Rokossovic, Rokossovic, okay, Dr. Ritvo, and Dr. Renner, and we're here to tell you about our joint ventures with ADPERT and AAAP Education Committee, and I will launch it with Dr. Ritvo. Okay, my part is brief, but that's very important. Disclosures, no overall disclosures. I'm always supposed to disclose, although not related to this. I'm contracted with a non-profit as their medical director, the Alliance for Benzodiazepine Best Practices. So our objectives summarize our current trends in addiction psychiatry training and recruitment in the state of addiction psychiatry education in general psychiatry residency programs and the impact on future addiction psychiatry workforce, describe the inter-organizational, so AAAP and ADPERT, for those not familiar, ADPERT is the General Psychiatry Residency Training Director Program, although it includes specialties as well, so their association. So our collaborative opportunities to address addiction psychiatry training, including creative incentives for fellowship recruitment, and then third, identify one to two innovative strategies to enhance addiction psychiatry education in general psychiatry residency programs. So I'm from the University of Colorado, I'm the fellowship director there, and I'm also the chair of the education committee with AAAP. So overall trends, you've probably heard, and if you're part of a residency program, you know, but general psychiatry has become increasingly popular. I know I feel lucky I got recruited over a decade ago because I think it would be hard to get into the programs I would want today. So it has the only other specialty that has had a similar increase as sports medicine. Between 2016 and 2021, there was a 26.3% increase in the number of first year ACGME trainees in psychiatry. So there's been a huge growth in programs, which is obviously great because we have a huge need in mental health. During that same period, we did see growth in addiction psychiatry fellowships, both in the number of programs and the number of filled positions, 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% increase in the number of positions filled, although this is, I won't say misleading, but if you actually look at just the last four years, especially since the pandemic, 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 in number of positions, we ended up filling 58% of the Addiction Psychiatry Fellowship positions nationally. It was still that 89 number, but we had a big jump in number of available positions because of HRSA funding. So for those that aren't aware, some of the efforts we've made to try to both increase recruitment, but also really increase our ability to track data and make sure that we're as unified as possible across the country and across our programs is in July, 2022. We had the majority of programs agree to use the Electronic Residency Application System, also referred to as ERAS, where all applicants coming in, submit all of their materials 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 as many programs as they want to pretty easily. And we can also track the number of applications coming in. A year later in July, 2023, we got the majority of programs to join the National Residency Match Program, referred to as the MATCH. 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 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 filling unless we have an internal candidate. But still, I think it's been useful in just really trying to even the playing field, not making it a scramble for people interviewing earlier and earlier and being offered and having to make a decision, but really getting to look at programs across the country. So 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. 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 gonna 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 also became addiction psychiatrists. So I will take that as a slight win, that we see one number that looks a little bigger, but again, I think if you narrowed the window and you look at more recently, we're not gonna continue to see that growth because we've had a much bigger growth in general psychiatry positions than we've had in recruitment into addiction. So with that, I will, this one's still me, okay, okay. So according to an annual medical school questionnaire, 143 out of 145 medical students said that the content on, quote, substance abuse, using an outdated term, was included in their required coursework, and 102 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, so definitely by medical school, if not before then, and what are they being exposed to? Well, it could, getting some exposure might be as little as one lecture on intoxication and withdrawal states. So there's a continued need for much more development of core competencies in substance use disorders with dedicated course and clinical experiences for medical students, and a continued need 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 in working with these patients. So in the addiction general psychiatry residency programs, we are only required to have one month of full-time equivalent training in addiction, so that is 2% of all of the four years of your residency training, and 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, right, for being able to treat the most prevalent psychiatric illnesses. 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 hours every week of didactics generally, and then it can vary by clinical site if they have additional. So eight hours is a very small piece, right, two weeks of your entire didactics, so. So there was a survey. Did you? Yeah, you do the, I think you're doing this part because you know the survey very well. Okay. Okay, so, so ADPERT had an addiction task force. This was started by Sandra DeYoung when she was president of ADPERT, and they did a survey of all addiction training within general psychiatry residency training programs. So they had an IRB from Emory. Ian Schwartz was one of the leads on that, and the goals really of this survey were to understand what the current state is of addictions training and programs, identify what the impediments were, really what the resource problems were, what were the gaps in training. I mean, we know that in medical schools, as Dr. Ritvro just mentioned, there's such a limited amount of requirements that what is it like in residency, right? We know what the ACGME requirements are, but what is actually happening on the ground? So we really wanted to figure out what was going on and then how we can help, how we can help fill the gaps. So there were two surveys, one to general adult training directors, and then one to the child and adolescent fellowship directors. So the survey was distributed via email, SurveyMonkey. There was an original email and then three friendly reminders. 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 emailed surveys, that's actually pretty much on par, usually about a third. So it's not too bad when we look at that. I mean, ideally we would have wanted more responses, but if we look at just survey literature in general, it seems to be on par. With the child surveys, that was sent to 109 child programs. There were 21 questions and the response rate was 43%. So very similar to the response rate from the general directors. It's uncertain whether or not the child directors were at the same places as the general directors. So the 85 program directors who responded, what they said was that 15.29% of programs had actual board certified faculty in addiction psychiatry. So that was only 13 program directors of 85, right? You can extrapolate what that means for the rest of the general psychiatry residency training programs, but that figure is quite small. Only 36% of programs reported having an addiction medicine faculty boarded, faculty or board certified faculty. And again, it's not clear whether there was overlap there, whether it was the same programs who had addiction medicine and addiction psychiatry faculty, or whether it was different programs. But the figure is higher for the addiction medicine faculty in general psychiatry residency training. So obviously lack of addiction trained faculty was a huge factor. It was an impediment that was cited by the program directors to providing more comprehensive training. So even the programs that had the faculty that were trained, even they identified feeling under resourced. So the programs with experts actually said that because there were so few of those experts, they were being pulled in so many different directions and were responsible for so many administrative things, as well as providing clinical care, that they actually found that teaching got the short shrift in that. And only 40% of the programs who responded required buprenorphine waiver training, which at that time was a DEA requirement. Of course, we know that is no longer. However, only 40% of the programs did require it at that time. And there was concern cited 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 of the number of faculty members that were trained in addiction. So the addiction psychiatry and addiction medicine. As we see, many don't know. There was a lot of don't knows, which is the green bar. And very few faculty. So in terms of seven or more, there was only 8%, I believe, of programs had seven or more faculty members in addiction psychiatry, and only 1% of addiction medicine. So the time spent in training. This was another really interesting question, because they wanted to understand where is this training being done? Where is the one month FTE equivalent actually occurring? So what they found was that the majority was really spending it in specialized settings. So they had, let's see here. So zero to one month, 38%. Some did not even have specialized settings. So about 36% didn't even have specialized settings. And then fewer programs had two to three months in a specialized setting. Very few programs had four to five months, and very few had more than six months. And then there was the general settings, because in places that don't have addiction-trained faculty, they usually don't have those specialized settings, and so they're providing this training requirement in general settings. This was in outpatient settings. So in specialized settings versus in general settings. So in specialized outpatient settings, zero to one month was 63% of programs. So a really large chunk. In general settings, it was a smaller chunk. Zero to one month was 17%. And it's interesting because many of the programs reported having a significant amount of time in outpatient general settings, but they simply were not providing addiction care in those settings, despite the likelihood of those patients being there being quite high. And we'll talk a little bit more about that later on. So the program identified barriers to providing clinical experiences in addiction psychiatry. So of course, the biggest bar here is limited number of faculty, and we already know that. Faculty with time to supervise. Because again, even those that have faculty found it difficult to use that faculty for training purposes. Then the next biggest impediment is a limited number of faculty with expertise. So not only do they not have people with time, maybe the ones that do have time, they don't have the expertise. They simply don't feel comfortable with this. And then insufficient clinical sites, specializing in addictions. Again, this notion that you have to have a specialized clinical setting in order to provide this care, which is not necessarily true. And we'll talk about ways to overcome that type of barrier. So the major takeaways from the survey. So addiction psychiatry usually takes place in general psychiatry settings, rather than specialty units, because they lack specialty units. This raises the question of what type of supervision are the residents receiving, since they don't have faculty that are knowledgeable and have expertise in this. So what are they really getting here? The programs have gaps in the curriculum in just basic areas of training, right? We're not even doing the basics here. We're just the rudimentary care. And that many programs indicated they would benefit from having more comprehensive curricula, they just didn't know where to start. And I will pass it on to. Okay, hello everyone. My name is Daniela Racosa. I come from Northwestern, and I hold a couple of clinical and educational roles there. I will tell you a little bit about the AAAP and ADPERT collaboration and actions to address the current state of addiction training. So a lot of you know ADPERT stands for American Association of Directors of Psychiatric Residency Training. So it's a big organization that is focused on general psychiatry training. So PDs, APDs, and program coordinators. It's a hub for clinician educators. It's a wonderful place, okay? It's been founded in 1970, and every year around the beginning of spring, end of February, beginning of March, there is a large meeting. All of us go to ADPERT, learn about the latest ACGME requirements, meet with our colleagues. I would encourage you if you have never visited to consider going to one of the ADPERT meetings. So ADPERT has been in the last, I would say six to seven years, focusing more specifically on addiction psychiatry. And ADPERT actually offers a couple of pretty focused resources and initiatives that can be helpful to programs that struggle with education in the area of addiction psychiatry. For example, for members, on the members part of the website, there is a place called VTO, Virtual Training Office. Think about VTO as a repository of curricula, collections of papers, all of the things that make educators happy, right? It's a collective knowledge, right, where you can tap in and think about, hey, I need papers on how to start, how to do microinductions on buprenorphine, and there they are. And actually, a lot of the colleagues from general residency programs, general psychiatry programs are utilizing VTO as a source of knowledge. Now, during the yearly conference, right, there is obviously most of work that's focused on general programs. However, there is a subspecialty caucus. So subspecialty caucus is actually a place for fellowship program directors to meet and talk about all of the problems that we are dealing with, okay? And addiction committee is a very important part of the focused efforts that ADPERT is putting out. I will tell you a little bit about its history and how it came to be. And one interesting part of what addiction committee does, Dr. Sandra DeYoung, who was past president of ADPERT, usually sends out on the Common Server tip of the month that's focused on addiction psychiatry tidbits or pearls, something that's really on trend, something that's now, something that general psychiatry program directors really need to know and incorporate. So a little bit about this interorganizational collaboration or cross-pollination, how does this look like, right? So I think it's a three-part collaboration. Like, it's an effort that includes Triple AP Education Committee. So we have a couple of people here that are currently co-chairing the committee, and we have Dr. Hofer who was chairing it previously and lived to tell. And then on the ADPERT side, there is an ADPERT Addiction Committee that actually started as a task force in 2017. And then I think a third really big part is APA, right? And what better than having a past APA president who is a famous addiction psychiatrist? What a great representation for our field. So common goals that all of these organizations share is improved education in addiction psychiatry, more addiction psychiatry-trained general psychiatrists, more addiction psychiatrists in general, and addressing recruitment challenges that are being more and more visible, right? And what are the outcomes that we are hoping to achieve? So we're hoping to ultimately get better clinical care for all of our patients with co-occurring disorders. That's quite self-explanatory. But we're hoping by improving access to care, having more physicians that are training, providing skilled addiction psychiatry care to alleviate some of the addiction epidemic. And I do believe that this strong collaboration, specifically between Triple AP and ADPERT, sends a very strong, very united and cohesive message to some of the stakeholders such as ACGME and ABPN and such. So this history of collaboration actually started in 2018 when Dr. Scott Oakman from Hennepin actually started the first, presented one of the first workshops that was focused on addiction education. And then in 2017, Dr. Sandra DeYoung that was AdPERS president at that time created Addiction Education Task Force, right? And in the years to come, there have been numerous projects co-sponsored by both organizations in terms of workshops presented on both conferences, papers that have been published in academic psychiatry, et cetera, et cetera, that reflected initiatives to improve the recruitment to addiction psychiatry, clarify the path to becoming addiction psychiatrists and outline some of the challenges. I think a very important moment for this particular task was 2020. The contributions of the task force have been acknowledged in terms of this now becoming a standing committee at ADPERT. This is the point where more focus was placed on surveys and needs assessments, organizing and curating curricular content and resources and making it available to training directors. What I mentioned, for example, the collection of papers in VTO was a project that was done by ADPERT Addiction Committee. It was a painstaking work. And then there are some separate subcommittees that are working on sub-subjects, right? For example, there is a Child and Adolescent Psychiatry Addiction Committee. And usually there is some scholarly output in terms of presenting in annual meetings like APA, AAAP and ADPERT. Now, I think what's important for all of us and to piggyback on what you said that there was so little of addiction psychiatry trained faculty is the creation of the Virtual Visiting Scholar Award. And this award was actually based on Victor Teichner Award for development of psychotherapy curricula in programs that had underdeveloped psychotherapy. This is an award that's actually a fantastic representation of this collaboration, of this collab between AAAP and ADPERT, right? So this is an annual award. Program directors and associate program directors who are ADPERT members can apply if they feel that they need more help with developing good, solid, robust addiction psychiatry training within the programs for their residents. Deadlines are pretty much the same as deadlines for ADPERT submissions. So I think that's somewhere around September, I believe. And awardees are matched with a particular expert, with a visiting scholar who has availability to mentor the program for a period of one year. And this mentoring has happened virtually. It can happen if there is a desire and opportunity and both have to happen in person as well. And there are actually two tracks of this award, one for general psychiatry and one for child. So child fellowship programs can get help with addiction training, but also general psychiatry residency programs can get it. And this application requires a structured project proposal describing from the scholar's perspective how would you improve the addiction psychiatry educational experience. So this can take many different forms in terms of revising a didactic curriculum, developing a new rotation, or perhaps forging partnerships and the community creating new opportunities with community partners. So these are some of the past awardees. We just saw Dr. Amy Ewell, who was one of the past visiting scholars and she was able to provide some guidance for Louisiana State University Health. I remember Dr. Oakman, who was helping University of Oklahoma School of Community Medicine, saying that this was a very powerful bi-directional experience where he also felt that he learned a lot from his colleagues that he was helping to improve curriculum. And he's a very accomplished and strong educator and addiction psychiatrist. This is some of the quoted really feedback from somebody who received hands-on help on how to develop better addiction psychiatry curriculum. This is from Dr. Pam McPherson. And this is a link for the advert website. This takes you basically to a part of the website where all the different awards are listed. Advert has a lot of different awards that are if you are in education, if you want to encourage your residents, your trainees to build their resume, and your junior faculty, encourage them to apply. But the full description of this award is listed on the website. And I think my personal connection to addiction community actually started with Adpert Award. As an international medical graduate, I was awarded the IMG Fellowship near Pati Rao Francis Lu. And my award was picking a mentor. And my mentor was Dr. Anna Schwartz, who was the current president of the task force. And this is how the story began for me. Plug in for faculty development opportunities. There are two new awards, new education awards by the AAAP that are good opportunities for faculty. One is AAAP award for medical student education, and one is more focused on residency education. So these are awards that are focused on clinicians and faculty who demonstrate a sustained record of outstanding contributions to either medical student or residency education. So with that said, I will officially give the podium to Alona. Thank you. And I failed to mention earlier, but I am co-chair of the Education Committee for AAAP along with Dr. Fritvo. And your first experience was through this IMG Fellowship. So I actually became involved through the VTO, through the virtual training office when Dr. Fritvo taught me how to use Dropbox. And I did not know. And that is how the whole story began for me. So there are many ways to get involved. And sometimes they're serendipitous. So we're gonna talk a little bit about some innovative strategies to enhance addiction psychiatry training in general psychiatry residency programs. So one of the things that came out of that survey was of course that we saw that there was a deficit in training sites, there was a deficit in faculty. So what that led to was a variety of publications that Dr. Rakocevic talked about as well as workshops that talked about this very issue, that talked about how can we do what we can with what we've got basically. And so while we were coming up with a visiting scholar and ways of enhancing, we really put our heads together to figure out what can we do with the existing infrastructure to try to teach our general psychiatry residents about addiction psychiatry. So we're gonna talk about how to do that in different settings, different general psychiatry settings. So we'll talk about the advantages, some of the challenges, as well as the teaching methods that can be employed. And this is just a very small sampling since there are many teaching methods for most of these. So for consultation liaison settings, so this is primarily in a general medical hospital. So the advantages of trying to include addiction training within that context are that you will see intoxication and withdrawal syndromes. And so that's an opportunity to learn how to manage those syndromes. You can also collaborate with specialty services such as transplant medicine, liver transplant is a big one for folks with alcohol use disorder. Pain medicine is a big one for those that maybe there's some overlap with chronic pain and opioid use disorder. And so you can try to teach through a collaborative setting with other specialties. Additionally, it's an opportunity to provide both psychoeducation and harm reduction to patients and to teach your colleagues, right? Teach them about discharging patients with naloxone for those that may be at high risk or those that maybe have respiratory illness and also are on an opioid at home, right? So there's different ways to provide that type of education and collaborative training opportunities. So those are just a few of the advantages. Now with the challenges, it's difficult, especially because many consultation leads on settings are quite busy. There's competing acute medical surgical needs. The patient may need to go to pre-op or they may be delirious post-op, right? There's a variety of challenges there. Sometimes you'll see conflation of substance use disorder with psychosocial needs and social work needs. And we see this even on my addiction psychiatry consult service. So one of the national metrics for trauma care and trauma surgery are that if somebody comes in and substances are a part of the trauma presentation, they are required, there's a checkbox, they are required to address the substance use. And so there's actually a social work consult for this very reason, to check the box, literally, as opposed to perform a medical evaluation and intervention. And that often gets conflated, at least at my institution. So that's definitely an issue. Sometimes there can be inadequate collaboration. We all know, we've all rotated through CL settings. Sometimes primary teams are less collaborative than we would like for them to be. And that can be problematic, especially if they're not comfortable with the substance use components, right, if they don't really want anything to do with the substance use. And the teaching methods, certainly at the bedside, interviewing patients, observing students and residents, interviewing patients, having case conferences, or reading articles based on the patients that you see, right? You see a patient with alcohol withdrawal, you could read an article about different ways of managing alcohol withdrawal, or perhaps medications for alcohol use disorder that you can then discuss with the patient after their acute withdrawal has subsided. So now let's move on to inpatient psychiatric units. Because as we all know, every psychiatry resident rotates through inpatient psychiatric units. It's a big part of our residency training. So some advantages here are that, one, it is usually an interdisciplinary team. So you can learn about the community resources available, the systems of care, especially for those with various kinds of insurances, what they may be eligible for, what they may not be eligible for. This is also a really good opportunity to be able to differentiate between substance-induced symptoms versus primary psychiatric disorders, which sometimes even the acute inpatient setting is insufficient time to be able to do that. However, if somebody comes in and they're acutely intoxicated on methamphetamine and they are admitted for psychosis, which I've seen countless times, once they sleep it off and they're just fine, then you can say with some confidence that it was acute methamphetamine intoxication that really was the culprit in their presentation and that they do not have a primary psychotic disorder. You also can learn to recognize and treat withdrawal syndrome. Certainly in acute psychiatric units, usually they don't have IV medications, but you can treat the lower-level withdrawal syndromes with oral medications for alcohol, for opioid withdrawal, and you can use medications for opioid use disorder as part of the withdrawal management as well. Some challenges are that you have a limited availability, oftentimes, of addiction-trained supervising faculty. The majority of faculty that work in inpatient psychiatric units typically are not addiction faculty. They are typically general psychiatrists who may or may not feel comfortable with addressing addiction in their patients. Patient engagement is also potentially an issue. Acute psychiatric symptoms, if you're really trying to get a grasp on somebody's mania, that may not be the best time to address their substance use disorder, though once you do have a handle on it and things are getting better, that could be a prime opportunity. I remember in my residency training, my program director saying, the patients in an inpatient unit are a captive audience. They're not going anywhere, so you have an opportunity to practice interviewing skills, to practice a whole bunch of things because they're not going anywhere. So that's just something to keep in mind. The teaching method, so again, practicing those interviewing skills with an observed interview. Brief and service activities, journal clubs, again, many of the things that we do for the CL setting in terms of case conferences, resident-led presentations can all be done in an acute inpatient psychiatric unit. So challenges and opportunities in the emergency department. So I feel like this is often where the rubber hits the road. We do have some advantages. There are several disadvantages, but there are some advantages. So management of physical health complications of substance use, particularly acute complications. Somebody comes in with sepsis from an abscess from injection drug use. That is a very acute presentation that you are able to intervene immediately. And you see this long-term effect of substance use on your patients. This is also another opportunity for collaborative education and teaching of your colleagues and the interdisciplinary care team. So peer teaching to nurses, nurse practitioners, other health care colleagues. Many times in these settings, you can have a peer support worker or a peer support professional that can be in emergency departments, which can be also an invaluable resource to work with. You, as the resident, can learn from them, much like they can learn from you. This is also an opportunity to learn about levels of care, as patients will present to the emergency department and perhaps later be referred to an outpatient withdrawal management center or possibly a residential treatment program if those are available. And so learning about those community resources can also be something that's available with the emergency room setting. So now some challenges. These are the ones we typically hear about. So the negative countertransference and compassion fatigue. We had a talk on stigma, several yesterday, actually, on stigma. And one of the things was that when you are hearing your colleagues or your superiors say things like patients are frequent flyers or they're always going to be here no matter what, that's hopeless, that can definitely be a downer. That can be discouraging to residents that are trying to learn how to best take care of these people and how to best instill hope in their patients. That's actually the opposite of that. So that can be problematic. It is a fast-paced environment, which oftentimes leads to very brief treatment relationships. I would say that's similar to the consult setting. So in the emergent setting, it may be even briefer. You may really just get a fleeting opportunity to talk to the patient. And of course, patients may be pretty contemplative. They may come there for the abscess and for sepsis, but they really have no desire to talk about their injection drug use or address their injection drug use in any way. Though I might add a hidden opportunity there might be to talk about harm reduction and injection practices, not sharing needles, things of that nature. Teaching methods, brief resident presentations on key topics. So this is, again, something you can do with the consult setting as well. So if you see a patient in acute withdrawal from a substance or acute intoxication, having a little brief 15-minute talk from the resident on what that looks like, on what the potential treatment options are, and what the differential diagnosis might be, and how you might differentiate it from a primary psychiatric disorder. And then, of course, bedside teaching, which is, I think, really a universal teaching method for all training sites. So the general psychiatry outpatient clinic. I had mentioned earlier that this is one of those settings that all psychiatry residents spent quite a bit of time in. I know for my residency, our third year we had a general psychiatry clinic, even in fourth year as well. So the advantages are that you are developing these longitudinal relationships with your patients. And you can see the full spectrum of recovery. That, to me, is one of the most magical things, that you can actually be with a patient while they're struggling, and then be with them all along the way to see them get better, to help them, to be there for that, and to watch them put their life back together. Frankly, that's what got me interested in this line of work, is that I saw these patients get better over the course of my third year psychiatry residency and working with them. This often gives you opportunities to gain experience with medications for addiction treatment. So for OUD, for AUD, having even just one faculty member, even a general psychiatrist who may be comfortable with these medications, will allow you to have a supervisor that then supervises you doing that in the general psychiatry clinic. Practicing motivational interviewing is something that is universal, and a really good opportunity to do that. I would say also it's an opportunity to practice BERT, which is also one of the teaching methods, is training on that. But that's, as I'm sure we've all heard about, is screening, brief intervention, and referral to treatment. Ideally, if it were up to me, the resident would be providing the treatment then and there. That's not always possible. Systems are different, and we appreciate that. But at the very least, they could provide a brief intervention, much like primary care can, and then refer to treatment as needed. Some challenges. So there are, of course, competing clinical priorities. There always are. I think it's a matter of how do you prioritize those competing demands. Management of the psychiatric symptoms. It's interesting. Sometimes I will cover resident supervision in the general psychiatry clinic, and these residents will say, this patient has treatment refractory depression, and they've tried this many SSRIs. And then I ask them, well, have you asked them about any substance use? And sometimes it's very revealing if the patient is drinking a bottle of wine every night, and nobody knew, nobody cared to ask. And of course, their depression is treatment resistant, right? But it's something that they hadn't thought about. They hadn't realized that, hey, I can actually intervene on this, too, and it would actually also help with the depression management. So again, limited availability of addiction-trained supervising faculty. This can be overcome if you have even just a half day of someone who is comfortable with managing addiction, does not necessarily have to be addiction-trained. And sometimes reluctance of patients to disclose that full history, right? If you don't ask, then you're never going to know. So the patients may not have asked and might not have relayed the part about drinking the bottle of wine because they didn't want to share that or they were concerned. We're going to do questions at the end. So the teaching methods that we're doing in the outpatient clinic. So training on SPURT, we mentioned that. Case conferences that we, I remember in my own residency outpatient clinic, we would have case conferences where we would present on a challenging patient that we have been treating and get expert advice and guidance from Dr. Renner here, who would then tell us about ways that maybe we hadn't thought about approaching the patient case and bring in some references of what is current in the literature about how to treat these patients. Now, challenges and opportunities in community and public sector settings. Now, as we saw in the survey, not that many residency programs have an opportunity to rotate through these settings. But for the ones that do, there is still an opportunity to include addiction training within that. So we have residential treatment centers, state psychiatric hospitals. Some of those still exist. They're still around. And patients will also have substance use problems. Sometimes homeless shelters, right, health care for the homeless, outstreet psychiatry is an emerging field in certain places. And in many places, it's well-established. But that's another opportunity to reach patients literally where they are. And mutual aid meetings is another opportunity. So we do this with our medical students, where we actually have them attend a mutual aid meeting and then do a reflective exercise on what that experience was like for them. At the very least, it can expose residents to people in recovery, which may be something they've never seen before. And they may see people who look just like they do, which can be very eye-opening. And so teaching methods here, or rather challenges, so insufficient networks and sites, that can always be a problem. Of course, with things like mutual aid meetings, you don't have professional support there. So that really would be like a one or two time thing. Limited availability of supervising faculty, which, as I'm sure you've noticed, is a pervasive theme in terms of challenges across all of these settings. And then the teaching methods, so observed interview at the bedside, case conferences, reflective essays, resident-led presentations, flipped classroom. I mean, there's a lot of creative solutions to not having a faculty member present at all times. And so one of those solutions, we're going to have Dr. Renner talk about an implementation of the BU model. Well, good afternoon, everybody. Thank you for joining us. This is going to be a fairly short presentation, because I want to just give you an example of what you can do in a setting where you may be the only addiction psychiatrist and the only one with the needed expertise to convey the teaching. I want you to think about what I did several decades ago, if you will. And I think it's important that you enlist your superiors. So that means the chairman of the department. That may mean the chairman of the clinic. It may mean whoever is going to oversee things in your setup, that they are supporting what you're going to do. And they're giving support to you to do it. And I think that, as we heard the other day, I think that we've reached the time that the addiction problems are so critical that the entire system has to be engaged in trying to do something about it. And I think you should make sure that message gets through to the people in charge. I think you then think about the location. Where are you going to do it? Well, the first part of this is easy, because the patients are everywhere. Really, you can almost have access to patients with the problems that we need to work with, no matter where you're located in your system. The question is really, where are the teaching staff? And so I think your first task is really identifying who are adequate teachers in your faculty. Is there an adequate teacher? Is there an addiction psychiatrist in the faculty? And can you match that person with where the patients are? So in some places, CL might be a better place to do this, because that's where the faculty is. In our situation, it was easier, because I was located in the outpatient clinic. So we basically took what was an existing outpatient continuity clinic. And I think that's the next thing to realize. Within the politics of a department, it's extremely difficult to say, I want to create a new program. I want you to give me six months of residence time to do something. What you do is take six months of residence time that's already existing and see what you can do to convert it into an adequate teaching program. And in this case, we were very lucky, because I was running a continuity clinic that was in the third and fourth year of the BU residency. And we had the residents there for 20 hours a week in the third year. And in the fourth year, they came back for half a day. So we had the potential of a two-year experience working long-term with patients in a setting. And I think that that's critical for two reasons. Addictions or chronic illnesses. I think if you really want to learn how to manage a chronic illness, I think you have to be in a setting where you can work with patients a long time. And I think we all know that what that means is, you start with them, usually right out of detox. There will be one or two or three relapses. And you continue working with them. And you pull them through the relapses. And you get the experience of seeing how people can put their lives together. And no matter how much of a struggle it is in the beginning, in two years, you will be astonished at what you can accomplish. And in this situation, I think the critical thing is, you want the residents to personally learn that they can work with patients. And they can be part of this recovery process. And that part of their experience in this continuity clinic can be adding addiction to the work. So matching the patients to the residents and finding a location that really works for your program is critical. I think that just a little bit about where we started. Our clinic was in downtown Boston. So we had easy access for patients. We were fairly close to a large veteran shelter in downtown Boston. So we were seeing lots of homeless people with lots of addiction problems. And almost all these patients were coming to us because somebody had referred them for some type of psychiatric problem. So it was extraordinarily rare to see someone who was just an addiction patient. But everybody usually had two or three psychiatric problems, plus their substance use, whether it was identified in the beginning or not. So we took a clinic that was already existent. We tried to build this experience for the residents during the time. And here, I think, was critical to have the support from the senior faculty in the department to know that the residents need to learn. And they're not going to learn if they're managing 30 or 40 patients a week. And in those, this was 20 years ago or 30 years ago we started it, we were able to have the residents have 10 or 15 patients a week. And that meant they could spend an hour with every patient or two hours with the patient. And I certainly recognize that in the very beginning with patients just out of detox, you sometimes needed to see them twice a week. And it was a labor intensive work in the beginning. And I think you will need the support from your senior faculty to make sure that that time is available for the residents. So think about how you're gonna make them use that time in an effective way. The staffing, we had other psychiatrists, psychologists, social workers, but I was the only addiction person. And I want you to think about this, how you can do it as a single person, and what you can do. Because what we set out to do was provide two hours a week of learning time for the residents. And that usually meant at least one hour of formal lectures, sometimes two hours, but at least one hour, and one hour of case conferences. And basically the way I ran the program was in the first month or so of the summer, I would present for the first four months, I would give the lecture. But at the beginning of that, I would also give the residents a long list of topics and assignments. Because the faculty that I had available to do the teaching were the residents. I didn't have a lot of other addiction experts in my back pocket that I could call on. And it really worked out that each resident had maybe four to six hours a year of lectures that they had to prepare. And they probably had a comparable number of case conferences that they were responsible for. Sometimes that was just, they would present to us a verbal discussion of a difficult patient. Sometimes they would bring the patient in and they would interview the patient in front of the group. So it was also an opportunity for them to interview, learn how to interview, be criticized in the course of their interviews how they did it. It was also an opportunity for them to learn how to teach. Because by the end of the year, they have now given a series of lectures. I think they've watched a number of lectures. I think you've had opportunities to work with them about how you do it. I think things are much easier nowadays because when we started this, the internet didn't exist the way it does now. PCSS didn't exist. All the, there are sites now with all these topics and all these lectures. If you want a resident to learn how to, you know, treat cocaine abuse, most of them in half an hour can probably find five or six lectures on the internet. But I would like them to come up with their own lecture. It's all right if they adapt something. But you want them to learn how to teach and find good material and be comfortable presenting that material to their peers. And this is just a sample of the topics that we covered in the course of a year. Because when you think about it, if you have an hour or two hours a week to do formal presentations, you have 50 to 75 hours a week of potential education faculty time to educate the residents. So these are just a variety of topics in addiction that you may want them to cover. I mean, I don't intend this to be something that's perfect or that everybody should use it, but it's just an example of the different things. And depending on the location of your clinic or your hospital or your population, there may be different issues. I think we got into the experience of doing diversity work very early because we had a diverse group of residents. And often it was a question, can you tell us about in your culture how substances are used or what's it like in X country, which is where you grew up? And can you introduce us to the culture that existed around substance use in your culture, in your home culture, if you will? So we had opportunities to bring these into the teaching environment. And so I would just end up with this, that I think that what we've done is come up with what I think is an ideal way for residents to learn how to do addiction work. It's a longitudinal, up to two year experience with individual patients. They have learned to live with them through their recovery. They have learned that patients can get better. They've learned to tolerate the relapses. They have learned to survive the patients who don't survive, perhaps, but also learned to survive the difficult back and forth for some patients. And I don't think this is anything they can ever learn in the emergency room. And I think we have to avoid exposing them to what's actually a small percentage of our patients who don't get better. And I think we have to focus on the patients who do get better and need that positive experience. And I think the last thing I would say is about stigma. I think part of the problem we have such a struggle with this is that people with substance use disorders are stigmatized in our culture. And I think the only, I don't think you can lecture people out of stigma. I don't think sending them to a day-long conference somewhere is gonna cure their mindset and what's behind the stigma. But I think getting to know patients very, very well will change their attitude. And knowing them also means being responsible. They're just not a name on your list that over the course of a year or so, you've gotten to know who they are. You should know who their family is. You should know their history. You should have a real sense of what their life has been like. And my general experience has been that that changes your idea about them. They become real people. And at the end, my experience has been that people often say they like doing this work. And I pointed to Lona here because I think, I look back on it, Lona, when you arrived at the beginning of your third year, I don't think you were really sure you wanted to be there particularly. Yeah, that was my experience too. And at the end of a two-year experience, I think we changed her mind. And I think she benefited from the opportunity to work long-term with these patients, to see them get better. And I think she, besides learning how to do addictions, I think you can see today, she learned how to teach. She learned how to deal with people in groups. I think she got a lot of experience out of this that were quite useful to her. But I will stop at this point because I think this just is an opportunity where I think you can both educate people about addictions, make them graduate from your program comfortable doing addiction work. And I think you can also produce people who are healthier, I think have dealt with some of their stigma. And I think have learned how to treat their patients with respect, which I think is really critical for this to work. So thank you. Yeah, and Dr. Renner is 100% correct. I will just share a brief anecdote because this is something very memorable for me. So starting in the clinic in my third year of residency, it was a dual diagnosis clinic. We were doing Suboxone. We were just learning how to do that. And it was relatively early on in the opioid epidemic. And I had this patient, a young OEF, OIF veteran who struggled with oxycodone. And he, and Dr. Renner warned us. He said, just expect them to still be using for the first six months. 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 six month mark, there was one day where he came in and he was just giddy, like with excitement, just giddy. And he was just, you know, smiling, energetic. And I was like, what's, you know, what's going? He's like, 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 he hadn't used. And even now I get goosebumps thinking about that because it was just such a magical moment for me personally, for him. And he did very well long-term, right? But it took time, it took effort. It took us believing in him, right, for that to happen. And I think that outpatient experience really affords that opportunity. So now we have a brief small group activity. I promise we'll have time for questions, ample time, but I would like folks to get together in groups 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 gonna give you about nine minutes to do that, okay? So please get in your groups and in nine minutes we will reconvene with some additional questions and Q&A. OK, 30 seconds is up. Sorry. But 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 at Columbia, that there's actually a lack of clinical training material, just that there's not specialty services. That there's not specialty services. And then the general services, the leadership doesn't feel comfortable managing addiction cases. And then 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 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 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, it's OK to start treatment. And if 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? In some of my training sites, well. But 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 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 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 person. Excellent. Thank you. What about this group back here? 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. 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. And that's one of the problems in some of the centers where there isn't that access where the residents are getting just what Dr. Renner was describing, the absolutely core necessity of residents to be exposed to change over time to demonstrate that addictions are treatable illness. Absolutely. Thank you. Let's move on to the next group. OK. So I think we just had a nice discussion. We're all, the three of us, 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, the 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. 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. It's actually very similar to what 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. Yes. 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. And what did you want to add? 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 to our distinguished panelists here. Yes, microphone. 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 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? 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, though, also bring up an important point about, I mean, how do we track outcomes? I will say Alona has 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 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 and 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 going to 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. This is very, so I'm a psychiatry resident, Marcus Ricari, I'm a PGI 3 at Beth Israel in Boston. So yeah, I guess I was wondering, because I was wondering, could you foresee a future in which there is no dual diagnosis or co-occurring clinic separate from a general psychiatry clinic? And because I think a lot of my co-residents, so I'm one of the few residents really interested in addiction. But a lot of my co-residents also want to know how to manage it independently, but not necessarily 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 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 or 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. I will just briefly add that, I don't know if this is still the case, but when I was in residency at Boston University, aside from the clinic Dr. Renner described, we actually had a clinic right at BMC as well. And there, it was called at that time the Behavioral Health Clinic. 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. Others did suboxone. It just kind of depended on the situation. And so I think it's certainly possible, because that wasn't known as a substance use clinic. It was just the clinic, right? And so people were treated for whatever ailed them. We actually did a survey two years after you finished, six-month period, 41,000 unique patients, seeing 40% of them had dual-infections. Well, there you go. I will just say that every outpatient clinic is actually a co-occurring disorders clinic, either you know it or not, OK? So let's get that out the way, OK? 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 months ago. Wonderful. In the addiction, 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 a longitudinal clinic, but six months is better than nothing. And so far, it 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 all have my email. I just tell them, if you have any questions, where you don't feel comfortable doing something, my phone is glued to my hand. I am 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. Any last burning? Rick, did you have a question earlier? Let me just throw it back to you guys. On your slide, and this goes back to the general clinic again, what you had was competing clinical, what was the last word? Like competing clinical priorities. Yeah, priorities. That was the right word. And I went to, well, what does that mean? Let's translate that in terms of the functionality of what's going on in the clinic. That's like, oh, well, we're treating major depression, and your patient has really terrible alcohol use disorder. Let's treat the depression. So that's not really competing. That's excluding. That's bad medicine. And that, to me, it's begging the question, how do we reduce the fear? And obviously, one part of it is reducing ignorance. We know that. We've been trying to do all the training all this time. But really, how do we reduce that siloing inertia to that? Like, well, no, this is what we do here, and that's this other stuff. 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 paradigm shift. It starts from the very bottom. 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 doing doing it. Yeah, but they do it, but how do they do it? And what do they do with the information that they get? It's a requirement. I would be very happy if people just started 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 where nothing is working. 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 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, 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. That's been a challenge we've faced is that you're usually kind of, it's more common to be required for the specialty service. Thank you. Thank you, everybody, for attending.

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