SBIRT Education for Both the Mind and the Heart? Assessing Changes in Medical Residents’ Attitudes to

Working with DrinkersMichael A. Mitchell, MA

VA Pittsburgh’s Interdisciplinary Program for Addiction Education and Research (“VIPER”)

VA Pittsburgh Healthcare System, Pittsburgh, PA

Broyles, L.M, Pringle, J.L., Kraemer, K.L., Childers, J.W., Buranosky, R.A., & Gordon, A.J.

Disclaimer• The views expressed in this presentation are those of the

authors and do not necessary reflect the position or policy of the Department of Veterans Affairs or the United States government.

Acknowledgements• Funding• SAMHSA/CSAT• This material is based upon work supported by the Office of

Academic Affiliations (Mitchell), Health Services Research and Development (Broyles, CDA 10-014) and with resources and the use of facilities at VA Pittsburgh Healthcare System.

• Authors have no conflict of interest to disclose.

“Knowledge without love will not stick. But if love comes first, knowledge is sure to follow.”

- John Burroughs

Background• Increased focus on developing and implementing SBIRT

training for medical residents and other health professionals• SAMHSA grant funding (n=17, 2008-2014)• Training characteristics include didactic, web-based,

experiential• Physicians’ attitudes play a role with inconsistent identification

and management with patients in primary care

Miller, N. S., Sheppard, L. M., Colenda, C. C., & Magen, J. (2001). Why physicians are unprepared to treat patients who have alcohol and drug related disorders. ‐ ‐ Academic Medicine, 76(5), 410-418.

Overview SBIRT Training Programs, Evaluation Strategy

• Majority appear to focus on addressing knowledge (cognitive) and skills (behavioral) elements of professional readiness

• Cognitive elements may be easier to change than emotional-laden elements

• Limited use of theory or conceptual frameworks in design, implementation and evaluation

El Guebaly, N., Toews, J., Lockyer, J., Armstrong, S., & Hodgins, D. (2000). Medical education in substance related disorders: ‐ ‐components and outcome. Addiction, 95(6), 949-957.

BASIC ROLE REQUIREMENTS

ROLE SECURITY

THERAPEUTIC COMMITMENT

Training• Knowledge• Skill

Support

Experience

Self-esteem

Role Adequacy

Role Legitimacy

Willingness

Satisfaction

Task-Specific Self-Esteem

Conceptual Framework for Professional Readiness to Work with Drinkers

Shaw, S. J., Cartwright, A. K. J., Spratley, T. A., & Harwin, J. (1978). Responding to drinking problems. Croom Helm Ltd., 2-10 St. John's Road, London SW11..

Gorman, D. M., & Cartwright, A. K. J. (1991). Implications of using the composite and short versions of the Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ). British journal of addiction, 86(3), 327-334.

Pennsylvania’s SBIRT Medical Residency Training Program• Program began November 2008• Multiple hospital systems• University of Pittsburgh Medical Center• Albert Einstein Medical Center• Williamsport Hospital and Medical Center• Forbes Regional Hospital

• Various medical sub-specialties• Resident curriculum • Basic SBIRT knowledge and skills (5 modules, learning objectives)• Knowledge on SBIRT applications in special settings, populations• Didactic, experiential, and web-based educational activities

Pringle, J. L., Melczak, M., Johnjulio, W., Campopiano, M., Gordon, A. J., & Costlow, M. (2012). Pennsylvania SBIRT Medical and Residency Training: Developing, Implementing, and Evaluating an Evidenced-Based Program. Substance Abuse, 33(3), 292-297.

Purpose• To assess changes in six components of professional readiness

for working with drinkers among internal medicine residents attending the SMaRT training program

Design and Methods• Pre-post test survey design• Administered pre-survey beginning residency year (July/August)• Participated in SMaRT training program• Administered post-survey end medical residency year (May/June)

• 80 Internal Medicine Residents, University of Pittsburgh

Professional Readiness Working with Drinkers

Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ)

• 7-point Likert scale (Strongly disagree Strongly agree)Domain Brief Definition

Role Adequacy Knowledge, Skills

Role Legitimacy Right

Role Support Professional support

Motivation Willingness

Task-Specific Self-Esteem Self-esteem

Satisfaction Work satisfaction

Anderson, P., & Clement, S. (1987). The AAPPQ revisited: the measurement of general practitioners' attitudes to alcohol problems. British Journal of Addiction, 82(7), 753-759

Analysis• Descriptive statistics• Wilcoxon Signed-Rank• Changes in AAPPQ six domains pre/post

Sample CharacteristicsDemographics (n=80)

Female 52%Age, mean (SD) 27 (1.8)

Race/ethnicityBlack/African-American 5%White/Caucasian 72%Asian/Asian-American 22%Bi-/Multi-racial 1%Not-Hispanic/Latino 97%

Training, Internal Medicine 100%Year, PGY-1 100%

Changes in Internal Medicine Residents’ Attitudes Pre/Post SMaRT Training

0

5

10

15

20

25

30

35

40

45

50

34

23

16

26

31

24

39.5

24

18

26

31

23 PrePost

* p-value < .05 (n = 80)

AAPP

Q S

umm

ary

Sub-

Scal

e Sc

ores

AAPPQ Sub-scales

Discussion• Training effective increasing Role Adequacy and Role Support• Education may have not meet needs for related to Motivation,

Task-Specific Self-Esteem, or Satisfaction• Alternatively, may have distilled sense of increased awareness

and appreciation for specialized care• Attitudinal factors may play a substantial role in sustained

practice change

“Knowledge without love will not stick. But if love comes first, knowledge is sure to follow.”

- John Burroughs

Future Implications• Future SBIRT training should consider strategies designed

explicitly to target intrinsic aspects, e.g. reflective activities• Incorporate diverse pedagogical and behavior change theories• Adult Education (Transformative learning)• Social Psychology (Theory of Planned Behavior, Prototype-

Willingness Model)• Humanities (Self-reflection, Narrative, Humanistic Medicine)

Contact Information

Michael A. Mitchell, MAMichael.mitchell10@va.govInterdisciplinary Program Addictions Education and ResearchCenter for Health Equity Research & PromotionVISN4 Mental Illness Research Education and Clinical Center VA Pittsburgh Healthcare SystemUniversity Drive (151C), Building 30, 2nd FloorPittsburgh, PA 15240412-360-2139

Transformative Learning

• Fundamental change in perspective, frame of reference• Mezirow’s 10 ordered phases for transformative learning

1) Experiencing a disorienting dilemma2) Undergoing self-examination3) Conducting a critical assessment of internalized assumptions4) Relating discontent to similar experiences of others5) Exploring options for new ways of acting6) Building competence, self-confidence7) Planning course of action8) Acquiring knowledge, skills for new course of action9) Trying out new roles, assessing them10) Reintegrating into society with other perspective

Cranton, P. (1994). Understanding and Promoting Transformative Learning: A Guide for Educators of Adults. Jossey-Bass Higher and Adult Education Series. Jossey-Bass, 350 Sansome Street, San Francisco, CA 94104-1310.

AAPPQ Sub-Scales, ExamplesRole Adequacy• “I feel I have a working knowledge of alcohol and alcohol-related problems”• “I feel I can appropriate advise my patients about drinking and its effects”

Role Legitimacy• “I feel I have the right to ask patients questions about their drinking when necessary”

Role Support• “If I felt the need I could easily find someone who would be able to help me formulate

the best approach to a drinker”Motivation• “I want to work with drinkers”• “I feel that there is little I can do to help drinkers”*

Task Specific Self-Esteem• “I feel I do not have much to be proud of when working with drinkers”*• “On the whole, I am satisfied with the way I work with drinkers”

Work Satisfaction• “I often feel uncomfortable when working with drinkers”*• “In general, it is rewarding to work with drinkers”

* Reverse scored