directorate of health to evaluate the present specialty training

Part 1 -18 months - 12 months in hospital(general medicine/surgery/psychiatry) and 6 months in municipal general practice
Part 2 - 0 to 3 years fro groups of specialties that naturally fit together
Part 3 Common platform for groups of speciality

Common compulsory cores

New speciality should take account of user involvement and interdisciplinary cooperation
Cooperation between specialists and municipalities

A specialist in Addiction medicine
should always involve the user
-group level
have non stigmatizing practice
 be competent in cooperating with different parts of health services
Developing plans for course work
Teaching goals
Assessment standard
Specification and accreditation = for teaching hospitals

Addiction medicine specialty - training and placement and course work laid out.