Addiction Medicine Training Fellowships in North America: A Recent Assessment of Progress and Needs.

OBJECTIVES: Although unhealthy substance use and addiction contribute to 1 in 4 deaths and are estimated to cost the US more than $740 billion annually, fewer than 12 hours of physician education over the 7 years of medical school and primary residency training specifically address alcohol and other drug-related issues. Addiction Medicine was formally recognized as a medical subspecialty in 2016 to address the need for physicians trained in prevention, treatment, and management of substance use. This study examines the characteristics of the Addiction Medicine fellowships in operation during this critical period in the subspecialty's development to identify needs and potential. METHODS: This study is a cross-sectional survey of Addiction Medicine Fellowship Directors from 46 fellowships accredited as of 2017 (43 in the United States and 3 in Canada). The response rate was 100%. RESULTS: Directors estimated significant growth in available fellowship slots between 2016 to 2017 and 2017 to 2018 (F = 49.584, P < .001). The majority of Directors reported that demand for their graduates was high (79.5%). Fellow training in screening, brief intervention, and referral to treatment spanned many substances and age groups, although fewer programs focused on nicotine and on adolescent populations. Notably, most directors reported that graduates completed waiver training to prescribe buprenorphine-naloxone (77.5%) and gained clinical experience in an opioid treatment setting (89.1%). Funding was the #1 need among 56.8% of Directors. CONCLUSIONS: Despite significant growth in Addiction Medicine fellowships over the past 6 years, meeting future workforce demands for Addiction Medicine specialists depends on access to funding to support fellowships.

Diabetes self-management in a low-income population: impacts of social support and relationships with the health care system.

OBJECTIVES: This article reports on results of a qualitative study of social supports and institutional resources utilized by individuals living with diabetes in a high-poverty urban setting. The goal was to examine how access to social capital among low-income populations facilitates and impedes their self-efficacy in diabetes self-management. METHODS: Semi-structured interviews were conducted with 34 patients with diabetes from a safety net primary care practice in Buffalo, New York. RESULTS: Facilitators and barriers to successful self-management were identified in three broad areas: (1) the influence of social support networks; (2) the nature of the doctor-patient relationship; and (3) the nature of patient-health care system relationship. Patients' unmet needs were also highlighted across these three areas. DISCUSSION: Participants identified barriers to effective diabetes self-management directly related to their low-income status, such as inadequate insurance, and mistrust of the medical system. It may be necessary for patients to activate social capital from multiple social spheres to achieve the most effective diabetes management.

The adoption and use of health information technology in rural areas: results of a national survey.

CONTEXT: Health information technology (HIT) is a national policy priority. Knowledge about the special needs, if any, of rural health care providers should be taken into account as policy is put into action. Little is known, however, about rural-urban differences in HIT adoption at the national level. PURPOSE: To conduct the first national assessment of HIT in rural primary care offices, with particular attention to electronic medical record (EMR) adoption, range of capabilities in use, and plans for adoption. METHODS: A national mail survey of 5,200 primary care offices, stratified by rurality using Rural-Urban Commuting Area categories, was conducted in 2007-2008. Regression analyses were used to assess the relationship between office characteristics and EMR adoption, capabilities used, and future adoption plans. RESULTS: A commercial EMR system was present in 31% of offices, with no significant differences by rurality. Of offices with EMRs, 12% reported using a full range of EMR capabilities, with 51% using a basic range and 37% using less than the basic range. Large Rural (adjusted OR = 3.71, P= .022) and Small Rural (aOR = 3.75, P= .049) offices were more likely than Urban offices to use a broader range of EMR capabilities. Among offices without EMRs, those in Isolated areas were less likely to have more immediate plans to adopt (aOR = 0.19, P= .02). CONCLUSIONS: HIT adoption and use in rural primary care offices does not appear to be lower than in urban offices. The situation, however, is dynamic and warrants further monitoring.

Defining differences in the instructional styles of community preceptors.

BACKGROUND AND OBJECTIVES: Variability exists in the instructional experiences of medical students in clinical settings. As relationships between community-based physicians and medical students expand, it is important to promote instructional styles that enhance teaching and learning. This study identified attitudes and approaches toward teaching that distinguish preceptors with high student ratings from those with lower ratings. METHODS: Interviews were conducted with a purposive sample of 14 preceptors who had received either high or low scores from first-year students on the MedEd IQ, a standardized tool for assessing ambulatory clinical training experiences. Transcripts were analyzed using a qualitative approach. RESULTS: High-scoring preceptors were distinguished by six attributes: welcoming novice clinicians as legitimate participants in a community of practice, creating a central role for students in patient care and teaching, regularly engaging students in self-reflection to monitor their progress, helping students discover learning opportunities in routine patient encounters, using feedback to shape rather than evaluate student performance, and creating an environment where novices felt comfortable practicing new skills with patients. CONCLUSIONS: The results suggest that high-scoring preceptors provide a decidedly different experience through their approach to the challenge of training inexperienced students. These findings have implications for preceptor selection criteria and faculty development curricula.