Medical education in alcohol and alcohol problems

Eurocare has published an important study of under- and post-graduate medical training in alcohol problems. What emerges is the inadequate preparation doctors throughout Europe receive to deal with the results of alcohol abuse. More encouragingly, the experts from a wide range of European countries agree on a series of measures which need to be put in place to remedy the situation.

One of the contributers from the United Kingdom is Professor Brian McAvoy, of the Department of Primary care at Newcastle University Medical School. He writes:

UK primary care perspective

Overview of Educational Programmes

In the UK there has been no centrally funded approach to improve medical education in alcohol problems, unlike in the United States and Australia. Consequently education and training are fragmented and unco-ordinated at all stages of a doctor's career - undergraduate, postgraduate and continuing medical education (CME). Nationally there is no standardised system for the education and training of general practitioners in relation to prevention, early detection and management of alcohol problems.

Undergraduate

Paton's questionnaire survey of 26 Medical Schools in 1984 revealed that they all arranged some formal teaching in alcohol but only one used a multidisciplinary approach; one had a regular seminar (run by the Medical Council on Alcoholism) and one had three formal sessions. The rest relied on an ad hoc approach by psychiatrists, physicians, pharmacologists, general practitioners and pathologists. Only occasionally were casualty officers, behavioural scientists or psychologists involved.

Crome's questionnaire survey in 1987 involved 13 separate departments in 26 Medical Schools. Of the 70 per cent respondents, 54 per cent provided formal teaching (lectures, seminars, symposia). The average time devoted to substance abuse teaching was 14 hours over 5 years, with an average of 6 hours being spent on alcohol - equivalent to 1 minute per week over the entire period of training. Only 21 per cent of clinical and non-clinical departments ensured that students were examined on the topic. Appeals have been made for a flexible 'core' curriculum or a set of guidelines ,increasing the emphasis on the importance of alcohol teaching at every opportune stage in the undergraduate experience and integrating such teaching through the curriculum.

It has also been suggested that each Medical School should make a designated teacher responsible for developing integrated teaching in alcohol and that one department, for example general practice, community and family medicine, psychiatry or public health, should take lead responsibility for organising systematic coverage.

Postgraduate

Once again, training and education are fragmented and limited. The various Royal Colleges have produced reports acknowledging the importance of alcohol abuse but it has been reported that a vice-president of the Royal College of Physicians had stated that 'alcohol is not specifically mentioned in any of the specialty training programmes'. A Diploma in Addiction Behaviour has been developed in London with the aim of 'training the trainers'. Training and education in relation to prevention, early detection and management of alcohol problems in general practice undoubtedly occurs during the 3 year vocational training period but the nature, amount and timing of this are determined by individual course organisers and trainers.

All the Royal Colleges have been urged to recognise the need to integrate relevant information, skills and assessment into postgraduate courses and examinations.

Continuing Medical Education

As is the case with earlier career experiences, training and education for established practitioners is ad hoc and fragmented. Anderson's questionnaire study of GPs in Oxfordshire and Berkshire in 1984 found that 66 per cent of respondents reported less than 4 hours total postgraduate training, or clinical supervision on alcohol. A similar study of GPs in Leicestershire, Derbyshire and Nottinghamshire in 1995 showed that this figure had dropped to 42 per cent - still a significant proportion.

The postgraduate education allowance (PGEA) is the principal component of CME for general practitioners but much of the educational activity is 'didactic, uni-profession and top-down' and shows little evidence of 'any convincing benefits for patient care'. The system allows doctors to play to their strengths rather than identify true educational needs, and is therefore unlikely to facilitate improved training and education on alcohol. The recently published Chief Medical Officer's review of continuing professional development in practice suggests a radical alternative to PGEA - Practice Professional Development Plans (PPDP). These would 'integrate and improve the educational process, developing the concept of the 'whole practice' as a human resource for health care, resembling the health promotion plan in general practice and increasing involvement in the quality development of practices'.

Effective Educational Programmes

There is no shortage of educational materials. The Medical Council on Alcoholism (MCA) is an independent organisation and registered charity which encourages health professionals to identify drinking problems among their patients, and to offer treatment and support.

The MCA organises educational events for student and postgraduate participants, publishes Alcohol and Alcoholism: the International Journal of the MCA, Alcoholism, a quarterly newsletter, and alcohol abuse detection leaflets and drinking diaries designed for use by general practitioners. The MCA has produced a list of 8 learning objectives for medical undergraduates, covering the following areas:

• Alcohol

• Alcohol and the individual

• Cost of alcohol misuse

• Clinical problems

• Psychiatric implication

• Identification and recognition

• Management

• Policies

It also distributes Alcohol and Health. A Handbook for Medical Students to all UK undergraduates and Hazardous Drinking. A Handbook for General Practitioners.

Alcohol Concern, the national agency on alcohol misuse, has produced a National Alcohol Training Strategy for all staff who work with people with alcohol problems. In a joint project involving the Standing Conference on Drug Abuse (SCODA) and Alcohol Concern, the Quality in Alcohol and Drugs Services (QUADS) group has produced a draft quality standards manual for alcohol and drug treatment services. The National Alcohol Training Forum, established by Alcohol Concern, has produced Talking it Through - a national vocational training pack for alcohol counsellor training.

In addition there are generic training packs such as Helping People Change (Health Education Authority) and Skills for Change (World Health Organization).

Finally, the UK Alcohol Forum has recently published Guidelines for the Management of Alcohol Problems in Primary Care and General Psychiatry.

In his review of the rôle and effectiveness of medical education in alcohol, Walsh concluded that 'with a few exceptions, such as the emphasis on feedback training in skill development, most recommendations about alcohol medical education reflect the findings of process evaluations and/or educator opinion. They are not sufficiently informed by theory or based on studies with rigorous methodologies'.Furthermore it is clear that the education of health care providers will require a complex set of responses. Traditional and limited 'educational' responses will not, of themselves, suffice.

Conclusion

Although there is no standardised system for the education and training of primary care workers in relation to prevention, early detection and management of alcohol problems, there are well established educational and training models and materials and explicit competencies and training recommendations available. The proposed changes in the NHS and the review of continuing professional development in general practice offer a unique window of opportunity for advancing this agenda in UK primary care.

"Just too busy"

Since Professor McAvoy wrote his contribution the situation has deteriorated as general practitioners find it increasingly difficult to meet the demands put on them as a result of alcohol abuse. His colleague, Dr Eileen Kaner, and a team of researchers, including Professor McAvoy, from the Department of Primary Health Care at Newcastle University Medical School have produced a study* on behalf of the World Health Organization (WHO) as part of a survey of alcohol problems in 14 countries.

It is estimated that 20 per cent of the workload of GPs arises from the effects of heavy drinking. This is, of course, compounded by the problems which arise from the fact that alcohol abuse creates medical problems for family members. Despite these figures new research shows that GPs feel less confident and less motivated to work with problem drinkers than they did ten years ago.

279 GPs in the East Midlands were interviewed by the researchers and it emerged that only one fifth had any confidence that they could help heavy drinkers reduce their alcohol consumption. Fifty-eight per cent said they could be more effective if given better training and more government support.

72 per cent of the doctors questioned agreed that they were "just too busy dealing with the problems people present with" to use brief alcohol intervention. Of the 14 countries in the WHO study, which included Canada, New Zealand, Thailand and Australia, the UK was second only to Hungary for GP workload. "This means their consultation time is very brief, often about five minutes only," said Dr Eileen Kaner, one of the researchers from the medical school at Newcastle University. She added that they felt they only had time to deal with immediate symptoms rather than underlying causes. However, Dr Kaner said that effective intervention could cut their workload since problem drinkers were twice as likely as others to present repeatedly with a variety of health problems, ranging from accidental injury to gastro-intestinal complications.

"If GPs had more training they could identify the underlying problems better," said Dr Kaner. She added that GPs were given "minimal" training about alcohol abuse at both undergraduate and postgraduate level, although its consequences made up a fifth of their workload.

A brief alcohol intervention programme, which takes only a few minutes, has been developed by the WHO and was introduced to the sample group of GPs by Dr Kaner and her fellow researchers. According to Dr Kaner, the programme can help a third of problem drinkers reduce their alcohol intake by a quarter and bring many back to below the danger level. 80 per cent of the doctors surveyed acknowledged that "early intervention for alcohol was proven to be successful."

The programme involves acknowledging the benefits of alcohol consumption, such as increased sociability, reinforcing safe levels of drinking and identifying problems linked to drinking. As such, of course, its usefulness in the recovery of chronically dependent drinkers is limited and many addiction therapists would argue that a discussion of "benefits" could be counter-productive. However, brief interventions are intended primarily for those "patients identified by screening as drinking above medically recommended levels but with mild or no dependence on alcohol."

Patients are also shown a graph of alcohol consumption in the UK and their place on it. "It may set them thinking. We also give useful tips for cutting down such as eating before going out and not drinking alcohol when you are thirsty," said Dr Kaner.

The researchers also provide telephone support for GPs using the brief intervention approach. Their study found 60 per cent would be more involved in treating heavy drinkers were more support provided. Part of the problem, said Dr Kaner, was that many alcohol referral services had been cut.

* Intervention for excessive alcohol consumption in primary health care: attitudes and practices of English general practitioners, Dr Eilenn Kaner et al., Alcohol and Alcoholism, Vol. 34, No. 4, 1999.