Education/Original ContributionImproving emergency medicine residents' approach to patients with alcohol problems: A controlled educational trial*,☆☆
Introduction
Alcohol problems are a leading cause of preventable illness and injury1 and represent a substantial portion of the 95 million emergency department visits each year.2 Recent evidence has demonstrated the efficacy of early intervention for patients with alcohol problems.3, 4 These studies have been performed in a variety of settings including primary care,5, 6 inpatient trauma centers,7 and EDs.8, 9, 10
The ED visit has also been shown to be a “teachable moment”11 and represents an ideal opportunity for screening and brief intervention.12, 13 Despite this knowledge, few emergency physicians incorporate routine screening, intervention, and referral into their practice.14, 15 Barriers to screening and intervention have been described and include physician characteristics such as education, attitudes and beliefs, perceptions of role responsibility, and confidence (self-efficacy).16, 17
Recently, attention has focused on the development of trained faculty and curricula in medical schools and graduate medical training programs.17 Federal programs such as the Substance Abuse and Mental Heath Services Administration's Faculty Development Program grants were established to meet this need. These grants helped to develop faculty with expertise in alcohol-related issues. Although the program focused on a broad scope of medical, nursing, and social work school educators, it was small, and its ability to trigger widespread change among emergency medicine faculty was very limited. Achieving progress toward the training of emergency medicine physicians in this realm requires medical educators to devote precious training time to screening and intervention for alcohol problems in the ED setting. Standard didactic educational programs have not been shown to effectively change physician behavior and subsequently improve patient outcome.18 There is evidence that skills-based interactive sessions can change practice.19, 20 This support, however, is methodologically limited because it is based on observational studies without adequate controls.
We hypothesized that training using a structured skills-based intervention would improve emergency medicine residents' knowledge and performance in screening and intervening with patients presenting to the ED with alcohol problems. To test this hypothesis, we developed a skills-based educational intervention and tested it in a controlled trial among emergency medicine residents. We also assessed whether emergency medicine residents' attitudes and beliefs, perceptions of role responsibility, and self-efficacy influenced their knowledge and performance.
Section snippets
Materials and methods
First- and second-year emergency medicine residents from Yale University and Harvard University participated. Both programs were similar in that they were new, 4-year programs with only 2 years of residents at the time of the study. The primary site hospitals were similar, urban, university, Level I trauma centers. The study was reviewed by the Human Investigation Committee and determined to be exempt from review under federal regulations.
Residents at Yale University received a 4-hour
Results
Seventeen residents comprised the intervention group, and 19 comprised the control group. Table 1 describes general characteristics, past alcohol education, and perceived clinical experience.Characteristic Intervention (n=17) Control (n=19) Difference (95% CI) Demographics Age, y, mean (SD) 30.2 (3.4) 30.4 (2.7) −0.2 (−2.3 to 1.9) Male sex, % 64.71 78.95 −14.2 (−43.4 to 15.0) Race/ethnicity, % White 76.47 89.47 −13.0 (−37.4 to 11.4) Asian 17.65 10.53 7.1 (−15.7 to 29.9) Other 5.88 0 5.9 (−5.3
Discussion
Multiple consensus statements have been issued recommending that physicians routinely perform screening and brief intervention with their patients, including the reports of the Institute of Medicine in 199029 and the US Preventive Services Task Force in 1997.30 National organizations such as the NIAAA31 and the American Medical Association32 have also made specific recommendations. Regardless of these efforts, most physicians do not conform to formal practice guidelines, including using
Acknowledgements
We thank Rebecca Mascia, BS, for assisting with data collection and Tara Tripp, MA, for statistical programming.
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Supported by grants #T15 SP07773 and #T26 SP08355 from the Center of Substance Abuse Prevention Faculty Development Program, Substance Abuse Mental Health Services Administration, US Department of Health and Human Services, Washington, DC (Dr. D'Onofrio and Dr. Samet).
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Address for reprints: Gail D'Onofrio, MD, MS, Section of Emergency Medicine, Yale University School of Medicine, 464 Congress Avenue, Suite 260, New Haven, CT 06519; 203-785-4363, fax 203-785-4580; E-mail [email protected]