Workshop: AAAP & AADPRT: Collaboration for Culture Change in Addiction Psychiatry Training (Workshop Jointly Sponsored by AAAP Education Committee & AADPRT Addiction Committee)-AAAP & AADPRT: Collaboration for Culture Change in Addiction Psychiatry Training (Workshop Jointly Sponsored by AAAP Education Committee & AADPRT Addiction Committee)

AAAP & AADPRT: Collaboration for Culture Change in Addiction Psychiatry Training (Workshop Jointly Sponsored by AAAP Education Committee & AADPRT Addiction Committee)
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Rokossovic, Rokossovic, okay, Dr. Ritbo and Dr. Renner.  to identify one to two innovative strategies to enhance addiction psychiatry education  and general psychiatry residency programs. So I'm from the University of Colorado, I'm the fellowship director.  but not at the same level as general psychiatry. So if you look between 2016 and 2021,  Tim Fong's next door to us.  It's gonna be hard competition, I'll have to speak up. So there was a 17% increase in programs and we did have a 15% decrease in the number of programs.  we have sat at that 89 to like 91 positions filled. So we really haven't made further movement,  which is concerning. I feel like I'm a broken record because I've had this conversation with a lot of people this meeting. But as we know, we have a large group  that is about to retire. We have no shortage of need in our subspecialty. And we have a lot of places across the country that do not have fellowships.  And if you don't have a fellowship, you're even less likely to have addiction psychiatrists on faculty. And if you have a fellowship and you're not recruiting fellows  into your fellowship regularly, you're less likely to be able to keep your faculty that you need not only to have addiction psychiatry,  clinical training, treatment and fellowship training, but to even meet your requirements for general psychiatry training. So it is still concerning.  And in 2024, because we continue to have this increase  For those that aren't aware, some of the efforts we've made to try to both increase...  is in July 2022.  in July and those get released mid-July and then on a rolling basis to programs to really try to make it so applicants can apply to.  And that's been really helpful. We're about to find out our results for our third year of match that will be on December 4th.  That's helpful because one it does it helps the applicants actually get to look at all these programs and decide where they want to go because of the numbers.  It is very much in their favor which has mean we've seen more programs mine included that have historically filled that whether it's because of the pandemic decreased  application numbers variety of factors we're not generally.  Unfortunately, thus far, using ERAS and the MATCH has not increased our overall recruitment,  but it is allowing us to at least track that information more easily. So finally, as far as trends in board certification, you can pull up all these numbers according  to the American Board of Medical Specialties. Currently about 2.8% of psychiatrists are also boarded in addiction psychiatry.  You know, it doesn't tell us who's about to retire, it doesn't tell us, I mean, that would all be really helpful information.  So there's about 1,500 addiction psychiatrists currently boarded compared to currently about 4,300 addiction medicine boarded individuals.  As far as new certifications over the last decade, and you can kind of pull up this information  and pull what dates you want, so of course the numbers are going to change depending on the period you're looking at, but we had 759 addiction psychiatrists become board  certified and 16,000 a little over general psychiatry. So that is actually a higher percentage, about 4.7% of general psychiatrists.  Still me, okay, okay. So according to an annual medical school questionnaire.  required coursework and a hundred and two said it was included in elective coursework but what that means in actuality right thinking about that our  greatest potential for recruiting into our field is start young you know so definitely by medical school if not before then and what are they being  exposed to well it could you know getting some  for us to really help look across all these programs to see what is being done and how  can we support them to continue to do this work and get more people interested as medical  students and see that people do get better and particularly see why having that additional psychiatric training is beneficial.  This is the largest disparity between how prevalent a psychiatric illness is and how much time is required to be devoted to learning in it.  So we're biased, but we could argue that is not adequate for being able to treat one of the most prevalent psychiatric illnesses. And so on average, in one of the surveys,  they found that addiction education in general psychiatry residency was about eight hours of the curriculum with a range of six to 14. So again, if you look at how many hours,  I don't know if every program does this, ours has four.  So, Adpert had an addiction task force.  of requirements that what  The general adult training director, so it was sent to 200 general programs. There were 23 questions.  The response rate was not that great, 42%, but with  So the 85 program directors who respond  extrapolate what that means for the rest of the generation.  that they didn't actually have ex-waivered faculty to help, so they felt a little weird asking residents to complete something none of the faculty had actually completed.  So this is just a pictorial representation.  So what zero to one?  There is an ad for  to get better clinical care for all of our patients with co-occurring disorders.  Numerous projects co-sponsored by both organizations in terms of workshops presented on both conferences, papers that have been published.  collection of papers, and VTO was a project that was done by Adpert Addiction Committee.  It was a painstaking work. And then there are some separate subcommittees.  OC program directors who are advert members can apply.  program for a period of one year. And this mentoring has happened virtually. It can happen.  So, this can take many different forms in terms of revising a didactic curriculum, developing  a new rotation, or perhaps forging partnerships in the community, creating new opportunities with community partners.  a very powerful bi-directional experience.  actually curriculums from Dr. Pam.  it on the website and I think my  Fellowship near Paterau.  taught me how to use Dropbox and I did not know and that is how the whole story began.  was, of course, that we saw that there was a deficit.  that talked about this very issue, that talked about how can we...  right, different general psychiatry settings. So we'll talk about the advantage.  And so there's actually a  So now let's move on to inpatient psychiatric units because  Once they sleep it off and they're just fine, right, then you can say with some confidence.  Some challenges are that you have a limited  I will just share a brief anecdote because  And that's okay, right? And so but I saw this gentleman every week faithfully. He would come he would do his urine drug screen  It would be positive. I would give him a suboxone and on we would go and  approaching the  I can't wait to piss today, I can't wait. And he was just so excited about it, and I was like, what? You know, and it was because it was negative.  It was because that was the first time.  of maybe four or five, and to talk a little bit about your own training programs, what  might be potential areas for growth, what might be some potential ways that you might  apply some of the information that's been shared today, and whether or not perhaps you have capabilities to consult with others, to actually help others if you have a very  robust experience at your institution. And we're going to give you about nine minutes.  Okay, everyone, our nine minutes is up.  Okay 30 seconds is up. Sorry but so so everyone we'd like to come back together in our big group. We have our experts here in the front. We would like  to hear from each group just about the major themes that came up for you. So let's start with this group over here on the right. What were some major themes  that came up in your conversations? How about Carlos?  Hi John Mariani. We just talked about our respective resources at the institutions that we're at and I could say more for where I'm at Columbia that  there's actually a lack of clinical training material just that there's not specialty services and then the general services the leadership doesn't feel  comfortable you know managing addiction cases and then it's even even though we have a lot of supervision it's hard to actually convince the leadership to let  those patients into the clinic because they're worried they're worried they don't have the expertise to manage it. So reflective of the survey findings it  almost sounds like. Thank you. Next group.  We talked about something similar in that like trying to increase exposure to addiction psychiatry can be challenging just because the limited number of us  and so one way that actually on the inpatient and outpatient side we've been trying to get our general colleagues more comfortable with actually asking  those questions and starting treatment is by offering to be their backup and saying you know it's okay to start treatment and if you at any point in  time you feel like this is too complex for you I'll be here and you can refer them to me. That's a creative solution. How's it working? I in some of my  training sites well but it's it's been a mixed bag for one reason or another and I don't think it's necessarily stigma on their part it's just that like the  amount of training I received at my institution was not fantastic for psychosis and Parkinson's disease but I have colleagues that are very  comfortable with that. Similarly but you know that's a lot less common than OUD right but so that's how I kind of look at it they just need the comfort zone of  I can start this and I know that if something goes awry I have the backup.  So there was some common themes. One, there was an issue of access. If you're working in a more rural area where there may not be an addiction psychiatrist, much  less a psychiatrist, it becomes more difficult  to engage in getting patients adequate treatment, which is rough. But then there was a common theme within some medical centers where John and I have  been fighting this fight for more than 40 years about having a dual diagnosis clinic where they at least recognize that patients have this complex comorbidity.  And connecting to what I was going to ask, but became an issue here, about, well, what is that all about when you have a general psychiatry clinic?  And you identify that there's a patient with a co-occurring substance use disorder, and it's a training clinic. Those residents should be able to treat those patients, right?  Just given the stats that you presented in the beginning, showing, I mean, in the DSM, the class of substance use disorders is the second most common diagnostic.  Do you remember, Rick, when we were residents, if they found out somebody was here? Out!  They got extruded from the mental health delivery system. Go to rehab. Go to detox. So one of our members of our group here, there is an addiction treatment group  where there are trained and certified addiction attendings. And then there's a general psychiatric outpatient group. And the residents don't, if they,  the addiction patients essentially get routed to the addiction place where there aren't residents.  was describing the absolutely core necessity of residents to be exposed to change over time to demonstrate that addiction is a treatable illness. Absolutely. Thank you.  Let's move on to the next group.  OK. So I think we just had a nice discussion. The three of us are very lucky that we all come from institutions with addiction psychiatry  fellowships and a lot of addiction psychiatrists. So I think we were just talking about how fortunate we are to be in those positions. And we're all kind of thinking about how  do we build earlier in medical students and residents. Some things that came up is one thing we talked about is at least at UCSF.  We built a residency, built a four-year longitudinal clinic. And then we were able to build an addiction psychiatry four-year clinic at the VA through that.  And so, so far, we have about 50% of residents who go through that clinic who end up doing our fellowship, sometimes more. So it's like a really great feeding ground.  And those who don't end up graduating very, I mean, pretty well trained in addiction. Now we only get one out of 16 a year. So you're getting kind of a, you don't get them all.  But the ones you do, you can really kind of help and take care of. And so that was one thing we talked about. Do they get to be in that clinic or just get assigned? They do.  If somebody comes in, they ask them interests. And if somebody comes in with an addiction interest, they'll get assigned to it. And then if nobody has an addiction interest,  they just put somebody in. And then we try to convert them. We actually have something very similar that I started at the University of Nebraska, which is a half-day clinic.  But if there's no interest, they just get assigned. And sometimes they're better off for it. What about this last group up here?  So we have three folks that are addiction trained, and then a PA that's worked in a CL inpatient setting. So the common theme is longer is better.  Two programs have a year, wish that they could move it to a third year. And you said you wanted to add something else.  What did you want to add? Oh, no, it's OK. OK, OK. And I think for us, I think creating more of those experiences, because we have training sites  now in two different locations, one at Jamaica Plain for BU students and one at Harvard South Shore. But the idea of longer is better and getting more faculty  supervision to see things change. So I think that's the common theme in our group. And I think across the whole discussion is longer is better with good supervision.  And people will sort out. This is a career path for them. Fantastic. I'm so heartened to hear about the robust discussions and conversations. That's awesome.  We do have some food for thought questions, and or we'll open it up to questions from the audience.  So, thank you for a terrific panel and discussion.  I think the need to enhance the addiction training in general settings has been very well explored in this context. I'm curious how we assess how well that's working going forward,  because obviously there's going to be, there's enough variability to begin with just in terms of what services there are, and if the idea is we're going to try and optimize  the training as best we can in the settings that we already have. That makes practical sense to me, but in terms of monitoring, are we making progress?  Is that helping us achieve the goals of either increasing interest in the field or just increasing expertise for general practitioners in whatever their settings will go on to be?  How do we track if that's working?  Do we have another microphone? I'll respond to that. There was, let's see. Thank you. There was a time when I was afraid that when we were doing as much as we were doing  that we would never get anybody for the fellowship because they would all graduate so expert on addictions that they wouldn't feel like they needed it. And it was just the opposite.  The more training we did inside the general residency, the more people want to stick around and take the extra year of the fellowship.  So I think it really nurtured that. Things have changed somewhat since COVID and I'm not quite sure exactly how things are sorting out at this point.  But in general before that, my experience has been that once the residents learned that they liked doing this, the patients got better, that it was very gratifying work,  they came back and wanted to do more. They wanted to do electives and then there were usually at least two people every year who usually would stay for the fellowship.  So it was very rewarding. I think you also bring up an important point about how do we track outcomes. I will say, I know Alona's done a very good job  of collecting and publishing stuff about everything from education experiences to interventions. I can subjectively say that I've had a similar experience  to Dr. Renner in that I'm embedded in a general psychiatry clinic and have been now for seven years. And the shift being there for about two days a week  and basically telling the residents, you'll all see patients with co-occurring disorders and you can curbside me when you're staffing with a general resident or general attending.  You can schedule them to come on the day I'm here even if you're not in the co-occurring clinic and if they're more moderate to severe, we can transfer them.  And there has been a shift over time but it would be really useful and unfortunately it's challenging to think  how do you capture that short of surveying everyone to death but in looking at the patients that are referred, we do now have an option for them to select  when making a referral in EPIC that they're referring to the co-occurring clinic. So I'm sure we could look at things like the volume of patients  and how much they stay in the system. But I'd love to hear other people's thoughts. Mike does. John and I share the same program in terms of leadership  but I've asked former graduates why with all that training in the residency, why would you do the fellowship? Why did you do the fellowship? And the common theme was,  well, I liked it enough, I knew I knew that and I knew how to handle outpatient but the levels of care, the transfer, the triage, the consultation, the more complex cases,  I feel like I needed that if I actually was gonna go do that as a career. So that's kind of the next step of why they would do that. They liked it, they knew they liked it  but then they knew they needed to fill out the skill sets in order to really practice all levels of care.  Thank you for this wonderful talk. Yeah, this is very, so I'm a psychiatry resident, Marcus Ricari, I'm a PGY-3 at Beth Israel in Boston.  So yeah, I guess I was wondering,  because I was wondering, could you foresee like a future in which there is no like dual diagnosis or co-occurring clinic and separate from a general psychiatry clinic?  Because I think a lot of my co-residents, so I'm one of the few residents like really interested in addiction  but a lot of my co-residents also want to know how to manage it independently  but not necessarily like focus on it in particular.  And I guess I'm wondering if, without having to do fellowship, could people be,  could it be incorporated into one thing?  Yeah, I mean, so I'm, while I have a co-occurring clinic on Thursday morning, it is actually in the general clinic.  And so while we, they kind of, they will put people that are in the moderate to severe, like I'll often get referrals directly from discharge from residential treatment,  so then I'm specifically the one supervising. But otherwise, our clinic population, which is, we're one of the few, besides community mental health, that take a lot of Medicaid.  And so we have a huge number of medically complex and psychiatrically complex patient and a huge majority of them. I'm also in Colorado, so there's a lot of cannabis.  And so a huge majority have some sort of use disorder. So our residents, whether they like it or not, are actually seeing these patients. I just think their comfort's increasing.  But I think what I've observed is there's huge regional variation and then the systems themselves vary and then it also depends how much faculty you have  and how they're embedded in the services.  and what you see is what you get. So whatever the patient has issues with, you're responsible for treating. So we would get all sorts of stuff, right?  I mean, some of my co-residents had to do long-acting injections for patients for their psychosis, right? Others did suboxone. It just kind of depended on the situation.  And so I think it's certainly possible because that wasn't.  I would just say that every outpatient clinic is actually a co-occurring disorders clinic, either you know it or not, okay? So let's get that out of the way, okay?  Do you have anyone who's addiction-trained amongst your faculty? Yes, so we have Dr. Hill and then now we have Dr. Sarkar who just joined a couple of months ago. Wonderful.  So no one in the general clinic, so this is addiction psychiatry, at least I don't think anybody in the general clinic is addiction-trained.  So here's what I did for my kind of a program, residency program at Northwestern, I created  an elective for fourth years, that's one afternoon a week, actually I sacrificed my admin time, which I always do, I always schedule patients in my admin time.  And I have two residents for six months who are seeing patients during that time. And it's not the most perfect model for longitudinal clinic, but six months is better than nothing.  And so far has been a wonderful experience and I hope that it continues, actually one of the colleagues who is about to finish told me that he would like to extend his rotation  because he feels that this is really preparing him for life out there in the wild and he's going to practice independently.  The other thing that I like to do, I give all of my residents and all of my colleagues my cell phone, they'll have my email, I just tell them if you have any questions whatsoever  where you don't feel comfortable doing something, my phone is glued to my hand, I'm one text or one email away, don't be shy, I will ask you guys questions if I'm not comfortable  with something like Parkinsonism, right, or we all have our weak spots, but if it's addiction related, I'm here, I'm your external hard drive, don't be shy to ask, and so far we  have been helping each other like that. It's been a good experience so far. Thank you. Any other questions? We have three minutes left. Rick, did you have a question earlier?  Well, let me just throw it back to you guys.  Because, I mean, on your slide, you know, and this goes back to the general clinic again, you know, what you had was competing clinical, what was the last word?  Competing clinical, like, priorities? Yeah, priorities, that was the right word. And I went to, well, what does that mean? Right?  Let's translate that into, like, in terms of the functionality of what's going on in the clinic.  That's like, oh, well, your patient has, we're treating major depression, and your patient has really terrible alcohol use disorder, let's treat the depression, right?  I mean, so that's not really competing, that's excluding, that's bad medicine, right?  And that, to me, I mean, it's begging the question, how do we reduce the fear and, obviously, one part of it is reducing ignorance, right? We know that.  We've been trying to do all the training all this time. But really, how do we reduce that siloing inertia, you know, to that, like, well, no,  this is what we do here, and that's this other stuff, you know, and I don't know, you know. I said, but wait a minute, that's affecting your clinical outcomes for this thing that  you're trying to treat over here. How do we better interface, and then how do we better train? I am all about, like, paradigm shift.  Like, it stands for, like, it starts from the very bottom. Like, every psychiatric evaluation needs to have a detailed substance use evaluation.  I mean, it's a good evidence-based clinical interview and differential diagnosis if you're done doing it.  Yeah, but they do it, but how do they do it, and what do they do with the information that they get, right?  I would be very happy if people just start asking questions about substances and just build up from there.  And sometimes you're just, when you have a patient with insomnia that's resistant to everything, and you ask how much caffeine are you taking, how many of the caffeinated  beverages, and you get 2,000 milligrams, and you say, like, oh, whoopsie, this is why nothing is working, right?  So we just have to remember to talk to our patients and ask questions and be a little bit like Colombo, like naive investigators. So modeling is really important.  I think it's modeling. I think it's modeling, yeah. I guess another, I know we're pretty much out of time, I mean, a different take on the  clinical priorities is just the fact, I mean, what you're hearing is a lot of locations have few addiction psychiatrists, and if they're using them to fill their specialty services,  they don't, you know, how do you make them available for the general service as well and embed them within a general clinic?  So right now I do it at the sacrifice of actually, I don't currently get to clinically supervise my fellows. I'm only in the general. That hopefully will change soon.  But that has been, that's been a challenge we've faced is it's, you're usually kind of, it's more common to be required for the specialty service. Thank you.  Thank you, everybody, for attending and participating.
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