In the United States in 2016, an estimated 20.1 million people aged 12 or older had a substance use disorder (SUD).1 The opioid crisis, with more than 42,000 overdose deaths in 2016, has received a significant amount of national attention.2,3 Despite the evidence of need reflected in morbidity and mortality, individuals with SUDs often encounter inadequate health care.4–6 Deficiencies include scarcity of addiction-trained clinicians, stigma, and health professionals’ inadequate knowledge of treatment options. Insufficient inclusion of SUDs in the curricula of health professions programs contributes to these problems.7–10
Health professions educational organizations recognize these curricular deficiencies and support improvements in SUD education.11 For example, U.S. medical schools have made curricular revisions to prepare future physicians for the opioid crisis. However, the majority of learning relies on passive transmission of knowledge to students through lectures and assessments of competencies by using written examinations.12 A systematic review of undergraduate medical education on substance abuse found that none of the 31 studies included in the review described educational outcomes beyond learner satisfaction or self-declared efficacy; no outcomes were reported reflecting learner behaviors or patient or health care outcomes.13 A systematic review of the curricula for behavior change counseling for medical trainees revealed similar gaps.14
Effectively preparing future health care providers capable of addressing the health care needs of patients with SUDs requires education that is evidence based, interprofessional, and experiential; that addresses stigma; and that is oriented to patients’ complex medical, social, and psychological needs.9,10,15,16 Education should not only focus on teaching students the basic science of addiction but also involve them in active reflection and discussion, challenge their existing beliefs, expose them to the struggles and successes of patients with SUDs, and model compassionate care.4,8,10,17–19 Students must also be given structured opportunities to practice counseling techniques, such as behavior change counseling.20 Behavior change counseling was developed on the foundation of motivational interviewing to create a patient-focused counseling process for practitioners, facilitating communication in a supportive, nonjudgmental manner.21
A course addressing students’ knowledge, attitudes, and behaviors requires an educational framework, such as Mezirow’s transformative learning theory, that intentionally engages them in learning, discussion, deliberate practice, and critical reflection.22 Mezirow’s theory uses a multistep process to enhance students’ ways of thinking, stimulating their ability to view and examine the world from new perspectives.
The purpose of this course was to provide students with opportunities to (1) improve their understanding of SUDs; (2) assess, challenge, and reflect on their attitudes toward patients with SUDs; (3) develop skills in patient communication; (4) receive direct observation, assessment, and feedback on behavior change counseling; and (5) learn with, about, and from other students and clinicians. The purpose of this study was to evaluate the impact of an interprofessional SUD course on students’ educational outcomes (including attitudes, behaviors, and decisions about patients’ treatment) and their attitudes toward interprofessionalism.
We developed our course using Mezirow’s transformative learning theory. Transformative learning theory centers around discourse and reflection, promotes knowledge construction, provides opportunities for application and experimentation with new roles, and broadens individuals’ existing views.22 By using this theory as a framework, we were guided in creating active learning exercises to encourage students’ engagement and interactions and the development of their learning and perspectives. Using Mezirow’s theory also enabled us to support the extension of students’ learning to a clinical setting, where students worked with patients with SUDs through behavior change counseling. This patient interaction allowed students to learn about their patients’ stories.
Reflecting on our past experiences with SUD education,23–25 we aimed for 3 thematic improvements: increase the representation of health professions students and health professionals who work with patients with SUDs; include more student-led, faculty-facilitated learning; and enhance the connection between classroom learning and patient care in the clinical setting.
To realize our thematic improvements, we intentionally included (1) nursing students and a nurse lecturer; (2) active learning opportunities; (3) class time for students to share their personal and professional stories and to learn from, with, and about one another; (4) student role-playing and faculty role-modeling; (5) patient cases and collaborative care questions to stimulate students’ discussions; (6) surveys to capture students’ growth; and (7) structured opportunities for students to connect learning to patient care experiences.
Description of SUD course
Study authors A.M., P.M., K.M.A., A.D., C.S., and S.H., all of whom hold faculty appointments within a health professions program, developed the course design. Starting in spring 2018, health professions students completing a 1-month psychiatry clerkship within the Duke University Health System participated in our course. Students represented medicine, physician assistant, pharmacy, social work, and the accelerated bachelor of science in nursing programs. Though they were in different academic years within their respective programs, all students had completed 1 year of preclinical course work.
We offered 5 sessions of the course: A new course started every month for 5 months with approximately 15 health professions students in each cohort. Students participated in 4 in-person, interactive class sessions focused on SUDs for 6 hours of class time each month, and they attended a 12-step recovery meeting and wrote a short reflection paper on their experience. Class topics included (1) developing empathy and recognizing personal bias; (2) behavior change counseling; and (3) recognition, screening, and treatment of patients with SUDs. Following these class sessions, students were given the option to counsel a patient with an SUD in the inpatient clinical setting using behavior change counseling.
An interprofessional group of faculty (S.H., C.S., and A.M.) taught the classes. Two faculty members (S.H. and C.S.) representing different health professions taught 3 of the 4 classes, modeling an interprofessional approach. All class sessions used active learning, including Socratic questioning, role-playing, case-based learning, and small- and large-group discussions. We created therapeutic cases from numerous sources including MedEdPORTAL, relevant textbooks and articles, and our own clinical experience. Table 1 contains a detailed description of the class sessions and the behavior change counseling experience.
Toward the end of their clerkships, students assessed their attitudes toward individuals with SUDs on the Substance Abuse Attitude Survey (SAAS)26 and their attitudes toward interprofessionalism on the Student Perceptions of Interprofessional Clinical Education—Revised 2 (SPICE-R2).27 For students’ self-assessment of learning, we used a retrospective pre–post approach, in which, for each survey question, students first characterized their current attitude and then reflected on their attitude before starting the course.28 We used the Behavior Change Counseling Index (BECCI) to assess students’ patient counseling skills.21
We selected these assessments to promote student reflection and to evaluate the impact of the course, including content-specific and transformative learning measures. The assessments are theoretically informed, are aligned with our study objectives, and possess validity evidence.
The SAAS assessment scale has 5 domains comprising 25 questions with 5-point Likert-type responses (ranging from 1 = strongly disagree to 5 = strongly agree).26 The 5 domains are permissiveness, nonstereotyping, treatment intervention, treatment optimism, and nonmoralism.
The SPICE-R2 assessment scale has 3 domains comprising 10 questions. The 3 domains are interprofessional teamwork and team-based practice, roles/responsibilities for collaborative practice, and patient outcomes from collaborative practice.27 The 10 questions on the SPICE-R2 have Likert-type responses ranging from 1 = strongly disagree to 5 = strongly agree.
The BECCI instrument scores a practitioner’s competency in using behavior change patient counseling.29 The 11-item BECCI scale has Likert-type responses ranging from 0 = not at all to 4 = a great extent. An additional question asks the observer to rate the approximate amount of time the practitioner speaks during the counseling as “more than half the time,” “about half the time,” and “less than half the time.”
Students voluntarily completed the SAAS and SPICE-R2 surveys online. The surveys have instructions directing students to first assess their current attitudes (postcourse) and then to reflect on their attitudes at the beginning of the course (precourse). Study author C.S. completed the BECCI survey online.
The Duke Office of Clinical Research managed the surveys using REDCap, which is a secure web-based application.30 A consent form that included the following statement accompanied the surveys: “Completion of the survey indicates implied consent to participate. Your participation is voluntary. If you wish to decline, simply do not fill in the survey.” Students received no incentive for completing the surveys, and the course director who determined their grade was not aware of students’ completion of surveys.
The Duke Office of Clinical Research served as an honest broker for the project, protecting and maintaining the integrity of collected data. The Duke Department of Biostatistics and Bioinformatics provided statistical support. The statistician deidentified access to the REDCap data export, which prevented any fields marked as identifying from being exported. The Duke University institutional review board determined that the project was exempted educational research.
The analysis of the primary outcome was a comparison of students’ individual SAAS scores pre to post survey. The analysis of the main secondary outcome was a comparison of students’ individual SPICE-R2 scores pre to post survey. Additional outcome analyses included the following: (1) comparison of medical and nonmedical students’ score changes on the SAAS and SPICE-R2 surveys, (2) description of BECCI scores, (3) comparison of medical and nonmedical students’ BECCI scores, and (4) description of patients’ willingness to accept treatment following behavior change counseling.
Descriptive statistics were presented for the SAAS, SPICE-R2, and BECCI survey scores using the mean, SD, median, and 25th and 75th percentiles. The mean difference (post − pre) was evaluated for the SAAS and SPICE-R2 surveys by using a paired t test and by computing the effect size for each score of interest. The effect size was computed as the mean difference divided by the SD of the differences. A Student t test with equal variance assumed was used to compare the survey scores between medical and nonmedical students.
Categorical data are presented using counts with percentages for nonmissing data. Comparison between medical and nonmedical groups was done using the chi-square or Fisher exact test (expected cell counts < 5) to test the null hypothesis that the proportions within each group were equal. All analyses were done using SAS version 9.4 (SAS Institute Inc., Cary, North Carolina), and a P value < .05 was considered statistically significant unless otherwise indicated.
Seventy-eight students completed the course over the 5-month study period. Sixty-two students completed at least the demographic and SAAS survey portions (response rate of 79%). One student completed the demographic and SAAS survey portions but did not complete the SPICE-R2 survey portion. The 62 students comprised 34 medical (55%) and 28 nonmedical (45%) students. Of the 28 nonmedical students, 14 were in the accelerated bachelor of science in nursing program, 11 were in the pharmacy program, 2 were in the physician assistant program, and 1 was in the social work program.
Table 2 presents the SAAS survey results. The total survey score and individual domain scores for nonmoralizing, treatment optimism, treatment intervention, and nonstereotyping demonstrate that the students’ attitudes toward patients with SUDs had improved significantly (all P < .01). Effect sizes across the total score and these 4 domains were positive and moderate (ranging from 0.49 to 0.67). The permissiveness domain did not demonstrate a significant change (P = .11). Examination of change in SAAS scores by separate student groupings—medical and nonmedical students—revealed that each student grouping had significant changes on total survey scores and on scores for the nonmoralizing, treatment optimism, treatment intervention, and nonstereotyping domains. We found no significant differences between the SAAS total scores or individual domain scores for medical and nonmedical students.
Table 3 displays the SPICE-R2 survey results. The total survey score and individual domain scores for interprofessional teamwork and team-based practice, roles/responsibilities for collaborative practice, and patient outcomes from collaborative practice demonstrate significant improvement in students’ attitudes toward interprofessionalism (all P < .01). Effect sizes for the total score and domains were positive and moderate (ranging from 0.36 to 0.72). We found no significant differences between the mean change in SPICE-R2 total score or individual domain scores for medical and nonmedical students.
Table 4 contains the results from the BECCI survey. Fifty-three of the 78 students completing the course (68%)—25 medical and 28 nonmedical—performed behavior change counseling with a patient with an SUD. Counseled patients were mainly between the ages of 18 and 49 and either Caucasian or African American. Forty of the 53 counseled patients (76%) reported a tobacco (n = 15; 28%), alcohol (n = 19; 36%), or opioid (n = 6; 11%) use disorder.
In comparing the individual BECCI questions and total BECCI scores for medical and nonmedical students, we found that only 2 questions reported a statistically significant difference, and both favored medical students. These were “asks questions to elicit how patient thinks and feels about the topic” (P < .01) and “uses empathetic listening statements when the patient talks about the topic” (P < .01).
Table 5 reports patients’ treatment decisions. Forty-one (77%) of the 53 counseled patients answered the survey question regarding treatment follow-up. Thirty-eight (93%) of these 41 patients indicated that they were willing to have follow-up care for their SUDs. There were no differences in patients’ treatment decisions based on their SUD.
We developed an SUD course that brought together students and faculty from different health professions programs, engaged students in their learning, explored their beliefs about SUDs and health care roles, and extended learning to the clinical setting. In doing so, we developed a course that directly responds to the need for interprofessional education that can prepare students for collaborative care31,32 and for health professions education that can achieve educational outcomes affecting students’ behaviors and patients’ care.33,34 Students’ understanding, attitudes and behaviors toward patients with SUDs and their attitudes toward interprofessionalism were enriched by our intentional course design, which continuously involved students in active learning with faculty facilitation. Students performed behavior change counseling in the clinical setting, and over 90% of counseled patients expressed a willingness for follow-up care. Our course findings demonstrate how to advance students’ learning to a higher level: from personal satisfaction and self-declared learning to changes in the students’ behavior and in patient outcomes.35
We used learnings from a previous iteration of our SUD course23–25 to make the following improvements to the course design used in this study: recruiting additional health professions students and faculty, using different types of active learning exercises, and providing students an opportunity to counsel a patient with an SUD. We observed students and evaluated their patient counseling using an assessment with validity evidence (BECCI), provided them with real-time feedback, and asked patients to indicate their willingness to seek follow-up care.
Mezirow’s transformative learning theory provided a useful framework to build course activities that enabled us to develop a community of students and faculty; create a course ethos in which all students were encouraged to actively participate; expose students to new care roles and perspectives through patient cases, role-play, and role-modeling; and support student–student and student–faculty interaction.
Following discussions on important topics such as stigma, personal bias, benefits of treatment interventions, and involving patients in their care decisions, students demonstrated positive attitudinal changes toward patients with SUDs. Unlike results from our previous course, which only showed that students changed significantly in terms of nonmoralizing, treatment optimism, and treatment intervention,24 results from our current course, indicate significant changes in 4 of the 5 domains on the SAAS survey. We feel that the lack of change in the permissive domain is due to questions in this domain on marijuana use, abstinence as a treatment goal, and the critical role of Alcoholics Anonymous in a person’s recovery. We did not address marijuana use in our course; we did discuss abstinence and Alcoholics Anonymous along with other important recovery treatments.
We created a learning environment where students shared their learning, experiences, beliefs, and personal stories. Students’ growth, both as individuals and as a group, is supported by our findings concerning attitudinal changes toward interprofessionalism. We included students and faculty from different health professions who shared their roles and their perspectives about patient care in classroom discussions. Faculty involved all student voices in discussions and modeled collaborative approaches to patient care. We attribute the significant improvement in students’ attitudes toward interprofessionalism in all domains of assessment (unlike our previous course in which significant improvement was more limited,24 as noted above) to these deliberate course enhancements.
On 10 of the 11 BECCI items and on their total BECCI score, students received ratings of either “to some extent” or “a good deal” that demonstrated their counseling effectiveness. Approximately 93% of patients showed a willingness to pursue follow-up care, indicating that the students’ counseling positively influenced patients’ treatment decisions. We have drawn directions for improvement in future iterations of the course from the BECCI items rating students’ ability to carry out the following actions when counseling a patient: challenge the patient, elicit the patient’s thoughts and feelings, exchange ideas with the patient, and give the patient information that is sensitive about behavior change, which all had median scores of less than or equal to 2. Role-playing counseling scenarios, using standardized patients, and having faculty model clinician–patient behavior change counseling are potential ways to help students learn how to engage patients in dialogue and strengthen their counseling skills.
Limitations of our study include using a single-year student cohort at a single institution; absence of a comparison group; absence of baseline objective measures of students’ knowledge of SUDs or their ability to perform behavior change counseling; and using a single person, one of the authors of this study, to observe students’ behavior change counseling. We did not assess students’ understanding of instructions on how to complete the SAAS and SPICE-R2 surveys using a retrospective pre–post approach. We did not compare this approach with a traditional pre- then postcourse assessment. Of the 78 students who completed the course, 14 (18%) did not initiate our attitudinal surveys and 25 (32%) did not complete behavior change counseling because of logistical issues with their clerkships. Participants did not obtain responses from 12 of the patients (23%) regarding their willingness to pursue follow-up care. We did not review patients’ charts after discharge from the hospital to determine their actual follow-up. Patients did not assess the students’ counseling.
Future goals are to include faculty representing the health professions programs of all the students participating in our course. Additional faculty observers need to be recruited and trained so that all students, regardless of clerkship location and time constraints, will have an opportunity to practice behavior change counseling with a patient in the clinical setting. We will explore ways to further develop the capabilities of health professions students to provide behavior change counseling, including nonmedical students’ skills of eliciting patients’ thoughts and feelings and using empathetic statements. We will invite patients to provide feedback to students, and we will review patients’ follow-up care. We will measure students’ retention of attitudinal improvement and skill development and explore ways to sustain learning and skills developed in our course.
1. Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results From the 2016 National Survey on Drug Use and Health. 2017. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; HHS publication no. SMA 17–5044, NSDUH series H-52. https://www.samhsa.gov/data
. Accessed February 9, 2019.
2. Centers for Disease Control and Prevention. Opioid overdose. https://www.cdc.gov/drugoverdose
. Published October 23,2017. Accessed February 9, 2019.
3. The White House. The opioid crisis. https://www.whitehouse.gov/opioids
. Accessed February 9, 2019.
4. Rasyidi E, Wilkins JN, Danovitch I. Training the next generation of providers in addiction medicine. Psychiatr Clin North Am. 2012;35:461–480.
5. Schottenfeld RS, O’Malley SS. Meeting the growing need for heroin addiction treatment. JAMA Psychiatry. 2016;73:437–438.
6. Edelman EJ, Fiellin DA. Alcohol use. Ann Intern Med. 2016;165:379–380.
7. AAMCNews. Training future physicians to address opioid crisis. https://news.aamc.org/patient-care/article/training-future-physicians-address-opioid-crisis
. Published September 18, 2017. Accessed February 9, 2019.
8. Crapanzano K, Vath RJ, Fisher D. Reducing stigma towards substance users through an educational intervention: Harder than it looks. Acad Psychiatry. 2014;38:420–425.
9. Ratycz MC, Papadimos TJ, Vanderbilt AA. Addressing the growing opioid and heroin abuse epidemic: A call for medical school curricula. Med Educ Online. 2018;23:1466574.
10. Ram A, Chisolm MS. The time is now: Improving substance abuse training in medical schools. Acad Psychiatry. 2016;40:454–460.
11. The White House, Office of the Press Secretary. Fact sheet: Obama administration announces public and private sector efforts to address prescription drug abuse and heroin use. https://obamawhitehouse.archives.gov/the-press-office/2015/10/21/fact-sheet-obama-administration-announces-public-and-private-sector
. Published October, 21, 2015. Accessed February 9, 2019.
12. Howley L, Whelan A, Rasouli T. Addressing the opioid epidemic: U.S. medical school curricular approaches. AAMC Analysis in Brief. January 2018;18. https://www.aamc.org/data/aib/485936/january2018addressingtheopioidepidemicu.s.medicalschoolcurricul.html
. Accessed February 9, 2019.
13. Kothari D, Gourevitch MN, Lee JD, et al. Undergraduate medical education in substance abuse: A review of the quality of the literature. Acad Med. 2011;86:98–112.
14. Hauer KE, Carney PA, Chang A, Satterfield J. Behavior change counseling curricula for medical trainees: A systematic review. Acad Med. 2012;87:956–968.
15. Josiah Macy Jr. Foundation. Improving health professions education to treat addiction: The time has come. http://macyfoundation.org/news/entry/improving-health-professions-education-to-treat-addiction
. Published May 23,2018. Accessed February 9, 2019.
16. Frances R. Help wanted: Medical educators in addiction psychiatry. Acad Psychiatry. 2018;42:273–276.
17. Miller NS, Sheppard LM, Colenda CC, Magen J. Why physicians are unprepared to treat patients who have alcohol- and drug-related disorders. Acad Med. 2001;76:410–418.
18. van Boekel LC, Brouwers EP, van Weeghel J, Garretsen HF. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug Alcohol Depend. 2013;131:23–35.
19. ASHP statement on the pharmacist’s role in substance abuse prevention, education, and assistance. Am J Health Syst Pharm. 2016;73:e267–e270.
20. Schoo AM, Lawn S, Rudnik E, Litt CJ. Teaching health science students foundation motivational interviewing skills: Use of motivational interviewing treatment integrity and self-reflection to approach transformative learning. BMC Med Educ. 2015;15:228.
21. Motivational Interviewing Network of Trainers (MINT). BECCI manual. https://motivationalinterviewing.org/sites/default/files/BECCIManual.pdf
. Published September 30,2002. Accessed February 9, 2019.
22. Phillipi K. Transformative learning in healthcare. PAACE J Lifelong Learn. 2010;19:39–54.
23. Muzyk A, Andolsek K, Mullan P, et al. Building a community of health professionals to establish a shared learning experience in psychiatry and substance use disorders for health professions students. Acad Psychiatry. 2018;42:279–282.
24. Muzyk AJ, Tew C, Thomas-Fannin A, et al. Utilizing Bloom’s taxonomy to design a substance use disorders course for health professions students. Subst Abus. 2018;39:348–353.
25. Muzyk AJ, Tew C, Thomas-Fannin A, et al. An interprofessional course on substance use disorders for health professions students. Acad Med. 2017;92:1704–1708.
26. Chappel JN, Veach TL, Krug RS. The Substance Abuse Attitude Survey: An instrument for measuring attitudes. J Stud Alcohol. 1985;46:48–52.
27. Dominguez DG, Fike DS, MacLaughlin EJ, Zorek JA. A comparison of the validity of two instruments assessing health professional student perceptions of interprofessional education and practice. J Interprof Care. 2015;29:144–149.
28. Goedhart H. The retrospective pretest and the role of pretest information in evaluative studies. Psychol Rep. 1992;70:699–704.
29. Lane C, Huws-Thomas M, Hood K, Rollnick S, Edwards K, Robling M. Measuring adaptations of motivational interviewing: The development and validation of the Behavior Change Counseling Index (BECCI). Patient Educ Couns. 2005;56:166–173.
30. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–381.
31. Sklar DP. Interprofessional education and collaborative practice—If not now, when? Acad Med. 2016;91:747–749.
32. Lypson M, Woolliscroft J, Spahlinger D. Health professions education must change: What educators need to know about the changing clinical context. Acad Med. 2015;91:602.
33. Reeves S, Fletcher S, Barr H, et al. A BEME systematic review of the effects of interprofessional education: BEME guide no. 39. Med Teach. 2016;38:656–668.
34. Steinert Y, Mann K, Anderson B, et al. A systematic review of faculty development initiatives designed to enhance teaching effectiveness: A 10-year update: BEME guide no. 40. Med Teach. 2016;38:769–786.
35. Kirkpatrick DL. Brown SM, Seidner CJ. The four levels of evaluation. In: Evaluating Corporate Training: Models and Issues. Evaluation in Education and Human Services. 1998.Vol 46. Dordrecht, the Netherlands: Springer.