Conclusions

Medical Student Training:

Medical students are eager to learn alcohol screening and brief intervention skills, but training time is scarce, and change in medical school curriculum is needed in order to "institutionalize" this training. Our experience was that this curriculum change is slow, given other "competition" for curriculum space from a multitude of other medical issues

Training Residents:

Training of residents in brief alcohol screening and intervention is feasible and well-received, although training time is difficult to obtain. Although data from this project show that residents will slightly increase their screening and brief intervention activity as a result of training, these increases are probably not enough to significantly affect the alcohol and drunk driving problems. Because residents do not systematically screen all of their patients, they become overly focused on "end-stage," obvious alcoholics, to the exclusion of alcohol abusers who might respond best to their brief interventions. Ultimately, system-level changes are needed so that providers will be reimbursed for performing behavior change interventions. When reimbursement patterns change, medical training priorities will follow.

Medical School Curriculum:

Given its magnitude of impact on the morbidity and mortality of patients, substance abuse is underrepresented within the University of Washington�s School of Medicine curriculum.

In order to "institutionalize" substance abuse training, "champions" (permanent faculty members who are committed to addressing and teaching substance abuse) are needed.

We believe that our approach of assessing the University of Washington curriculum�s substance abuse content and presenting the results in comparison to the NIAAA�s curriculum standards may be one effective approach, as long as this information reaches the Dean�s attention. In our case, the resulting changes have been incremental, not quantum in nature.

Substance abuse medical training demands continuity across both years of training and across clinical settings in which medical training happens. For this reason, we believe that a "theme approach" holds the most promise. Under a "theme approach," substance abuse is seen not as a curriculum topic but as a common theme appearing throughout medical school, in all courses taken and in all clinical settings. The theme is that substance abuse affects a large proportion of patients in all medical populations and that it can and should be addressed in all medical settings. If substance abuse is taught across all medical settings, future physicians in all medical specialties are most likely to address it during their careers.

Continuing Medical Education:

Brief alcohol interventions is a difficult topic to "sell" to the directors of continuing medical education, and physicians in practice show little interest in learning more about it. If reimbursement patterns change, physicians are more apt to address alcohol problems among their patients.

Barriers to implementing screening and intervention in trauma centers:

Physicians� concerns that screening for alcohol abuse may result in denial of coverage of care by the insurance companies appear to be based on firm reality as codified in the statutes of most states.

12 states have not adopted the model law giving insurers statutory authority to exclude coverage for injuries due to alcohol use.

Connecticut now requires acute care hospitals to include in the record of each trauma patient a notation about the extent and outcome of alcohol screening. This must be spread into other states.

Information about alcohol screening should be kept in separate parts of the medical record, to which access is restricted.

Current hospital "consent to care" forms could be changed to not give blanket permission to release information to outside agencies such as insurance companies.