1. SBIRT Education for Both the Mind and the Heart? Assessing Changes in Medical Residents’ Attitudes to Working with Drinkers Michael 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.

2. 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.

3. 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.

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

5. 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.

6. 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.

7. 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.

8. 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.

9. Purpose To assess changes in six components of professional readiness for working with drinkers among internal medicine residents attending the SMaRT training program

10. 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

11. Professional Readiness Working with Drinkers Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ) 7-point Likert scale (Strongly disagree  Strongly agree) DomainBrief Definition Role AdequacyKnowledge, Skills Role LegitimacyRight Role SupportProfessional support MotivationWillingness Task-Specific Self-EsteemSelf-esteem SatisfactionWork 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

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

13. Sample Characteristics Demographics (n=80) Female52% Age, mean (SD)27 (1.8) Race/ethnicity Black/African-American5% White/Caucasian72% Asian/Asian-American22% Bi-/Multi-racial1% Not-Hispanic/Latino97% Training, Internal Medicine100% Year, PGY-1100%

14. Changes in Internal Medicine Residents’ Attitudes Pre/Post SMaRT Training * p-value <.05 (n = 80) AAPPQ Summary Sub-Scale Scores AAPPQ Sub-scales

15. 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

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

17. 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)

18. Contact Information Michael A. Mitchell, MA Michael.mitchell10@va.gov Interdisciplinary Program Addictions Education and Research Center for Health Equity Research & Promotion VISN4 Mental Illness Research Education and Clinical Center VA Pittsburgh Healthcare System University Drive (151C), Building 30, 2 nd Floor Pittsburgh, PA 15240 412-360-2139

19. Transformative Learning Fundamental change in perspective, frame of reference Mezirow’s 10 ordered phases for transformative learning 1)Experiencing a disorienting dilemma 2)Undergoing self-examination 3)Conducting a critical assessment of internalized assumptions 4)Relating discontent to similar experiences of others 5)Exploring options for new ways of acting 6)Building competence, self-confidence 7)Planning course of action 8)Acquiring knowledge, skills for new course of action 9)Trying out new roles, assessing them 10)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.

20. AAPPQ Sub-Scales, Examples Role 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